Drainology Symposium at ESTS 2026
Summary from symposium “Delivering High‑Value Thoracic Surgery: Outcomes, Processes and Quality Improvement” at the ESTS Annual Meeting, Athens, Greece on 8 June 2026.
The ESTS 2026 Lunch Symposium highlighted the challenge of translating variable chest drain practices into standardized, patient-centred care. Significant heterogeneity exists in drain size, suction use, and digital system adoption, with prolonged air leak identified as a key driver of morbidity and length of stay. Evidence questioned routine practices such as small-bore drains and suction, while supporting digital systems for more objective monitoring and safer, earlier decision-making.
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Speakers outlined a stepwise pathway toward standardisation, including early drain removal, omission in selected procedures, and expansion to anatomical resections in appropriate patients. However, adoption is limited by cultural and organizational barriers, requiring multidisciplinary collaboration, clear protocols, and ongoing audit.
Reducing drain duration emerged as the most important factor for improving outcomes and lowering costs. Programs like OPCATS demonstrated that selective, protocol-driven drainage can shorten hospital stays and support ambulatory thoracic surgery, enabling more efficient, value-based care.
Key messages
- Chest drain management remains highly variable but clinically decisive: Substantial differences in drain size, suction use, and digital adoption persist across centres, directly influencing prolonged air leak, complications, and length of stay.
- Standardized, data-driven pathways can safely reduce intervention: Objective criteria enable earlier drain removal and even selective drain omission in appropriate patients, supporting improved recovery without increasing risk.
- Reducing drain duration is key to value-based care: Chest drain duration is the strongest predictor of hospital stay, with protocolized approaches offering significant gains in efficiency, cost savings, and patient-centred outcomes.
Evaluating the baseline of quality improvement and variability of care
Mr. Andrea Billè – Guy’s & St Thomas’ NHS Foundation Trust, London, UK
A fundamental observation emerging from contemporary thoracic practice is the marked heterogeneity in chest drain management. Across European institutions, there are substantial differences in drain size selection, use of suction, and adoption of digital drainage systems.
Data from a large multicentre prospective registry, including 3,348 patients across 21 international centres, confirm that this variability persists even after adjusting for case mix.
Digital system uptake ranged from 4% to 92%, suction strategies varied between 8% and 84%, and drain sizes ranged from 20 Fr to 32 Fr. This variability highlights the absence of universally accepted evidence-based standards. Despite advances in surgical techniques, postoperative outcomes remain closely linked to prolonged air leak (PAL), which was observed in 8.9% of patients and represents a primary determinant of morbidity and hospital length of stay.
Importantly, multivariable analysis identified both patient-related factors (e.g. smoking, pulmonary function) and management-related factors as key contributors. Among the latter, drain size emerged as an independent protective factor, with larger calibre drains significantly reducing the risk of PAL (adjusted odds ratio 0.62 per +4 French size increment).
These findings challenge the increasing preference for small-bore drains, suggesting that such strategies may inadvertently increase postoperative complications, including surgical emphysema and the need for reinsertion.
The role of digital chest drainage systems warrants particular attention. While registry analyses demonstrate a statistically significant increase in recorded PAL when digital systems are used (OR 1.58), this effect occurs without any associated increase in clinically relevant outcomes such as LOS, reintervention, or readmission. This strongly suggests that digital systems provide greater sensitivity in air-leak detection, rather than contributing to worse outcomes. Indeed, they are associated with consistent directional improvements across safety endpoints, as well as modest reductions in LOS (~0.32 days).
With respect to suction, available randomized controlled trials provide inconsistent and often conflicting evidence. Studies by Cerfolio[1] and Marshall[2] suggest potential advantages of water seal, while subsequent trials have failed to consistently replicate these findings. Collectively, this body of evidence does not support the routine use of external wall suction as a standardised approach.
Similarly, traditional conservative thresholds for fluid output prior to drain removal appear to be overly restrictive. Evidence indicates that drains can be safely removed at daily outputs of up to 450–500 mL[3],[4], with low reintervention rates (~2.8%[5]) and a reduction in postoperative infections when removal is performed earlier.
Beyond these technical parameters, the session emphasised the importance of patient-centred outcomes. Chest drains are a major contributor to postoperative pain, delayed mobilisation, impaired pulmonary function, and reduced participation in physiotherapy[6]. Early removal or avoidance of drains is associated with improved outcomes, highlighting the need to align chest drain management strategies with patient experience.
In summary, the data clearly demonstrate that chest drain management remains highly variable and insufficiently standardised, despite being a major determinant of clinical and patient-reported outcomes.
Creating standardised drain management pathways
Lars Geenen, PhD – Stichting Zuyderland Medisch Centrum, Heerlen, The Netherlands
Building on the observed variability, the next step is the development of structured, standardised clinical pathways. However, current international guidelines offer only limited guidance, as they are largely based on low-level evidence and expert consensus, often accompanied by conflicting recommendations.
National survey data from the Netherlands further illustrate the extent of variation in clinical practice. Although approximately 65% of surgeons consider their approach to be “progressive,” there remains considerable inconsistency in key parameters such as acceptable air leak thresholds (ranging from 0 to 40 ml/min), fluid output thresholds and timing of drain removal. This discrepancy points to a gap between perceived and actual standardisation.
To address this, a stepwise implementation strategy was proposed. The first step involves early chest drain removal, guided by objective criteria such as an air leak below 40 ml/min, without strict fluid thresholds, and with the possibility of removal on postoperative day (POD) 0. Importantly, internal evaluations demonstrated that such an approach does not increase complication rates.
The second step extends this concept to the omission of chest drains in selected procedures, particularly wedge resections. Evidence from both meta-analyses[7],[8] and institutional data[9] indicates that drain omission in these cases is safe and associated with a reduction in length of stay of approximately one day.
The third and most progressive step is the selective omission of drains in anatomical lung resections. Observational data suggest that up to 61% of patients show no relevant air leak shortly after surgery, indicating that routine drainage may be unnecessary in a substantial proportion of cases.[10] An initial cohort study confirms the feasibility of this approach, with short hospital stays (POD 0–2) and low complication rates.
Despite these promising results, implementation remains challenging. Barriers are not limited to clinical concerns, such as the risk of delayed air leak, but include significant behavioural and organisational factors, including entrenched habits, institutional culture, and the desire for clinical reassurance.
Successful implementation therefore depends on:
- multidisciplinary collaboration
- strong clinical leadership
- clearly defined protocols
- continuous data feedback and audit systems
Transforming data and pathways into value-based clinical care
Prof. Eric Lim – Royal Brompton Hospital & Imperial College London, UK
The final step is translating data and pathways into measurable healthcare value. Central to this is the identification of key determinants of resource utilisation. [11]
This finding has profound health-economic implications. The cost of an inpatient bed day ranges from £ 400 to £ 600 in the UK, and significantly higher in other healthcare systems. Even modest reductions in drain duration can therefore translate into substantial savings. For example, in a unit performing 1,000 lung resections annually, reducing drain duration by one day per patient could save approximately £ 500,000 per year.
At a global level, with an estimated 400,000–500,000 lung resections performed annually, the cumulative economic burden of prolonged drainage extends to billions of healthcare dollars.
The OPCATS (Optimum Patient Care for Ambulatory Thoracic Surgery) programme provides a proof of concept for how such improvements can be realised in practice.
Among 175 patients, 56% had no air leak at the end of surgery, and 64% of those managed according to protocol underwent on-table drain removal, resulting in measurable reductions in hospital bed utilisation.
These findings support a broader paradigm shift toward:
- selective rather than routine drainage
- ambulatory or day-case thoracic surgery
- elimination of drain-related discharge delays
However, implementation at scale is hindered by persistent barriers, including a deeply rooted culture of surgical autonomy, risk aversion, and limited alignment between evidence and clinical behaviour.
References
[1] Cerfolio RJ, Bass C, Katholi CR. Prospective randomized trial compares suction versus water seal for air leaks. The Annals of Thoracic Surgery. 2001;71(5):1613-7.
[2] Marshall MB, Deeb ME, Bleier JI, et al. Suction vs water seal after pulmonary resection: a randomized prospective study. Chest. 2002;121(3):831-5.
[3] Cerfolio RJ, Bryant AS. Results of a prospective algorithm to remove chest tubes after pulmonary resection with high output. The Journal of thoracic and Cardiovascular Surgery. 2008;135(2):269-73.
[4] Bjerregaard LS, Jensen K, Petersen RH, et al. Early chest tube removal after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day. European Journal of Cardio-Thoracic Surgery. 2014;45(2):241-6.
[5] Xing T, Li X, Liu J, et al. Early removal of chest tubes leads to better short-term outcome after video-assisted thoracoscopic surgery lung resection. Annals of Translational Medicine. 2020;8(4):101.
[6] Yang D, Zheng X. Enhanced recovery after surgery program focusing on chest tube management improves surgical recovery after video-assisted thoracoscopic surgery. Journal of Cardiothoracic Surgery. 2024;19(1):253.
[7] Laven IE, Daemen JH, Janssen N, et al. Risk of pneumothorax requiring pleural drainage after drainless VATS pulmonary wedge resection: a systematic review and meta-analysis. Innovations. 2022;17(1):14-24.
[8] Huang L, Kehlet H, Holbek BL, Jensen TK, Petersen RH. Efficacy and safety of omitting chest drains after video-assisted thoracoscopic surgery: a systematic review and meta-analysis. Journal of Thoracic Disease. 2021;13(2):1130.
[9] Laven IE, Franssen AJ, van Dijk DP, et al. A no-chest-drain policy after video-assisted thoracoscopic surgery wedge resection in selected patients: our 12-year experience. The Annals of Thoracic Surgery. 2023;115(4):835-43.
[10] Publication pending
[11] Internal data, Eric Lim’s group, Royal Brompton Hospital, London (unpublished)