Targeted intrapleural analgesia through an integrated chest tube after thoracoscopic lung resection: a randomized controlled trial

Introduction

Effective postoperative pain control is critical in thoracic surgery to ensure adequate ventilation, prevent complications, and facilitate early recovery (1,2). However, chest drains are a major source of postoperative pain and impaired respiratory function (3,4). Refai et al. reported that chest tube removal reduced static and dynamic pain scores by approximately 40–42% and improved forced expiratory volume by approximately 13% (5). These findings underscore that chest tube-related discomfort can severely compromise early postoperative respiratory mechanics.

Enhanced recovery after surgery (ERAS) pathways explicitly recognize chest drains as a pain source requiring aggressive management. ERAS protocols emphasize early chest tube removal and opioid-sparing analgesia as key goals (2). Indeed, chest tubes cause musculoskeletal and neuropathic pain that limits mobility (6-8). Therefore, ERAS guidelines (9,10) for lung surgery recommend evidence-based drain management (e.g., using a single small-bore tube, avoiding routine suction, and prompt removal even at higher fluid outputs) to achieve earlier drain removal, improved pain control, and faster recovery (11,12).

To directly address chest tube pain at its source, regional analgesic techniques have been explored. Demmy et al. showed that instilling 0.25% bupivacaine into the pleural space via a chest tube significantly lowered visual analog scale (VAS) pain scores and 24-hour opioid requirements after thoracoscopic surgery (13). Similarly, a recent randomized trial found that continuous intrathoracic infusion of ropivacaine through the drain significantly reduced tube-related pain compared to systemic analgesia alone (14). These studies demonstrate that targeted pleural analgesia can effectively relieve chest tube discomfort. However, current approaches may require a separate intrapleural catheter or repeated manual instillation through a conventional drain, increasing procedural complexity.

To address this issue, we developed a novel drainage-analgesia integrated (DAI) chest tube that combines drainage and local drug delivery in one device. The DAI chest tube incorporates a sealed infusion channel in the catheter wall, enabling localized delivery of analgesic or anti-inflammatory agents through the integrated infusion lumen and lateral microporous side holes, while preserving a closed negative-pressure system. In effect, the chest tube is transformed into a targeted treatment delivery portal for in situ analgesia along the chest tube tract. By integrating the drug-delivery lumen into the standard drain, this design avoids additional punctures or accessories and may provide more consistent pain relief at the source of irritation.

The current trial evaluated the safety and preliminary analgesic signal of this integrated infusion-channel chest tube compared with a conventional chest tube in patients undergoing video-assisted thoracoscopic surgery (VATS) lung resection. Rather than aiming to replace established regional analgesic techniques, this study was designed to test whether localized intrapleural delivery through the drain itself could reduce chest tube-related pain under an otherwise standardized perioperative analgesic pathway. Given the exploratory nature and open-label design of this single-center trial, the findings were intended to inform the feasibility, safety profile, and design of future confirmatory studies. If successful, the DAI approach would address an important unmet need in postoperative care by providing clinicians with a simple, built-in tool for localized analgesia. This could translate into significantly improved patient comfort and accelerated functional recovery following lung resection, thereby enhancing the clinical value of ERAS protocols. We present this article in accordance with the CONSORT reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1603/rc).

Methods

Study design and ethics

This was a prospective, single-center, open-label, parallel-group randomized controlled trial conducted at Shanghai Pulmonary Hospital, Tongji University School of Medicine. The protocol was approved by the institutional ethics committee of Shanghai Pulmonary Hospital, Tongji University School of Medicine (No. L25-863), and written informed consent was obtained from all participants before enrollment. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Because the investigational and standard drainage (STD) tubes differed visibly in structure and external connectors, patients, surgeons, anesthesiologists, and ward nurses were not blinded to group allocation.

Participants

The sample size estimation was calculated based on the primary endpoint, defined as the difference in mean VAS pain score at 24 hours after surgery between the two groups. Considering the expected difference between groups (12,14,15), a two-sided significance level of 0.05, a statistical power of 80%, and an anticipated dropout rate of 10%, the required sample size was estimated accordingly with a 1:1 allocation ratio. Patients who were scheduled for elective thoracic surgery and required postoperative chest drainage were screened for eligibility. The key inclusion criteria were as follows: age 18–75 years; thoracoscopic anatomical or non-anatomical lung resection; and anticipated placement of a single chest tube at the end of surgery. The key exclusion criteria were as follows: known allergy to amide local anesthetics; chronic opioid use; severe hepatic or renal dysfunction; pregnancy; inability to provide informed consent; and/or intraoperative conditions requiring deviation from the predefined drainage plan. Before randomization, final eligibility was confirmed after patients had provided written informed consent and agreed to comply with the standardized postoperative analgesic and outcome-assessment protocol, including the patient-controlled analgesia (PCA)-based analgesic regimen and scheduled VAS/QoR-15 assessments. Patients who withdrew consent for these protocol-mandated postoperative procedures or declined the scheduled postoperative assessments before allocation were considered screening failures and were not randomized.

Randomization and allocation

Patients were randomly assigned in a 1:1 ratio to receive either the DAI system or the STD chest tube. Randomization was performed using a computer-generated block randomization sequence with variable block sizes, stratified by sex and age group (<60 vs. ≥60 years), to ensure balanced allocation across key clinical subgroups. Allocation was concealed and was revealed only after eligibility was confirmed before surgery.

Interventions

All patients received standard perioperative anesthesia and multimodal analgesia according to the institutional perioperative pathway. Postoperative chest drainage followed an institutional standard operating procedure (SOP) for uniportal VATS lung resection. The final indication for chest drainage was confirmed intraoperatively by the operating surgeon according to the institutional SOP, and all tubes were inserted through the observation-port incision under thoracoscopic guidance. In the DAI group, a DAI chest tube was used. In the control group, an STD chest tube without the integrated drug-delivery function was used. Other aspects of perioperative management, including postoperative rescue analgesia, chest tube care, mobilization, and discharge planning, followed the same institutional pathways in both groups.

Design and principle of the DAI system

The DAI system used in this study was a study-specific prototype/custom-manufactured investigational device. The chest tube was manufactured as an integral multi-lumen structure, combining three fan-shaped drainage lumens and one built-in axially continuous infusion lumen within the same tube body. The overall tube structure and the distribution of the distal sealing end-cap and side holes are shown in Figure 1A,1B. The infusion lumen extends from the proximal Luer-lock connector to the distal segment of the tube and is embedded within the tube wall (Figure 1C,1D). The distal axial outlet of the infusion lumen is closed with a small sealing plug. The enlarged cross-sectional schematic further illustrates the connection between the proximal Luer-lock connector and the infusion lumen (Figure 1E).

Figure 1 Structural design and schematic of the DAI chest tube. (A,B) The overall structure of the drainage tube comprises one drug-infusion lumen and three fan-shaped drainage channels distributed circumferentially along the tube wall. (C,D) Axial and perspective views showing the configuration of the multi-channel design with evenly distributed side holes along the infusion lumen. (E) Enlarged cross-section showing the connection between the proximal Luer-lock connector and the infusion lumen. DAI, drainage-analgesia integrated.

The prototype of the DAI chest tube is shown in Figure 2A. Uniform side holes are distributed along the distal portion of the infusion lumen to enable controlled local drug release (Figure 2B). At the proximal end, the infusion lumen is connected to a standard Luer-lock interface, enabling syringe-based or infusion-set-based administration without additional puncture or auxiliary catheter placement (Figure 2C). The distal sealing end-cap was used to occlude the axial outlet of the infusion lumen after tube trimming or positioning so that infused medication exited through the lateral side holes rather than through the tube tip (Figure 2D and Video 1). The blue part of the sealing component is a temporary break-away handle for insertion; after the plug is seated, the handle is snapped off at a preformed frangible neck and removed, leaving only the intraluminal sealing plug at the tube end. The sealing component was inspected after insertion and again at tube removal to confirm that no dislodgement, detachment, or retained component had occurred. After placement under thoracoscopic guidance, localized drug dispersion through the side holes was confirmed intraoperatively without visible leakage from the tube end (Figure 2E). This configuration enables efficient localized analgesic delivery while preserving routine postoperative drainage function.

Figure 2 Prototype fabrication and intraoperative application of the DAI chest tube. (A) The assembled drainage tube integrating the drainage and drug-infusion functions. (B) Uniform side holes (white arrows) along the distal section for controlled local drug delivery. (C) The proximal infusion channel with a Luer-lock connector and the break-away sealing component before insertion. The tail of the end-cap serves as a temporary handle to guide insertion of the sealing plug. (D) After the sealing plug is seated within the distal axial outlet of the infusion lumen, the external handle is snapped off at a preformed frangible neck and removed, leaving only the intraluminal sealing portion embedded at the tube end. (E) Intraoperative image showing localized drug dispersion (black arrows) through the side holes after placement beneath the thoracoscopic field, achieving targeted postoperative perfusion without leakage. DAI, drainage-analgesia integrated.

Anesthesia, postoperative drainage, and analgesic management

Upon arrival in the operating room, patients received supplemental oxygen, standard monitoring (blood pressure, electrocardiography, and oxygen saturation), and intravenous access. General anesthesia was induced with propofol (1.5–2 mg/kg), sufentanil (0.5 µg/kg), and dezocine (5 mg), followed by rocuronium (0.6 mg/kg) after loss of consciousness. Once complete neuromuscular blockade was achieved, double-lumen endotracheal intubation was performed under direct vision, and tube position was confirmed by fiberoptic bronchoscopy. Anesthesia was maintained with propofol (4–8 mg/kg/h) and remifentanil (0.05–0.1 µg/kg/min), with intermittent rocuronium, using a lung-protective ventilation strategy (tidal volume 4–6 mL/kg with recruitment maneuvers). Thirty minutes before the end of surgery, ondansetron (4 mg) and intravenous acetaminophen (500 mg) were administered.

At the end of surgery, all patients were connected to an intravenous PCA system for postoperative systemic analgesia. The intravenous PCA protocol included a continuous background infusion of sufentanil at 2 µg/h, a patient-controlled bolus dose of 1 µg, and a lockout interval of 10 minutes.

In the control group, an STD chest tube was routinely inserted into the pleural cavity through the surgical incision. In the experimental group, the STD chest tube was replaced with the DAI chest tube, and the integrated infusion lumen was connected to a programmable infusion pump for intrapleural local anesthetic delivery. The infusion solution consisted of 100 mg ropivacaine and 400 mg lidocaine, diluted to a total volume of 300 mL. The pump was set to deliver an initial bolus of 20 mL, a basal infusion rate of 0.1 mL/h, and a programmed pulse dose of 20 mL every 4 hours, with no patient-controlled bolus, and a maximum limit of 23 mL/h.

Postoperatively, a scheduled basic analgesic regimen was implemented with oral paracetamol (500 mg every 8 hours). When pain control was inadequate, defined as a VAS pain score at rest >4, rescue analgesia was administered using paracetamol-dihydrocodeine tablets containing 500 mg paracetamol and 10 mg dihydrocodeine tartrate.

Data collection and outcomes

Baseline data were collected, including patient demographics [age, sex, and body mass index (BMI)], comorbidities, and perioperative variables, such as surgical type and operative duration. Postoperative data were collected according to the predefined study protocol. Postoperative opioid-related data were captured from the intravenous PCA device and reported as cumulative sufentanil consumption (µg) and the number of PCA activation attempts. Use of rescue paracetamol-dihydrocodeine was recorded separately as a categorical outcome and was not converted into morphine equivalents.

Pain intensity was assessed using a 10-point VAS pain score at rest and during coughing at 1, 6, 12, 24, and 48 hours after surgery, as well as at the time of chest tube removal for patients whose hospitalization extended beyond 48 hours. Drainage tube-related adverse events, including tube occlusion, dislodgement, leakage, sealing-component detachment, unintended retained components, and subcutaneous emphysema, were prospectively monitored and documented.

Pain associated with chest tube removal was evaluated immediately at the time of tube withdrawal. Additional postoperative adverse events, including nausea and vomiting, were also recorded.

The primary endpoint was the between-group difference in the mean VAS pain score at 24 hours postoperatively. The secondary endpoints included VAS pain scores at 1, 6, 12, and 48 hours, and at tube removal; total drainage volume; time to chest tube removal; PCA usage; postoperative length of stay; and the incidence of device-related adverse events and serious adverse events. Overall postoperative recovery was assessed using the Quality of Recovery-15 (QoR-15) questionnaire administered at 24 and 48 hours after surgery and at the time of chest tube removal.

Statistical analysis

Continuous variables are presented as mean ± standard deviation and were compared using the Student’s t-test or the Wilcoxon rank-sum test, as appropriate. Categorical variables were compared using the chi-square (χ²) test or Fisher’s exact test. Changes in VAS pain scores over time were analyzed using repeated-measures analysis of variance. All statistical tests were two-sided, and a P value <0.05 was considered statistically significant. Statistical analyses were performed using SPSS software (version 26.0; IBM Corp., NY, USA). The graphs and figures presented in this study were generated using R software (version 4.4.1).

Results

Characteristics of the study participants

From December 2025 to March 2026, a total of 77 patients scheduled for uniportal VATS were screened for eligibility. Thirty patients were excluded before randomization: 18 declined to participate, six had surgery cancelled, and six withdrew consent for the standardized postoperative analgesic and outcome-assessment protocol before allocation. Finally, 47 patients were randomized and received the allocated intervention, including 22 patients in the DAI group and 25 patients in the STD group. No patient was excluded after randomization, and all randomized patients were included in the comparative outcome analysis (Figure 3).

Figure 3 Flow diagram of patient enrollment and analysis. DAI, drainage-analgesia integrated; STD, standard drainage.

Baseline demographic and clinical characteristics were comparable between the two groups (Table 1). The mean age of the patients in the DAI and STD groups was 63.2±9.3 and 61.6±8.8 years, respectively (P=0.56). The proportion of female patients was 59.1% in the DAI group and 64.0% in the STD group (P=0.77). The BMI was similar between groups (24.9±2.6 vs. 24.5±2.0 kg/m², P=0.60). Pulmonary function indices, including forced vital capacity (FVC), forced expiratory volume in the first second (FEV₁), and the FEV₁/FVC ratio, did not differ significantly between the groups (FVC: 3.1±0.9 vs. 2.9±0.7 L, P=0.36; FEV₁: 2.5±0.7 vs. 2.3±0.6 L, P=0.50; FEV₁/FVC: 79.3%±6.8% vs. 80.7%±9.5%, P=0.57). The distribution of American Society of Anesthesiologists (ASA) physical status classification was also comparable, with most patients categorized as ASA I–II (90.9% vs. 100%, P=0.21). Regarding surgical procedures, the proportions of patients undergoing single lobectomy or single sublobar resection were balanced between groups, while a small proportion in each group underwent other types of procedures, such as bilobectomy or multiple segmentectomy. The mean surgery duration and estimated blood loss were similar (70.7±39.1 vs. 74.4±28.8 min, P=0.71; 37.7±14.1 vs. 47.6±34.2 mL, P=0.20).

Overall, there were no statistically significant differences in the baseline demographic or perioperative characteristics between the DAI and STD groups, indicating good comparability for subsequent analyses.

Postoperative pain intensity and analgesic requirements

Postoperative pain intensity, assessed using the VAS at rest and during coughing, is illustrated in Figure 4. Both groups exhibited a peak in pain scores at 12–24 hours after surgery, followed by a gradual decline over the subsequent time. Compared with the STD group, the DAI group demonstrated significantly lower VAS scores at 24 and 48 hours at rest (P=0.006 and P=0.02, respectively), and at 12, 24, and 48 hours during coughing (P=0.02, P=0.01, and P=0.001, respectively). No significant differences were observed at other time points, indicating that the DAI device effectively alleviated pain during the early postoperative phase when discomfort is typically most intense.

Figure 4 Comparison of postoperative pain intensity and its temporal evolution between the DAI and STD groups after VATS surgery. Trends of postoperative VAS pain scores at rest (A) and during coughing (B) at 1, 6, 12, 24, and 48 hours, and tube removal time after VATS. Data are presented as mean ± standard error. DAI, drainage-analgesia integrated; STD, standard drainage; VAS, visual analog scale; VATS, video-assisted thoracoscopic surgery.

Cumulative sufentanil consumption within 48 hours after surgery is shown in Figure 5. Although the total opioid requirement did not differ significantly between groups (P=0.49), the number of PCA activations was significantly lower in the DAI group than in the STD group (P=0.004). Because both groups received the same continuous background sufentanil infusion, the lower number of PCA activations should be interpreted as a reduction in patient-perceived breakthrough analgesic demand. Overall, the DAI system was associated with lower early postoperative pain scores and fewer PCA activation attempts within the first 48 hours after VATS, but it did not reduce total systemic sufentanil consumption.

Figure 5 Comparison of cumulative sufentanil consumption and PCA activations within 48 hours after surgery. Box plots illustrating cumulative sufentanil consumption (0–48 hours) in the DAI and STD groups. Individual hollow circles are overlaid, with circle size proportional to the number of PCA activations. PCA activation attempts should be interpreted as an indicator of patient-perceived breakthrough analgesic demand. DAI, drainage-analgesia integrated; PCA, patient-controlled analgesia; STD, standard drainage.

Perioperative analgesic use and safety outcomes

The perioperative medication and drainage-related data are summarized in Table 2. As mentioned above, the total and cumulative sufentanil consumption within 24 (P=0.85) and 48 (P=0.49) hours after surgery were comparable between the DAI and STD groups, indicating that the overall opioid requirement was not significantly affected by the DAI device. However, the number of PCA activations was significantly lower in the DAI group than in the STD group (0.1±0.4 vs. 0.9±1.1 times, P=0.004), suggesting a lower patient-perceived need for additional analgesic boluses. The use of rescue analgesia was comparable between the two groups, with no statistically significant difference observed (P=0.10). In addition, both the time to chest tube removal and total drainage volume were similar between the groups, showing no significant differences (P=0.24 and P=0.68, respectively). The mean postoperative length of stay was 3.7±0.8 days in the DAI group and 3.8±1.2 days (P=0.79) in the STD group.

As shown in Table 3, the incidence of common adverse events, including nausea, vomiting, hypertension, and bradycardia, was similar between the two groups. No device-related complications or unexpected safety issues were observed. Overall, the DAI system was associated with fewer PCA activation attempts without reducing total opioid consumption or adversely affecting drainage, hospitalization, or safety outcomes.

Postoperative patient-reported recovery

The patient-reported recovery results, as assessed by the QoR-15 questionnaire, are shown in Figure 6. At 24 hours after surgery, the QoR-15 scores did not differ significantly between the DAI and STD groups (P=0.46), indicating comparable very early postoperative recovery between the groups. However, at 48 hours and at tube removal time, the patients in the DAI group achieved higher QoR-15 scores than those in the STD group, suggesting a faster improvement in subjective recovery and overall comfort when the DAI system was used (P=0.01 and P=0.03, respectively). Thus, while the two drainage strategies resulted in similar lengths of hospital stay, the DAI device was associated with a qualitatively better recovery trajectory.

Figure 6 Comparison of postoperative QoR-15 scores between the DAI and STD groups. Line plots showing postoperative QoR-15 scores at 24 and 48 hours, and tube removal time after surgery. DAI, drainage-analgesia integrated; QoR-15, Quality of Recovery-15; STD, standard drainage.

Discussion

This single-center open-label randomized trial suggests that integrating a dedicated injection channel into an STD chest tube may provide a feasible method for localized intrapleural analgesic delivery after VATS lung resection. Under a standardized systemic PCA regimen, patients in the DAI group reported lower early postoperative pain scores and fewer PCA activation attempts, suggesting improved patient-reported pain comfort. These preliminary signals were observed without major changes to the routine perioperative workflow, supporting further evaluation of this strategy in future clinical studies. Moreover, we also need to emphasize that 14 of 25 patients in the STD group did not activate the PCA device, suggesting that additional PCA boluses were not required by a substantial proportion of control patients and that the standardized background systemic analgesic regimen may have attenuated the detectable incremental effect of the DAI intervention.

The rationale behind this intervention lies in the concept of “pain source deconstruction.” Chest tubes are known to be a major source of post-thoracotomy pain due to their contact with the pleura and intercostal nerves. Studies have shown that pain intensity drops sharply after chest tube removal, with improvements in both static and dynamic pulmonary function (5,16,17). Our approach, which targets analgesia precisely at this interface, may mitigate that discomfort at its origin. This localized analgesic effect facilitates deeper breathing, improved coughing, and earlier mobilization, all of which are essential components of ERAS protocols (2,18,19).

This study further extends previous research on the administration of intrapleural analgesia via chest drains. For example, Demmy et al. demonstrated that intermittent bupivacaine instillation via chest tubes significantly reduced VAS pain scores and opioid requirements following thoracoscopy (13). Similarly, Cogan et al. (20) reported rapid and substantial pain relief without increased infection risk using the same method. However, these studies typically relied on external pumps or separate catheters, which increased the procedural complexity and the potential for device dislodgement or contamination (20). Conversely, our integrated design simplifies the process: medication is administered through a built-in Luer-lock port while the same chest tube is used for drainage, thereby avoiding an additional intrapleural catheter and simplifying workflow. Of note, to address the potential risk of detachment, the sealing component was inspected after placement and again at tube removal, and device-related events such as tube dislodgement, leakage, occlusion, sealing-component detachment, and retained components were prospectively monitored. No such device-related event was observed in this cohort.

From an implementation standpoint, the device requires no change to the surgical placement technique, and nursing staff can easily learn the administration process. The design also offers flexibility beyond analgesia, including the potential to serve as a port for pleurodesis or targeted anti-inflammatory therapies in cases of prolonged air leak or persistent pleural symptoms. These features may support further clinical evaluation of the DAI system, especially in ERAS-aligned institutions seeking workflow-compatible approaches to localized chest tube-related pain control.

No device-related complications were observed, and the overall safety profile was consistent with other intrapleural analgesia reports. Nonetheless, this trial had a number of limitations. First, it was a single-center, open-label study, which may introduce performance bias, particularly in patient-reported outcomes. A future sham-controlled, assessor-blinded, or multicenter design would be needed to isolate the device-specific effect more rigorously. Second, the perioperative analgesic pathway used in this trial included standardized intravenous PCA with continuous background sufentanil infusion, and regional blocks such as intercostal, paravertebral, serratus anterior plane, or erector spinae plane blocks were not routinely incorporated into the protocol. This design was chosen to isolate the incremental effect of intrapleural drug delivery through the integrated chest tube under otherwise identical systemic analgesia. Therefore, the DAI system should not be interpreted as a replacement for established regional analgesic techniques. Future studies should evaluate this device against or in combination with contemporary regional-block-based and opioid-minimizing pathways. Additionally, it did not evaluate chronic pain or long-term quality-of-life endpoints—factors increasingly emphasized in research on thoracic surgery outcomes. Future multicenter studies should assess the durability of analgesia and explore whether early localized pain control may reduce the incidence of chronic post-thoracotomy pain syndromes.

Conclusions

This open-label randomized trial suggests that a structurally integrated analgesic-channel chest tube is feasible for targeted intrapleural local anesthetic delivery and was associated with improved early patient-reported recovery. Compared with the STD group, the DAI chest tube was associated with lower pain scores and fewer PCA activation attempts, while improving early patient-reported recovery. Its simplicity, observed safety, and compatibility with existing perioperative workflows support further evaluation in ERAS-oriented studies. Further multicenter studies are warranted to confirm these findings and optimize local analgesic strategies for improved long-term benefits.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1603/rc

Trial Protocol: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1603/tp

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1603/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1603/prf

Funding: This study was supported by the National Natural Science Foundation of China (No. 82574416); the Noncommunicable Chronic Diseases-National Science and Technology Major Project (Nos. 2024ZD0529000 and 2024ZD0540700); the National Key Research and Development Program of the Ministry of Science and Technology of China (Nos. 2022YFC2407401 and 2024YFC3044600); the Shanghai Hospital Development Center Project (No. SHDC12025126); the Shanghai Science and Technology Commission Project (No. 24YF2735500); and Shanghai Pulmonary Hospital Projects (Nos. LYRC202412, fkjy2405, fkcy2406, and fkyc2615).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1603/coif). H.T. reports grant support from Noncommunicable Chronic Diseases-National Science and Technology Major Project (No. 2024ZD0540700); Shanghai Science and Technology Commission Project (No. 24YF2735500); and Shanghai Pulmonary Hospital Projects (Nos. fkjy2405, fkcy2406, and fkyc2615) to the institution. Y.R. reports grant support from Shanghai Pulmonary Hospital Project (No. LYRC202412) to the institution. C.C. reports grant support from Noncommunicable Chronic Diseases-National Science and Technology Major Project (No. 2024ZD0529000); and the National Key Research and Development Program of the Ministry of Science and Technology of China (Nos. 2022YFC2407401 and 2024YFC3044600) to the institution. X.H. reports grant support from Shanghai Hospital Development Center Project (No. SHDC12025126); and the National Natural Science Foundation of China (No. 82574416) to the institution. H.T., Y.R., J.S., C.C. and X.H. report a utility model patent related to the device evaluated in this manuscript: “A negative pressure drainage device integrated with an axial end-sealable injection channel”; Patent No. ZL 2025 2 1627053.6; Publication No. CN 223569737 U. The patent is owned by Shanghai Pulmonary Hospital. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The protocol was approved by the institutional ethics committee of Shanghai Pulmonary Hospital, Tongji University School of Medicine (No. L25-863), and written informed consent was obtained from all participants before enrollment. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg 2017;152:292-8. [Crossref] [PubMed]
2. Batchelor TJP. Enhanced recovery after surgery and chest tube management. J Thorac Dis 2023;15:901-8. [Crossref] [PubMed]
3. Zhang JT, Dong S, Chu XP, et al. Randomized Trial of an Improved Drainage Strategy Versus Routine Chest Tube After Lung Wedge Resection. Ann Thorac Surg 2020;109:1040-6. [Crossref] [PubMed]
4. Lai Y, Wang X, Zhou H, et al. Is it safe and practical to use a Foley catheter as a chest tube for lung cancer patients after lobectomy? A prospective cohort study with 441 cases. Int J Surg 2018;56:215-20.
5. Refai M, Brunelli A, Salati M, et al. The impact of chest tube removal on pain and pulmonary function after pulmonary resection. Eur J Cardiothorac Surg 2012;41:820-2; discussion 823. [Crossref] [PubMed]
6. Spaans LN, Dijkgraaf MGW, Susa D, et al. Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery: A Randomized Noninferiority Trial. JAMA Surg 2025;160:855-64. [Crossref] [PubMed]
7. Jin J, Sun H, Zhang X, et al. Comparison of Intercostal Nerve Block and Serratus Anterior Plane Block for Perioperative Pain Management and Impact on Chronic Pain in Thoracoscopic Surgery: A Randomized Controlled Trial. Clin J Pain 2024;40:691-9. [Crossref] [PubMed]
8. Clephas PRD, Orbach-Zinger S, Gosteli-Peter MA, et al. Regional analgesia techniques for postoperative pain after breast cancer surgery: a network meta-analysis. Cochrane Database Syst Rev 2025;6:CD014818. [Crossref] [PubMed]
9. Song L, Chen X, Zhu L, et al. Perioperative outcomes of bi-pigtail catheter drainage strategy versus conventional chest tube after uniportal video-assisted thoracic lung surgery. Eur J Cardiothorac Surg 2023;64:ezad411. [Crossref] [PubMed]
10. Yeung JH, Gates S, Naidu BV, et al. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016;2:CD009121. [Crossref] [PubMed]
11. Wei S, Zhang G, Ma J, et al. Randomized controlled trial of an alternative drainage strategy vs routine chest tube insertion for postoperative pain after thoracoscopic wedge resection. BMC Anesthesiol 2022;22:27. [Crossref] [PubMed]
12. Yang F, Wang X, Xu H, et al. A novel drainage strategy using chest tube plus pleural catheter in uniportal upper lobectomy: A randomized controlled trial. Thorac Cancer 2023;14:399-406. [Crossref] [PubMed]
13. Demmy TL, Nwogu C, Solan P, et al. Chest tube-delivered bupivacaine improves pain and decreases opioid use after thoracoscopy. Ann Thorac Surg 2009;87:1040-6; discussion 1046-7. [Crossref] [PubMed]
14. Tang W, Hao Y, Wu G, et al. Comparison of the effectiveness of two different concentrations of ropivacaine for intrapleural analgesia in reducing stimulatory pain caused by chest tubes after uniportal video-assisted thoracoscopic surgery: a randomised controlled study. BMC Anesthesiol 2025;25:119. [Crossref] [PubMed]
15. Qin J, Lei Z, Li R, et al. Intrapleural injection of bupivacaine liposome for pain management after thoracoscopic surgery. Sci Rep 2025;15:24433. [Crossref] [PubMed]
16. Wildgaard K, Ravn J, Kehlet H. Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg 2009;36:170-80. [Crossref] [PubMed]
17. Chen CT, Tung HH, Chen YC, et al. Cold application for pain and anxiety reduction following chest tube removal: A systematic review and meta-analysis. J Clin Nurs 2023;32:574-83. [Crossref] [PubMed]
18. Sauro KM, Smith C, Ibadin S, et al. Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials. JAMA Netw Open 2024;7:e2417310. [Crossref] [PubMed]
19. Pilkington M, Nelson G, Cauley C, et al. Development of an Enhanced Recovery After Surgery Surgical Safety Checklist Through a Modified Delphi Process. JAMA Netw Open 2023;6:e2248460. [Crossref] [PubMed]
20. Cogan J, André M, Ariano-Lortie G, et al. Injection of Bupivacaine into the Pleural and Mediastinal Drains: A Novel Approach for Decreasing Incident Pain After Cardiac Surgery - Montreal Heart Institute Experience. J Pain Res 2020;13:3409-13. [Crossref] [PubMed]

(English Language Editor: L. Huleatt)