The application analysis of 8F ultra ne chest drainage tube in thoracoscopic lobectomy for lung cancer

Yongbin Song Hebei Medical University Chong Zheng Hebei North University Shaohui Zhou Hebei General Hospital Hongshang Cui Hebei General Hospital Jincong Wang Ningbo University Medical School Jianxun Wang Hebei North University Wenhao Wang Hebei General Hospital Lijun Liu Hebei General Hospital Junfeng Liu (  junfengliu4h@163.com ) Hebei Medical University Third A liated Hospital https://orcid.org/0000-0002-0240-6608


Abstract
Background Currently, thoracoscopic lobectomy is widely used in clinical practice, and postoperative placing of ultra ne drainage tube has advantages in reducing postoperative pain and accelerating postoperative recovery of patients.This study aim to investigate the feasibility and safety of placing 8F ultra ne chest drainage tube after thoracoscopic lobectomy and its superiority over traditional 24F chest drainage tube.
Methods: A retrospective data analysis was undertaken on 134 patients who placed 8F ultra ne chest drainage tube or 24F chest drainage tube with thoracoscopic lobectomy for lung cancer from January Conclusion:Compared with 24F chest drainage tube, the application of 8F ultra ne chest drainage tube after thoracoscopic lobectomy can signi cantly shorten the drainage time,reduce the total drainage volume,reduce the postoperative pain degree,shorten the hospital day,and effectively detect postoperative intrathoracic hemorrhage. It is an effective, safe and reliable drainage method.

Background
At present, the surgical method of lung cancer is gradually changing from thoracotomy to minimally invasive operation, and thoracoscopic lobectomy is widely used in clinical practice [1][2][3][4].The purpose of placing a thoracic drainage tube after lobectomy is mainly to drain the blood and gas in the thoracic cavity, prevent re ux of exudate, reconstruct the normal negative pressure in the thoracic cavity, promote lung expansion and prevent intrathoracic infection [5,6].However, postoperative placing chest drainage tube will aggravate the wound pain, resulting in low e ciency of cough and inactivity of ambulating, which is not conducive to early postoperative recovery [7][8][9].The concept of enhanced Recovery after surgery (ERAS) aims to optimize perioperative measures, alleviate surgical stress, reduce complications and achieve the goal of accelerated recovery by combining minimally invasive surgery [10].In this study, the data of 67 such patients from were retrospectively analyzed and compared with 67 patients with conventional 24F chest drainage tube. To investigate the feasibility and safety of placing 8F ultra ne chest drainage tube after thoracoscopic lobectomy, and its advantages over 24F chest drainage tube.

Patient selection
We retrospectively reviewed the medical data of patients with lung cancer who underwent video-assisted Lung lobe and other thoracic organs need to be excised simultaneously.
According to the above criteria, 67 cases of postoperative placing 8F ultra ne chest tube were selected by computer-generated random number and included in the experimental group (group A). Similarly, 67 cases of postoperative placing 24F chest drainage tube were selected and included in the control group (group B). General data of the two groups were compared as shown in Table 1.

Surgical Approach
Patients in both groups underwent VATS lobectomy and systematic MLND, single-lung ventilation, and the lateral decubitus position. After disinfection, observation hole was made in the 7th intercostal space of the midaxillary line. A 1.5 cm incision was made and thoracoscope was placed. For the lesion of the upper lobe,an incision (3 ~ 4 cm) was made in the 4th intercostal space of the anterior axillary line.For the lesion of the middle or lower lobe,an incision (3 ~ 4 cm) was made in the 5th intercostal space of the anterior axillary line.Without rib spreading, apply ultrasonic scalpel and linear cut-close device complete resection of blood vessels, bronchi, and lobes.For both group A and Group B, the upper lobectomy was used with double drainage tube.In case of middle or lower lobectomy, placing single drainage tube.
In group A, 8F ultra ne chest drainage tubes(ABLE®;Baihe,Guangdong,China) were placed postoperatively. The upper tube was placed in the 2rd intercostal space of the midaxillary line, and the lower tube was placed in the 7th ~ 9th intercostal the space of posterior axillary line. In group B, 24F chest drainage tubes(Cobonyy®;Kebang,Suzhou,China) were placed along the 7th intercostal observation hole after surgery.See Fig. 1.
After operation, electrocardiogram(ECG) and vital signs were monitored continuously and routine uid was supplemented. Blood gas analysis, electrolyte analysis and bedside chest radiograph were reviewed on the rst day after operation. Computer Tomography (CT) examination was performed on the third day after the operation. Nursing care of thoracic drainage was performed to ensure unobstructed drainage tube.
The criteria for chest tube removal were as follows: (1)  Statistical analysis SPSS 20.0 software was adopted for data analysis (IBM,Armonk, NY). Continuous variables were expressed as mean ± standard deviation(SD). Categorical variables were expressed as frequencies and percentages.Signi cant differences between the groups were assessed using Student's t -tests for continuous variables, and x 2 -tests for categorical variables. Mann-Whitney test was used for ordinal categorical variable. A p-value of less than 0.05 was taken as a level of signi cance for all analyses.

Results
There was no signi cant difference in the general data between the two groups, indicating no statistical signi cance(P > 0.05),as shown in Table 1.Compared with Group B, Group A showed signi cant advantages in pain score(POD 1,2 and 3), postoperative drainage volume,drainage days,and postoperative hospital stay (P < 0.05), as shown in Table 2.

POD postoperative days
Postoperative complications of the two groups: subcutaneous emphysema, pulmonary infection, atelectasis, chest tube reinsertion, and intrathoracic hemorrhage were not signi cantly different (P > 0.05), as shown in Table 3.Thirty-seven cases of subcutaneous emphysema were found 1 ~ 3 days after operation, among which 33 cases were mild subcutaneous emphysema, which was cured by full exhaust drainage through thoracic drainage tube, and the remaining four cases were cured after chest tube reinsertion due to drainage tube dislocation or poor drainage.All the ten cases of pulmonary infection were found 3 ~ 4 days after operation, and were cured by ECG monitoring,anti-infection and nutritional support.Eleven patients with atelectasis were found 3 ~ 4 days after operation, and all of them showed poor performance of active cough and sputum excretion.Two cases of thoracic hemorrhage were found in the postoperative recovery room. After a thoracotomy in time and effective hemostasis, the patients were cured and discharged from the hospital.

Discussion
The routine use of chest drainage tube after lobectomy is helpful for pleural effusion to be discharged from the body, eliminate the residual cavity of the chest and promote the reexpansion of the lung. It is very important to reduce pulmonary infection and timely detect intrathoracic bleeding and other postoperative complications [5].Therefore, the selection of chest drainage tube should rst consider the safety and effectiveness of patients [13].With the promotion and use of the concept of ERAS and minimally invasive surgery deeply rooted in the hearts of the people in recent years [10], we realize that postoperative pain and diaphragm stimulation caused by thick chest tubes may not be conducive to the accelerated recovery of patients after operation.So, it is of great clinical signi cance to explore whether 8F ultrathin chest drainage tube is safe and reliable compared with traditional thick chest drainage tube, in order to accelerate the recovery of patients.
Due to the pressure of the drainage tube on the intercostal nerve and diaphragm, the placement of the closed thoracic drainage tube will cause postoperative chest This study showed that there were statistically signi cant differences in pain scores between the two groups on POD 1,2 and 3 after surgery(3.72 ± 0.65point vs 3.94 ± 0.67point,P = 0.027 ;2.72 ± 0.93point vs 3.13 ± 1.04point,P = 0.016;1.87 ± 0.65point vs 2.39 ± 1.22point,P = 0.005).Pain scores in group A were signi cantly better than those in group B.Postoperative pain increases, which affects the recovery of patients' respiratory function and increases the risk of postoperative respiratory complications.The postoperative pain was reduced, which enhanced the initiative of cough and sputum, promoted lung expansion, reduced lung infection, and was more conducive to ambulation.
The operation of 8F ultra ne chest drainage tube is simple, the extubation is convenient and quick.After extubation, the incision closes naturally and it is not easy to inject air.Just apply the normal dressing externally.However, after the extubation of 24F thick thoracic duct, in order to avoid the intake of air or leakage of drainage outlet, vaseline gauze or reserved suture ligation is needed, which is more complicated and risky, and long surgical scar will be left after healing, affecting the appearance and leaving psychological trauma that is di cult to heal for the patient.After switching to ultra ne chest drainage tube, the incision was small, the perivascular tissue in ammatory response was mild, postoperative scar was small, and it was more beautiful.
In this study, the drainage days in group A were shorter than those in group B((4.25 ± 1.79d vs 6.04 ± 1.96d,P = 0.000), the postoperative hospital stay in group A were shorter than those in group B(8.46 ± 2.48d vs 9.37 ± 1.70d,P = 0.014),and the total postoperative drainage volume was also lower than that in group B(1100.42 ± 701.57 ml vs 1369.39 ± 624.25 ml,P = 0.021). The differences were statistically signi cant.The inner wall of the ultra ne chest drainage tube is smooth, with strong anti-coagulation ability and good exibility. It can be coiled in the costophrenic angle or followed between the lung and chest wall, making drainage more smooth and su cient.However, the texture of the thick chest tube is hard, and it is not easy to be completely placed in the costophrenic angle or followed between the chest wall and the lung lobe. Therefore, it may compress the lung lobe and diaphragm muscle, and stimulate the increase of pleural effusion.
Although the inner diameter of 8F ultra ne chest drainage tube is smaller than that of traditional 24F drainage tube, patients ambulate earlier, promote uid accumulation and drainage faster due to its advantage in pain management, and the risk of atelectasis and pulmonary infection does not increase signi cantly compared with the thick drainage tube(5.97% vs 10.45%,5.97% vs8.96%,P 0.05).If the lung recovers well and coughs without bubble over ow, patients using 8F ultra ne chest drainage tube can replace the water-sealed drainage bottle as the drainage bag, so that patients can ambulate more easily, which is also the convenience of the thin drainage tube.
For patients with postoperative air leakage, drugs such as high glucose can be injected into the chest to promote thoracic adhesion.The operation of 8F ultra ne chest drainage tube is simple and aseptic, while injecting drugs into thoracic cavity through traditional 24F chest drainage tube is tedious and easy to be contaminated.
Among the 67 patients in group A, 2 patients with intrathoracic hemorrhage were found in the postoperative resuscitation room and underwent secondary surgery for hemostasis, and all of them were cured and discharged. The results showed that although the 8F ultra ne chest drainage tube had a thicker and smaller inner diameter, it could still nd the intrathoracic hemorrhage in time and effectively.
8F ultra ne chest drainage tube also has several problems:(1) Among the cases in group A, the reasons for the chest tube reinsertion in 3 patients were drainage tube dislocation. Therefore, the depth of the catheter should be exibly grasped according to the thickness of the chest wall in clinical practice. It should not be too shallow or too deep. Too shallow may cause the drainage tube to come out, and too deep the drainage tube may bend into an angle in the chest cavity to affect the drainage.(2)The ultra ne chest drainage tube should be placed at another puncture point, not through the surgical incision.Because if the tissue around the tube is not dense enough, there may be uid seepage around the mouth of the tube;drainage ori ce exudation may also occur after extubation.

Conclusion
In conclusion, the application of 8F ultra ne chest drainage tube after thoracoscopic lobrectomy can reduce postoperative pain, fully drain, facilitate ambulating, accelerate postoperative recovery, and do not increase the risk of postoperative complications such as subcutaneous emphysema, pulmonary infection, atelectasis. At the same time, it can detect postoperative thoracic hemorrhage timely and effectively, which is an effective, safe and reliable way of drainage. The appearance of placing chest drainage tube