Drainology Symposium at ISMICS 2026
Summary from symposium “Chest Drain Management in Cardiothoracic Surgery: Innovation, Outcomes, and Cost-Benefit” at the ISMICS Annual Meeting in Miami, Florida on 12 June 2026
The ISMICS symposium addressed chest drain management as an important component of postoperative care in thoracic and cardiac surgery. Discussions highlighted the limitations of traditional, largely subjective assessment methods and the potential benefits of more objective, quantitative approaches to monitoring air leak and fluid drainage. Improved measurement may support more consistent decision‑making, facilitate earlier mobilization, and potentially contribute to optimized timing of chest tube removal. In cardiac surgery, immediately effective drainage remains relevant for preventing complications such as retained blood syndrome. While digital drainage systems may introduce upfront costs and require workflow adaptation, their integration into structured perioperative pathways may help improve consistency and efficiency of care across multidisciplinary teams.
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Key messages
- Digital drainage systems transform postoperative care: Objective, continuous measurements replace subjective assessments, enabling standardized chest tube management, improved team communication, and more consistent decision‑making.
- Clinical and economic value are closely linked: Reduced complications (e.g., retained blood, prolonged air leak), shorter drainage duration, and earlier discharge translate into meaningful cost savings and improved hospital throughput.
- Integration into ERAS is key to impact: When embedded within structured ERAS pathways, digital systems support early mobilization, safer earlier tube removal, and data‑driven, team-based care tailored to institutional needs.
Introduction
Chair: Prof. Kevin Lobdell – Perfect Care, Charlotte, USA
Prof. Kevin Lobdell framed the symposium as an opportunity to rethink Drainology as a scientifically grounded and increasingly important component of perioperative care. He emphasized that chest drain management extends beyond simple mechanical considerations, encompassing broader physiological processes such as inflammation, coagulation, and healing. Reflecting on decades of surgical practice, he noted that these aspects have historically been underappreciated but are now being better understood through emerging data. The session aimed to address key practical questions on number and positioning of chest tubes, management, and criteria for removal, while highlighting the importance of translating best practices into reliable, scalable clinical pathways. Ultimately, he encouraged participants to adopt a more thoughtful, standardized, and evidence-informed approach to chest drainage, whether within ERAS frameworks or broader quality improvement initiatives.
Optimizing Chest Drain Management in Minimally Invasive Thoracic Surgery
Jobelle Joyce Anne R. Baldonado, MD – Moffitt Cancer Center, Tampa, USA
Dr. Jobelle Baldonado addressed a critical yet often underappreciated determinant of postoperative outcomes in thoracic surgery: chest drain management. Despite major advances in minimally invasive techniques (such as VATS, robotic surgery, and enhanced recovery after surgery (ERAS) protocols) postoperative chest tube management remains largely subjective and continues to influence key outcomes: pain management, mobilization, length of stay, and patient satisfaction.
Dr. Baldonado emphasized that prolonged air leak (PAL) remains one of the most common complications following pulmonary resection, particularly given the increasing complexity of modern patient populations, including individuals with COPD, prior surgeries, and those undergoing sublobar resections. Notably, even in highly refined minimally invasive procedures, the duration of hospitalization is often dictated less by the surgical technique itself and more by how chest tubes are managed postoperatively. This underscores the need to apply the same precision and standardization to postoperative care as is now routine in the operating room.
A central limitation of traditional analog drainage systems is their reliance on subjective interpretation. Terms such as “small, intermittent leak” or “bubbles only on cough” are inherently variable and prone to interobserver inconsistency. Dr. Baldonado highlighted that even experienced clinicians may arrive at different management decisions when assessing the same analog system. This variability impacts not only clinical decision-making but also team communication and workflow efficiency.
Digital drainage systems represent a paradigm shift from descriptive to data‑driven care. By providing continuous, objective measurements of air leak (expressed in ml/min), along with trend analysis over time, these systems facilitate reproducible and protocolized decision-making. They also offer more stable intrapleural pressure regulation and are portable, facilitating early mobilization, a key pillar of ERAS pathways. Importantly, digital systems allow all members of the care team to “speak the same language,” reducing ambiguity and enhancing coordination.
Dr. Baldonado presented compelling evidence supporting the use of digital systems. Meta-analyses encompassing thousands of patients have consistently demonstrated reductions in prolonged air leak, chest tube duration, and length of hospital stay.[1],[2] A recent multicenter randomized controlled trial[3] further confirmed that digital drainage enables earlier chest tube removal and discharge (typically by approximately one day) without compromising safety. While individual randomized trials have shown some variability[4], the overall body of evidence strongly supports the clinical benefit of digital systems.
Beyond traditional outcome measures, additional advantages include reduced interobserver variability in decision-making[5], improved patient satisfaction due to increased mobility[6], and enhanced confidence among clinicians in determining readiness for chest tube removal. Dr. Baldonado also shared institutional experience from Moffitt Cancer Center, where adoption of digital drainage led to measurable reductions in chest tube duration and hospital stay, supporting broader implementation following internal evaluation.
Importantly, she acknowledged that implementation requires consideration of cost, institutional workflows, and protocol standardization. However, even in settings where length of stay differences are modest, the gains in objectivity, consistency, and team communication are viewed as highly valuable.
In conclusion, Dr. Baldonado argued that chest drain management remains a critical bottleneck in postoperative recovery after minimally invasive thoracic surgery. Digital drainage systems offer a practical and evidence-based solution by transforming subjective assessments into objective, reproducible data, thereby enabling standardized, protocol-driven care. For thoracic surgeons committed to precision surgery and ERAS principles, adoption of digital drainage represents a logical and impactful step toward optimizing patient recovery.
Dr Baldonado summarized: “We have spent decades perfecting minimally invasive thoracic surgery. Well, digital drainage may be one of the simplest ways to perfect recovery.”
Evaluation of the Clinical and Economic Impact of Digital Drainage Systems Compared to Conventional Methods in Cardiac Surgery
Priv.-Doz. Dr. med. Johannes Petersen, MHBA – University Heart and Vascular Center Hamburg (UKE), Germany
Dr. Johannes Petersen provided a comprehensive and clinically grounded evaluation of digital versus conventional (analog) chest drainage systems in cardiac surgery, with particular emphasis on their economic implications in the setting of increasing global healthcare cost pressures. His analysis placed chest tube management within the broader framework of enhanced recovery after surgery (ERAS), highlighting its central role in optimizing both clinical outcomes and resource utilization.
Dr. Petersen began by underscoring that meaningful cost reduction in surgical care is best achieved through three parallel strategies: minimizing complications, eliminating unnecessary processes, and shortening hospital length of stay. Within this context, he presented findings from the randomized INCREASE study[7], which demonstrated that ERAS protocols in cardiac surgery significantly reduce ICU and overall hospital stay while maintaining equivalent postoperative functional outcomes. Economic analysis from this cohort[8] revealed cost savings of up to €1,900 per patient, primarily driven by reduced ICU and ward utilization, despite modest increases in physiotherapy costs. Importantly, earlier discharge also increases institutional throughput, allowing treatment of a greater number of patients within existing capacity.
A central clinical focus of the talk was retained blood syndrome (RBS), a well-recognized but often underappreciated contributor to postoperative morbidity. Retained blood promotes inflammatory cascades and is associated with atrial fibrillation, pericardial effusions, deep sternal wound infections, renal dysfunction, and increased mortality.[9],[10] Consequently, maintenance of effective chest drainage and tube patency is a critical element of ERAS pathways[11]. Comparative data suggest that digital drainage systems[12], alongside active clearance technologies, reduce rates of retained blood, postoperative atrial fibrillation, re-exploration for bleeding, and ICU length of stay.
Dr. Petersen then addressed the economic dimension in greater depth, drawing on cost‑effectiveness models developed by the UK National Institute for Health and Care Excellence (NICE)[13] and the York Health Economics Consortium.[14] These analyses demonstrate that although digital drainage systems incur higher upfront costs, they generate downstream savings through shorter hospital stays, reduced staff monitoring time, fewer imaging studies, and lower rates of complications and reinterventions. Estimated savings reach approximately €850 per patient and up to €1 million annually for a medium‑volume cardiac program, with even greater savings in combined cardiac–thoracic units. Additionally, improved efficiency translates into increased bed availability and procedural throughput—factors highly relevant to hospital administrators.
Complementing these models, Dr. Petersen presented real-world data from Germany. A randomized comparison of digital and analog systems demonstrated reductions in chest X-rays and re-thoracotomies in the digital group, although differences in ICU and hospital length of stay were not statistically significant.[15] Subsequent cost analysis using institutional billing data confirmed lower direct costs related to these complications in patients managed with digital systems.[16] He also highlighted a frequently overlooked aspect: reduced material waste with digital devices, reflecting broader sustainability benefits.
In conclusion, Dr. Petersen argued that digital drainage systems represent a clinically meaningful and economically sound innovation in cardiac surgery. While initial costs may be higher, the cumulative benefits (reduced complications, improved efficiency, and enhanced resource utilization) support their integration into modern ERAS pathways. Nevertheless, he emphasized that cost-effectiveness remains context-dependent and called for further prospective, ideally randomized, studies to refine the economic evidence base.
Integrating Digital Drainage Systems into ERAS Cardiac Protocols
Sameer Hirji, MD, MPH – Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
Dr. Sameer Hirji addressed the integration of digital chest drainage systems into Enhanced Recovery After Surgery (ERAS) pathways in cardiac surgery, framing digital drainage as a key enabler of standardized, data‑driven perioperative care. Drawing on more than 15 years of ERAS experience and large clinical datasets, he highlighted how incremental, “micro-improvements”, such as optimized chest tube management, can significantly influence recovery trajectories, complications, and resource utilization.[17]
Dr. Hirji began by reinforcing the central pillars of ERAS in cardiac surgery: early mobilization, optimized pain control, goal‑directed fluid therapy, and standardized drain management. While ERAS pathways have demonstrated clear benefits, including reductions in length of stay, opioid use, and overall cost, traditional chest drainage systems remain a weak link in this framework. Analog systems are limited by subjective interpretation, inconsistent drainage performance, and variability in timing of chest tube removal. These factors contribute to delayed recovery and increased complication risk.
A key clinical concern is retained blood syndrome (RBS), which arises from inadequate drainage and leads to a cascade of inflammation, fibrosis, and impaired cardiopulmonary function[18]. This condition is associated with increased rates of atrial fibrillation, re-exploration, prolonged hospitalization, and mortality.[19] Dr. Hirji emphasized that optimizing drainage is therefore not simply a technical issue but a critical determinant of postoperative outcomes.
Digital drainage systems offer a structured solution by enabling continuous, objective monitoring of air leak and fluid output. These systems provide real-time quantitative data, and display trends over time, facilitating more informed and timely clinical decision-making. Their portability and lightweight design support early ambulation, one of the most important drivers of recovery within ERAS protocols.
Importantly, digital systems help standardize care. Rather than relying on subjective bedside assessments or fixed time-based protocols (e.g., chest tube removal on postoperative day two or three), clinicians can use objective thresholds tailored to patient-specific trends. This approach allows for earlier and safer chest tube removal, including potential removal on postoperative day one in selected patients.
Dr. Hirji also reviewed emerging evidence supporting digital drainage. Comparative studies demonstrate reductions in postoperative atrial fibrillation, re-exploration rates, and retained blood when digital systems or active tube clearance technologies are employed.12 These benefits appear particularly pronounced in the early postoperative period, when effective drainage is most critical.18
Beyond clinical outcomes, digital drainage enhances team communication and workflow efficiency. By providing standardized data, it empowers advanced practice providers (APPs), nursing staff, and ICU teams to participate in consistent, protocol-driven care. This reduces ambiguity, decreases dependence on subjective judgments, and supports decentralized decision-making in high-volume or resource-constrained settings.[20],[21]
Looking ahead, Dr. Hirji emphasized the importance of integrating digital drainage into structured ERAS workflows.[22] He outlined a practical framework in which intraoperative baseline assessment is followed by continuous postoperative monitoring, with decisions guided by predefined thresholds and individualized trends. He also highlighted the potential for further innovation, including integration with predictive analytics and decision-support tools.
In conclusion, Dr. Hirji argued that digital drainage systems represent a critical advancement in the evolution of ERAS cardiac protocols. By transforming subjective assessments into objective, actionable data, they enable standardized, team-based, and patient-centered care. Their adoption offers the potential to improve outcomes, accelerate recovery, and optimize resource utilization, ultimately advancing the quality and efficiency of modern cardiac surgical practice.
References
[1] Wang H, Hu W, Ma L, et al. Digital chest drainage system versus traditional chest drainage system after pulmonary resection: a systematic review and meta-analysis. Journal of cardiothoracic surgery. 2019;14(1):13.
[2] Zhou L, Guo K, Shang X, et al. Advantages of applying digital chest drainage system for postoperative management of patients following pulmonary resection: a systematic review and meta-analysis of 12 randomized controlled trials. General Thoracic and Cardiovascular Surgery. 2023;71(1):1-1.
[3] Comacchio GM, Marulli G, Mendogni P, et al. Comparison between electronic and traditional chest drainage systems: a multicenter randomized study. The Annals of Thoracic Surgery. 2023;116(1):104-9.
[4] Aldaghlawi F, Kurman JS, Lilly JA, et al. A systematic review of digital vs analog drainage for air leak after surgical resection or spontaneous pneumothorax. Chest. 2020;157(5):1346-53.
[5] Varela G, Jiménez MF, Novoa NM, et al. Postoperative chest tube management: measuring air leak using an electronic device decreases variability in the clinical practice. European Journal of Cardio-Thoracic Surgery. 2009;35(1):28-31.
[6] Pompili C, Detterbeck F, Papagiannopoulos K, et al. Multicenter international randomized comparison of objective and subjective outcomes between electronic and traditional chest drainage systems. The Annals of Thoracic Surgery. 2014;98(2):490-7.
[7] Petersen J, Stock S, Brettschneider C, et al. Interdisciplinary and Cross-Sectoral Perioperative Care Model in Cardiac Surgery: ERAS Implementation in the Setting of Minimally Invasive Heart Valve Surgery (INCREASE)—Results of a Randomized Controlled Trial. European Journal of Cardio-Thoracic Surgery. 2026;68(2):ezag061.
[8] Petersen J, Kloth B, Konertz J, et al. Economic impact of enhanced recovery after surgery protocol in minimally invasive cardiac surgery. BMC Health Services Research. 2021;21(1):254.
[9] Kramer PA, Chacko BK, Ravi S, et al. Hemoglobin-associated oxidative stress in the pericardial compartment of postoperative cardiac surgery patients. Laboratory investigation. 2015;95(2):132-41.
[10] Balzer F, von Heymann C, Boyle EM, et al. Impact of retained blood requiring reintervention on outcomes after cardiac surgery. The Journal of thoracic and cardiovascular surgery. 2016;152(2):595-601.
[11] Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations. JAMA surgery. 2019;154(8):755-66.
[12] Kalisnik JM, Zujs V, Zibert J, et al. The impact of a chest drainage system on retained blood-associated complications after cardiac surgery. European Journal of Cardio-Thoracic Surgery. 2025;67(Supplement_1):i9-17.
[13] Evans JM, Ray A, Dale M, et al. Thopaz+ portable digital system for managing chest drains: a NICE medical technology guidance. Applied health economics and health policy. 2019;17(3):285-94.
[14] York Value calculator; YHEC Medela Thopaz+ Chest Drain Model – FINAL – 31.07.25.xlsm. Data on file Medela.
[15] Van Linden A, Hecker F, Courvoisier DS, et al. Reduction of drainage-associated complications in cardiac surgery with a digital drainage system: a randomized controlled trial. Journal of thoracic disease. 2019;11(12):5177.
[16] Publication pending
[17] Zakhary W, Forner AF, Holzhey D, et al. From fast track to enhanced recovery after Cardiac surgery: 15 years of experience with the Leipzig concept in a specialized post-anesthesia care unit. Journal of Clinical Anesthesia. 2026;110:112137.
[18] Niemann B, Grieshaber P. Retained blood syndrome after cardiac surgery. European Journal of Cardio-Thoracic Surgery. 2025;67(Supplement_1):i3-8.
[19] Al Saqer LA, Fox LA, Castells AM, et al. Retained Blood Syndrome Is Associated With High Mortality and Morbidity After Cardiac Surgery. Journal of Cardiac Surgery. 2025(1):5567661.
[20] de Araújo PH, de Macedo JP, D’ambrosio PD, et al. Digital versus conventional chest drainage systems in resource-limited setting: a comparative analysis. Interdisciplinary CardioVascular and Thoracic Surgery. 2025;40(11):ivaf175.
[21] Palleiko BA, Singh A, Strader C, et al. Clinical outcomes and staff satisfaction after adoption of digital chest drainage system for minimally invasive lung resections. Journal of Thoracic Disease. 2024;16(5):2963-74.
[22] Smith A, Patel A, Mansoor M, et al. Following cardiac surgery, do digital drainage systems versus underwater seal impact postoperative outcomes?. Interdisciplinary CardioVascular and Thoracic Surgery. 2025;40(5):ivaf053.