Drainology Symposium at STS 2025

22 May 2025

Summary from symposium “Disrupting the Status Quo in Cardiac and Thoracic Perioperative Care” at the 61st STS Annual Meeting, Los Angeles, USA on January 24th, 2025.

The focus of this session was to present and discuss novel and disruptive technology and practices in caring for postoperative cardiac and thoracic patients in order to maximize the benefits of minimally invasive surgical strategies for patients.

Author: Heather L. Mason, PhD, Coufetery Comms, heathermason80@outlook.com

 

“Being a perfect surgeon is not enough. You need to be involved in the entire care of your patients from the moment in which they enter into your office, to the moment 30 days after or 90 days after when they leave it.”

With this introduction from Dr Gianluca Torregrossa the stage was set for the Symposium “Disrupting the Status Quo in Cardiac and Thoracic Perioperative Care” at the STS annual meeting. Together with Prof Stephen Cassivi, he moderated the session that challenged the status quo, showcasing disruptive technologies that are reshaping the field, discussing technologies so transformative that, in a few years, we’ll wonder how we managed without them.

Leveraging Technology to Support Robotic Thoracic Surgery

Andrew R. Brownlee, MD

Providence Cedars-Sinai Tarzana Medical Center, USA
Medical Director of Thoracic Surgery, Assistant Professor of Surgery

Addressing the Length of Stay (LOS) Challenge

Dr Brownlee discussed an intervention implemented at Cedars-Sinai aimed at improving patient care and outcomes by reducing the length of hospital stays. The focus was on the use of digital chest drains for thoracic surgery patients, allowing for earlier removal of chest tubes and safer discharges. The changes in established protocols were driven by the need to address capacity issues at the hospital, which has 1100 beds and is always full. The LOS index, a quality metric, was used to monitor and improve patient throughput.

The thoracic surgery service at Cedars-Sinai is large and busy, with seven surgeons performing around 400 anatomic resections and 1500 cases annually. The hospital’s robust data collection system provided detailed information on patient comorbidities, procedures, and expected lengths of stay. The intervention involved updating the ERAS protocol, implementing digital chest drains, and setting criteria for chest tube removal based on air leak measurements (<20 ml/min/12 hours), and drainage volumes (400cc/24 hours).

Improved Outcomes with Digital Drainage Systems

By implementing digital chest drains, Cedars-Sinai established clear criteria for early chest tube removal: air leaks of <20 ml/min for 12 hours and drainage output below 400 ml. The impact was notable:

• Mean LOS for pulmonary resections decreased by 1.5 days.

• Readmission rates dropped despite earlier discharges.

• Fewer patients required discharge with a chest tube.

These findings reinforce that digital chest drains not only expedite patient recovery but also enhance safety, countering the traditional belief that early discharge increases readmission risks.

A Cost-Effective, High-Impact Intervention

With hospital bed costs in California exceeding $4,300 per day, reducing LOS translates into substantial financial savings. The Cedars-Sinai team calculated that this single intervention saved approximately $800,000 annually. Beyond cost-effectiveness, digital drainage fosters greater efficiency, reduces nursing workload, and enhances patient experience – critical factors in today’s value-based healthcare landscape.

Conclusion: A New Standard in Post-operative Care

The transition from analog to digital chest drainage is not just an incremental improvement; it represents a paradigm shift in post-operative care. The evidence is clear – real-time, accurate data enables safer, faster patient recovery. Cedars-Sinai’s success story serves as a model for institutions seeking to optimize surgical outcomes and operational efficiency. The question is no longer if digital chest drains should be adopted, but when and how soon can they be implemented across the board.

“When you’re talking about patient care and making safe decisions, [with digital drains] you can have a safe discharge with lower readmissions and actually lower number of patients going home with a chest tube”

 

Leading Change in Perioperative Cardiac Surgery Care to Improve Patient Results

Gloria Färber MD

Saarland University Medical Center, Homburg, Germany
Professor and Chair, Department of Cardiac Surgery

Optimizing the Entire Patient Journey

Professor Färber discussed strategies to improve patient outcomes after cardiac surgery, emphasizing the importance of optimizing the entire perioperative process. She highlighted the need for proper risk assessment, patient selection, and the timing of surgical procedures. Classical risk scores like STS and EuroScore, along with tools to assess frailty and organ dysfunction, are essential for predicting and mitigating risks.

Preoperative Risk Mitigation

Preoperative optimization, including managing diabetes and nutrition status, can reduce the risk of complications such as organ dysfunction, wound infection, and bleeding. Minimally invasive surgery is recommended to reduce surgical trauma, improve visualization, and enhance work ergonomics.

Digital Drainage Systems Reduce Postoperative Complications

Techniques such as endoscopy and digital drainage systems are suggested to improve safety and patient outcomes.

Intraoperative strategies include balancing pathology with the procedure, keeping cardio bypass time and cross-clamp time as short as possible, minimizing surgical trauma, and using advanced technologies such as minimally invasive circuits and special coatings for cardiopulmonary bypass. Postoperative care focuses on managing complications, which occur in up to 67% of cases¹. Around 36% of chest drains clog, and the majority clog below the skin and remain unseen². This clogging is the leading cause of retained blood, which is the leading trigger of postoperative atrial fibrillation (POAF). POAF increases the risk of stroke, heart failure, and kidney failure and leads to higher rates of readmission³ and mortality^4,5. Strategies to prevent POAF include posterior left pericardiotomy⁶ and the use of active clearance systems for chest tubes^7,8.

Digital Drainage Systems Allow Early Mobilization

Prof. Färber also emphasized the importance of early mobilization and extubation to improve patient outcomes and recommended digital drainage systems for qualitative and quantitative monitoring⁹ and control of postoperative bleeding.

“Moving is improving, and patient outcomes can be improved if the patient is mobilized early. Old [drainage] systems that have suction that is connected to the wall immobilize patients.”

References

1. Pahwa S, Bernabei A, Schaff H, et al. Impact of postoperative complications after cardiac surgery on long-term survival. J Card Surg. Jun 2021;36(6):2045-2052. doi:10.1111/jocs.15471
2. Karimov JH, Gillinov AM, Schenck L, et al. Incidence of chest tube clogging after cardiac surgery: a single-centre prospective observational study. Eur J Cardiothorac Surg. Dec 2013;44(6):1029-36. doi:10.1093/ejcts/ezt140
3. Balzer F, von Heymann C, Boyle EM, Wernecke KD, Grubitzsch H, Sander M. Impact of retained blood requiring reintervention on outcomes after cardiac surgery. J Thorac Cardiovasc Surg. Aug 2016;152(2):595-601.e4. doi:10.1016/j.jtcvs.2016.03.086
4. Gaudino M, Di Franco A, Rong LQ, Piccini J, Mack M. Postoperative atrial fibrillation: from mechanisms to treatment. Eur Heart J. Mar 21 2023;44(12):1020-1039. doi:10.1093/eurheartj/ehad019
5. Haneya A, Diez C, Kolat P, et al. Re-exploration for bleeding or tamponade after cardiac surgery: impact of timing and indication on outcome. Thorac Cardiovasc Surg. Feb 2015;63(1):51-7. doi:10.1055/s-0034-1390154
6. Gaudino M, Sanna T, Ballman KV, et al. Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial. Lancet. Dec 4 2021;398(10316):2075-2083. doi:10.1016/s0140-6736(21)02490-9
7. Sirch J, Ledwon M, Püski T, Boyle EM, Pfeiffer S, Fischlein T. Active clearance of chest drainage catheters reduces retained blood. J Thorac Cardiovasc Surg. Mar 2016;151(3):832-838.e2. doi:10.1016/j.jtcvs.2015.10.015
8. St-Onge S, Chauvette V, Hamad R, et al. Active clearance vs conventional management of chest tubes after cardiac surgery: a randomized controlled study. J Cardiothorac Surg. Mar 23 2021;16(1):44. doi:10.1186/s13019-021-01414-0
9. Pompili C, Papagiannopoulos K, Sihoe A, Vachlas K, Maxfield MW, Lim HC, Brunelli A. Multicenter international randomized comparison of objective and subjective outcomes between electronic and traditional chest drainage systems. Ann Thorac Surg. Aug 2014;98(2):490-6; discussion 496-7. doi:10.1016/j.athoracsur.2014.03.043

 

Optimizing Perioperative Care to Maximize Benefits of Minimally Invasive Thoracic Surgery

Bernard J. Park, MD 

Memorial Sloan Kettering Cancer Center, New York, USA
Professor of Clinical Cardiothoracic Surgery at Well Cornell College

Minimally Invasive Techniques (MIS) and ERAS Protocols have revolutionized Thoracic Surgery

Professor Park highlighted the evolution of Video-Assisted Thoracoscopic Surgery (VATS) and robotic techniques, noting that the first series of VATS lobectomies were performed in the 1990s. Now, the majority of anatomical resections are done minimally invasively and robotically, reducing pain and improving the quality of life for patients¹, while reducing costs². However, they emphasized the importance of Enhanced Recovery After Surgery (ERAS) protocols, which aim to speed up recovery, reduce hospital stays, and enhance patient satisfaction through standardized, evidence-based care. Key components of ERAS are multi‑disciplinary and include preoperative patient education, smoking cessation, exercise, and clear communication about discharge plans. Also, perioperative strategies involve antibiotic therapy, prevention of thromboembolism, and anesthesia management, focusing on regional blocks and avoiding epidural anesthesia. Postoperative care highlights early ambulation, chest tube management, and preventing complications such as atrial fibrillation (POAF)³. Several studies have shown how the combination of MIS and ERAS has reduced costs⁴, drain duration, length of hospital stay^5,6, complications, and readmission rates⁵.

Digital Drainage Systems allow Continuous Recording

Digital drains for chest tube management allow a continuous recording of airflow and the ability to maintain stable negative intrathoracic pressure (which can be ultra-low [-2 to -3 cmH2O]). This qualitative data enables informed decisions on drain removal and reduces variability in care. The portability of the system allows for early mobilization, further reducing complication rates. Thus, digital drains have an advantage over traditional drains, showing a reduction in the occurrence of air leaks, chest tube duration, and length of hospital stay⁷, while improving patient outcomes.

Overall, Professor Park highlighted the transformative impact of minimally invasive techniques, ERAS protocols, and digital drainage systems in thoracic surgery, leading to better patient outcomes, reduced costs, and improved efficiency of care.

“The innovation of regulated digital pleural drainage with liberalized volume criteria has really been associated with improved outcomes and shorter hospital stays, no question about it.”

 References

1. Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. Jun 2016;17(6):836-844. doi:10.1016/s1470-2045(16)00173-x
2. Brunelli A, Chapman K, Pompili C, et al. Ninety-day hospital costs associated with prolonged air leak following lung resection. Article. Interactive Cardiovascular and Thoracic Surgery. 2020;31(4):507-512. doi:10.1093/icvts/ivaa140
3. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. Jan 1 2019;55(1):91-115. doi:10.1093/ejcts/ezy301
4. Zehr KJ, Dawson PB, Yang SC, Heitmiller RF. Standardized clinical care pathways for major thoracic cases reduce hospital costs. Ann Thorac Surg. Sep 1998;66(3):914-9. doi:10.1016/s0003-4975(98)00662-6
5. Hubert J, Bourdages-Pageau E, Garneau CAP, Labbé C, Ugalde PA. Enhanced recovery pathways in thoracic surgery: The Quebec experience. Article. Journal of Thoracic Disease. 2018;10:S583-S590. doi:10.21037/jtd.2018.01.156
6. Maruyama R, Miyake T, Kojo M, et al. Establishment of a clinical pathway as an effective tool to reduce hospitalization and charges after video-assisted thoracoscopic pulmonary resection. Jpn J Thorac Cardiovasc Surg. Sep 2006;54(9):387-90. doi:10.1007/s11748-006-0014-5
7. Zhou J, Lyu M, Chen N, et al. Digital chest drainage is better than traditional chest drainage following pulmonary surgery: a meta-analysis. Eur J Cardiothorac Surg. Oct 1 2018;54(4):635-643. doi:10.1093/ejcts/ezy141

 

Impact of Re-exploration for Bleeding. New Drainology Paradigms in MICS

Marc Ruel, MD, MPH

UCSF Department of Surgery
Professor and Chief, Division of Adult Cardiothoracic Surgery

Executive Summary

Professor Marc Ruel discussed the high risks of re-exploration for bleeding in cardiac surgery and the importance of prevention through effective drainage. A study of 16,793 patients showed a 12% mortality rate for those requiring re-exploration, compared to 2.8% for those who did not. Case studies highlighted the dangers of failed drainage, emphasizing the need for reliable systems. Balancing patient comfort with effective drainage is crucial, as multiple drains can be uncomfortable but necessary. Digital drainage systems can help prevent complications, reducing the need for re-exploration and improving patient outcomes by ensuring safer, more efficient post-surgical recovery.

“Drains matter, and there’s a catch-22 between the drain that you want to put in and the comfort of the patient.”

 

Protocols to Facilitate Early Extubation after Aortic Surgery

Mark D. Peterson, MD, PhD

NYU Langone Health
System Director of Aortic Surgery

Executive Summary

Dr Mark Petersen showed how early extubation in the operating room is part of a protocol aimed at getting patients out of bed within three hours and walking within 4.5 hours post-surgery. Studies confirm its safety and benefits for respiratory and neurological outcomes when proper protocols are followed. Key strategies include preoperative optimization, intraoperative opioid-sparing techniques, and strict postoperative pain control. While early extubation enhances recovery and reduces complications, patient selection is crucial, as some may not qualify due to comorbidities or surgical complexities. A tailored approach and multidisciplinary collaboration are essential for successful implementation and improved patient outcomes.

«How can we improve the outcomes and get patients home sooner? A big part of that protocol is actually extubating patients in the operating room.”

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