Chest tube provocative clamping in patients having moderate or intense air leaks after lung resection to accelerate recovery.

Background: Postoperative air leak is the most common complication after pulmonary resection. "Provocative clamping" was first described in 1992 in the context of guiding chest tube removal despite persistent air leak. However, early provocative clamping after pulmonary resection has not been evaluated. This study aimed to evaluate whether provocative clamping leads to severe complications following lung cancer surgery in patients with air leaks, particularly in the context of early chest tube removal. Methods: This retrospective single-center study included patients who underwent pulmonary resection between September 2022 and October 2023. Air leak on postoperative day 1 or 2 was classified as grade 0-1 (low) or grade 2-4 (high). Low air leak allowed for immediate chest tube removal if there was no apparent pneumothorax or if pleural effusion was <200 mL. Meanwhile, high air leak necessitated chest tube clamping. Radiography was performed 24 hours after (with clamping) if there was no increase in subcutaneous emphysema or symptoms. The chest tube could then be removed if there was no increased pneumothorax. Results: This study included 74 patients (53 had low leak, and 21 had high leak). The mean chest tube insertion durations were 2.2 days for low leak (range, 1-5 days) and 3.2 days for high leak (range, 2-7 days). The hospital lengths of stay were 3.7 days for low leak (range, 1-6 days) and 4.5 days for high leak (range, 3-8 days). One patient (1.3%) had a prolonged air leak (>5 days). No tension pneumothorax occurred during hospitalization or after discharge. One patient in the high leak group developed hydropneumothorax at 3 weeks after discharge, in whom the chest tube was reinserted. Conclusions: Use of provocative clamping immediately after pulmonary resection appears to be safe for high-grade air leak patients.