Skip to main content

Early chest tube removal after thoracoscopic lobectomy with the aid of an additional thin tube: a prospective multi-institutional study



There is no evidence concerning the appropriate drainage volume for indicating chest tube removal after pulmonary lobectomy. A prospective multi-institutional cohort study was designed to elucidate the safety of early chest tube removal after thoracoscopic lobectomy.


Between April 2009 and November 2011, 310 patients with suspected or histologically documented lung cancer were screened. Patients without air leakage or bloody, chylous, or purulent pleural effusion underwent chest tube removal on the day after thoracoscopic lobectomy, independent of the drainage volume. The subjects were classified into three groups as tertiles according to the drainage volume that was observed for approximately 24 h after surgery. The associations between the drainage volume and the development of complications were investigated, with several clinical factors taken into account.


The 162 patients who were enrolled underwent early chest tube removal via this protocol and were classified into three groups according to their drainage volume (0–219 mL, n = 52; 220–349 mL, n = 56; and ≥ 350 mL, n = 54). A 7F backup tube placed within the dead space to prevent troubles was removed by postoperative day 4 in all patients because nothing happened. Univariate and multivariate analyses showed that the drainage volume was not associated with the risk of complications.


Early removal of the chest tube on the day after thoracoscopic lobectomy appears to be a safe treatment protocol in patients without air leakage or bloody, chylous, or purulent pleural effusion; however, careful surveillance is needed for patients who have a drainage volume of ≥ 350 mL/day.

Clinical registration number

University Hospital Medical Information Network Clinical Trials Registry, 000028971 (Japan).

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  1. Younes RN, Gross JL, Aguiar S, Haddad FJ, Deheinzelin D. When to remove a chest tube? A randomized study with subsequent prospective consecutive validation. J Am Coll Surg. 2002;195:658–62.

    Article  Google Scholar 

  2. Brunelli A, Beretta E, Cassivi SD, Cerfolio RJ, Detterbeck F, Kiefer T, et al. Consensus definitions to promote an evidence-based approach to management of the pleural space. A collaborative proposal by ESTS, AATS, STS, and GTSC. Eur J Cardiothorac Surg. 2011;40:291–7.

    Article  Google Scholar 

  3. Refai M, Brunelli A, Salati M, Xiume F, Pompili C, Sabbatini A. The impact of chest tube removal on pain and pulmonary function after pulmonary resection. Eur J Cardiothorac Surg. 2012;41:820–3.

    Article  Google Scholar 

  4. Cerfolio RJ, Pickens A, Bass C, Katholi C. Fast-tracking pulmonary resections. J Thorac Cardiovasc Surg. 2001;122:318–24.

    Article  CAS  Google Scholar 

  5. Nakanishi R, Fujino Y, Yamashita T, Oka S. A prospective study of the association between drainage volume within 24 hours after thoracoscopic lobectomy and postoperative morbidity. J Thorac Cardiovasc Surg. 2009;137:1394–9.

    Article  Google Scholar 

  6. Nakanishi R, Yamashita T, Shinohara S, Kato M, Miura T. Early removal of chest tube after thoracoscopic lobectomy. Kyosai Med J. 2013;62:206–10 (article in Japanese).

    Google Scholar 

  7. Goldstraw P, Crowley J, Chansky K, Giroux DJ, Groome PA, Rami-Porta R, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol. 2007;2:706–14.

    Article  Google Scholar 

  8. Swanson SJ, Herndon JE, D’Amico TA, Demmy TL, McKenna RJ Jr, Green MR, et al. Video-assisted thoracic surgery lobectomy: report of CALGB 39802-A prospective, multi-institution feasibility study. J Clin Oncol. 2007;25:4993–7.

    Article  Google Scholar 

  9. Okada M, Sakamoto T, Yuki T, Mimura T, Miyoshi K, Tsubota N. Hybrid surgical approach of video-assisted minithoracotomy for lung cancer: significance of direct visualization on quality of surgery. Chest. 2005;128:2696–701.

    Article  Google Scholar 

  10. Zhang Y, Li H, Hu B, Li T, Miao JB, You B, et al. A prospective randomized single-blind control study of volume threshold for chest tube remival following lobectomy. World J Surg. 2014;38:60–7.

    Article  Google Scholar 

  11. Bertholet JW, Joosten JJ, Keemers-Gels ME, van den Wildenberg FJ, Barendregt WB. Chest tube management following pulmonary lobectomy: change of protocol results in fewer air leaks. Interact Cardiovasc Thorac Surg. 2011;12:28–31.

    Article  Google Scholar 

  12. Cerfolio RJ, Bryant AS. Results of a prospective algorithm to remove chest tubes after pulmonary resection with high output. J Thorac Cardiovasc Surg. 2008;135:269–73.

    Article  Google Scholar 

  13. McKenna RJ Jr, Mahtabifard A, Pickens A, Kusuanco D, Fuller CB. Fast-tracking after video-assisted thoracoscopic surgery lobectomy, segmentectomy, and pneumonectomy. Ann Thorac Surg. 2007;84:1663–8.

    Article  Google Scholar 

  14. Göttgens KW, Siebenga J, Belgers EH, van Huijstee PJ, Bollen EC. Early removal of the chest tube after complete video-assisted thoracoscopic lobectomies. Eur J Cardiothorac Surg. 2011;39:575–8.

    Article  Google Scholar 

  15. Bjerregaard LS, Jensen K, Petersen RH, Hansen HJ. Early chest tube removal after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 mL/day. Eur J Cardiothorac Surg. 2014;45:241–6.

    Article  Google Scholar 

  16. Xie HY, Xu K, Tang JX, Bian W, Ma HT, Zhao J, et al. A prospective randomized, controlled trial deems a drainage of 300 mL/day safe before removal of the last chest drain after video-assisted thoracoscopic surgery lobectomy. Interact Cardiovasc Thorac Surg. 2015;21:200–5.

    Article  Google Scholar 

  17. Wang NS. The preformed stomas connecting the pleural cavity and the lymphatics in the parietal pleura. Am Rev Respir Dis. 1975;111:12–20.

    CAS  PubMed  Google Scholar 

  18. Li J. Ultrastructural study on the pleural stomata in human. Funct Dev Morphol. 1993;3:277–80.

    CAS  PubMed  Google Scholar 

  19. Miserocchi G. Physiology and pathophysiology of pleural fluid turnover. Eur Respir J. 1997;10:219–25.

    Article  CAS  Google Scholar 

  20. Zocchi L. Physiology and pathophysiology of pleural fluid turnover. Eur Respir J. 2002;20:1545–58.

    Article  CAS  Google Scholar 

  21. Craig SR, Leaver HA, Yap PL, Pugh GC, Walker WS. Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac Surg. 2001;20:455–63.

    Article  CAS  Google Scholar 

  22. Nakanishi R, Fujino Y, Oka S, Odate S. Video-assisted thoracic surgery involving major pulmonary resection for central tumors. Surg Endosc. 2010;24:161–9.

    Article  Google Scholar 

  23. Villamizar NR, Darrabie MD, Burfeind WR, Petersen RP, Onaitis MW, Toloza E, et al. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg. 2009;138:419–25.

    Article  Google Scholar 

  24. Jiang H, Wang J, Yuan DF, Fang JW, Li Z. Feasibility and safety of early chest tube removal after complete video-assisted thoracic lobectomy. Indian J Cancer. 2014;51:60–2.

    Article  Google Scholar 

  25. Allen MS, Darling GE, Pechet TT, Mitchell JD, Herndon JE, Landreneau RJ, et al. Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer: initial results of the randomized, prospective ACOSOG Z0030 trial. Ann Thorac Surg. 2006;81:1013–9.

    Article  Google Scholar 

  26. Hristova R, Pompili C, Begum S, Salati M, Kefaloyannis M, Tentzeris V, et al. An aggregate score to predict the risk of large pleural effusion after pulmonary lobectomy. Eur J Cardiothorac Surg. 2015;48:72–6.

    Article  Google Scholar 

  27. Light RW. Pleural diseases. Dis Mon. 1992;38:266–331.

    Article  CAS  Google Scholar 

  28. Olgac G, Cosgun T, Vayvada M, Ozdemir A, Kutlu CA. Low protein content of drainage fluid is a good predictor for earlier chest tube removal after lobectomy. Interact Cardiovasc Thorac Surg. 2014;19:650–5.

    Article  Google Scholar 

Download references


This study was supported by research grants from the Kyosai Medical Society (No. 20–27 to Ryoichi Nakanishi).

Author information

Authors and Affiliations


Corresponding author

Correspondence to Ryoichi Nakanishi.

Additional information

This article is based on the data of a study first reported in the Kyosai Medical Journal 2013; 62:206–10 (article in Japanese).

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PDF 1486 KB)

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nakanishi, R., Fujino, Y., Kato, M. et al. Early chest tube removal after thoracoscopic lobectomy with the aid of an additional thin tube: a prospective multi-institutional study. Gen Thorac Cardiovasc Surg 66, 723–730 (2018).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: