{"paper_id":"3f988fcb-ac62-4e6f-904e-6724f91df114","body_text":"Digital chest drainage versus traditional chest drainage in children after pulmonary resection: A systematic review and meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Digital chest drainage versus traditional chest drainage in children after pulmonary resection: A systematic review and meta-analysis Rakesh Ahmed, Anna Durr, David Healy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5422732/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Pulmonary resection is commonly performed as curative treatment for congenital thoracic malformations. There is a plethora of high-quality evidence showing improved outcomes with digital chest drainage systems compared to traditional water-seal systems in adults. By contrast, there is a relative paucity of research with children and therefore much uncertainty in post-operative chest drain management in paediatrics. Methods A systematic review and meta-analysis was conducted to assess the effect of digital chest drainage systems in paediatric patients after pulmonary resection. Data sources included PubMed, Cochrane Central Register of Controlled Trials, EMBASE, and SCOPUS, with information from 1 January 2007 to 20 July 2024. The qualitative analysis included three observational studies. The quantitative analysis included 74 patients across two observational studies that compared digital and traditional chest drainage systems. A fixed effects model was used to produce a pooled estimate for a meta-analysis of means if the studies were homogenous, otherwise a random effects model was used. Results The meta-analysis showed a statistically significant reduction in hospital length of stay (SMD − 0.63 days, [95% CI: -1.1;-0.16, p = < 0.01]) and number of chest x-rays performed (SMD − 1.2 x-rays, [95% CI: -1.7;-0.7, p = < 0.0001]) in the digital group compared to the traditional group. Although a reduction in chest tube duration was seen in the digital group, this was not statistically significant (SMD − 2.2 days, [95% CI: -14.5;10.07, p = 0.2622]). There were no significant differences in development of pulmonary complications between the digital and traditional drainage groups (p = 0.8392). Conclusion The use of digital chest drainage systems demonstrated a shortened hospital length of stay and quantity of chest x-rays performed in paediatric patients following pulmonary resection. The overall certainty of these findings is limited by the low quality of the available evidence. Lung cancer pulmonary resection digital chest drain paediatrics Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Pulmonary resection including wedge resection, segmentectomy, and lobectomy are commonly performed procedures in paediatric thoracic surgery ( 1 ). This is most often used as curative treatment for congenital disorders such as congenital pulmonary airway malformations, bronchopulmonary sequestration, or congenital lobar emphysema. There are no clear guidelines in the management of congenital lung lesions and practice can vary considerably across centres ( 2 ). Many experts favour early elective resection of lesions rather than delay and develop complications such as malignancy or recurrent infection. Surgery is often completed in infancy to allow compensatory growth of remaining lung tissue and research has shown that this tends to have little to no effect on a patient’s pulmonary function in adulthood ( 3 ). The number of pulmonary resections indicated in children are increasing with higher incidence and diagnosis of these congenital disorders secondary to higher quality and improved access to imaging ( 4 ). In concert with this increase, the use of digital chest drains such as the Thopaz Chest Drain System, Medela, has risen rapidly since their introduction in 2007 ( 5 , 6 ). These systems offer an electronic recording of the volume of air leak which would otherwise be measured subjectively by the clinician by the presence or absence of air bubbles in the traditional water seal drainage system. The presence of air leak is clinically valuable information in the decision for drain removal, which is otherwise a barrier to discharge. The argument for the use of electronic drains is strengthened when considering that inter-observer variability in identifying air leaks is a well-recognised phenomenon, even among experienced clinicians ( 7 ). An objective reading confirming the absence of an air leak may expedite drain removal and this is thought to be the primary factor that can result in a shortened length of stay for patients compared to their peers ( 6 , 8 ). Many randomised controlled trials have been conducted in the adult population demonstrating advantages of digital drainage systems over their traditional counterparts following pulmonary resection ( 6 ). Digital chest drainage has been associated with a reduced drainage duration, reduced length of stay, and reduced cost when compared to traditional chest drainage ( 7 ). They also allow the continuous recording of air leakage to better inform decision making in chest drain management compared to the snapshot that clinicians would normally see at the bedside with traditional drainage. The large evidence base for these findings, particularly that of improved patient satisfaction, outcomes, and cost provides sound reasoning to expand the usage of digital drainage systems globally ( 7 ). By contrast to the adult population, there is a relative paucity of information in children, both on digital chest drainage and in post-operative chest drain management as a whole. Considering the success found in adults, it would be reasonable to believe that digital chest drainage systems would lead to similar improvements for children. This provided the rationale for our systematic review, and to our knowledge, this is the first meta-analysis of this topic. The aim of this systematic review was to assess the post-operative outcomes in a paediatric population undergoing pulmonary resection who were managed with digital chest drains post-operatively. Randomised controlled studies or observational studies that were included and identified to have a traditional drainage control group were to be included for a meta-analysis to assess post-operative outcomes such as hospital length of stay, number of chest x-rays performed, and post-operative pulmonary complications. Methods Review protocol and search strategy This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines ( 9 ). A protocol was designed and registered at PROSPERO (574095). All authors participated in the development of the search strategy, which was developed in conjunction with a research librarian from Children’s Health Ireland, Crumlin. The structured search strategy included natural language and Medical Subject Headings, grouped into three concepts: electronic chest drain, thoracic surgery, and paediatrics. Structured searches (Supplementary Table 1) were conducted in PubMed, Cochrane Central Register of Controlled Trials (Cochrane CENTRAL), EMBASE, and SCOPUS for studies from the 1st of January 2008 up to 20th of July 2024. These dates were chosen as electronic chest drains were introduced into adult clinical practice in 2007 ( 10 ). There were no language restrictions. Study selection and data extraction Studies meeting the below PICO criteria were included: Population: All studies involving patients aged less than eighteen years old who had undergone lung resection surgery (wedge resection, segmentectomy, lobectomy, and pneumonectomy) were included. Studies with patients over eighteen years old were excluded. Intervention: Patients who had electronic chest drainage systems (Thopaz, DigiVent, etc.) placed during their surgery until they were removed post-operatively. Outcomes: Primary outcomes were time to chest drain removal (days) and hospital length of stay (days). Studies that did not report these were excluded. Secondary: Number of chest x-rays performed, duration of air leak (days), rate of prolonged air leaks (days), hospital readmission, and severe complications (Clavien-Dindo ≥ 3). Study design: randomised controlled trials, quasi-experimental studies, and observational studies were included. Title, abstract, and full-text screening were performed independently by two authors using the COVIDENCE online software with conflicts settled by a third author. Once the relevant studies were included, data extraction was performed independently by two reviewers using a data extraction template based on our selected outcomes. Risk of bias assessment Risk of bias was assessed for all studies included. For observational studies, the Cochrane Collaboration’s ROBINS-I tool was used ( 11 ). This is a domain based critical evaluation tool which considers bias because of selection, confounding, classification, deviations from intended interventions, missing outcome data, and in measurement of the outcome and selective reporting. If all questions were considered to have low risk of bias, the paper was considered to have low risk of bias overall. If one or more domains were considered to have moderate risk of bias, the paper was considered to have moderate risk of bias overall. If one or more domains were considered to have serious risk of bias, the paper was considered to have serious risk of bias overall. If one or more domains were considered to have critical risk of bias or multiple domains were considered to have serious risk of bias, the study was considered to have critical risk of bias. Two authors conducted the risk of bias for all studies. Disagreements were settled by a third author. Synthesis of results Meta-analysis was performed on outcomes in which two or more observational studies presented comparable data. For the meta-analysis of standardised mean differences (SMD) and the meta-analysis of proportions, a common effects model was used if the heterogeneity was 0%, and a random effects model used if the heterogeneity was greater than this to create a points estimate summary of the analysed studies. Heterogeneity was assessed with the I 2 statistic with homogeneity defined as I 2 of 0%, low heterogeneity defined as an I 2 of less than 50%, moderate heterogeneity defined as an I 2 of 50–70%, and severe heterogeneity by an I 2 over 70%. The chi-squared test was used to test for homogeneity, with a p-value of < 0.1 being significant. Results were presented as means with standard mean difference (SMD) with 95% CI for continuous outcomes and as proportions with odds ratio (OR) with 95% confidence intervals (CI) for dichotomous outcomes. All analyses were conducted with the ‘meta’ packages using R software (R version 4.4.1). Results A total of 162 articles were identified with 7 duplicates removed by the software (Fig. 1 ). A total of 155 titles and abstracts were screened and a total of 6 full texts were reviewed. Of the texts reviewed, one was excluded because of wrong study type, one was excluded because of wrong study population, and one was excluded because of duplicate publication. In total 3 studies were included, with no randomised controlled trials and three observational studies. The characteristics of each study is summarised (Table 1). Two of these studies had historical controls whereas one study had no control. Descriptive characteristics of the included studies Table 1 shows the study details of the three included observational studies published in 2016, 2019, and 2023 including population and outcomes reported. The trials evaluated 85 patients in total, with 47 patients allocated to intervention groups and 38 patients retrieved from historical control groups. The average age of participants per study ranged from 18 months to 10.7 years old. The indication for drain removal varied between studies, generally defined as an air leak of less than 10ml/min for 6 and 24 hours with a fully expanded lung on chest x-ray. Surgeries performed across studies included segmentectomy and/or lobectomy. The data for each of these distinct surgeries were reported as one group in each study. Risk of bias assessment Out of the three studies, we considered one to be at critical risk of bias and two to be at moderate risk of bias overall (Fig. 2 , 3 ). Costa et al was considered to be at critical risk of bias due to confounding and reporting bias. Pérez et al was considered to be at moderate risk of bias because of confounding, classification of intervention, and reporting bias. Frediano et al was considered to be at moderate risk of bias because of confounding, selection, and reporting bias. Confounding bias was primarily related to weak historical control groups or no control group at all. Duration of chest drainage Duration of drainage in days post-operatively until drain removal was reported in two studies against controls (n = 74). A random effects model is used for the meta-analysis with Knapp-Hartung adjustments because of the small number of studies included. The data showed no statistically significant difference between the digital chest drainage group and the traditional chest drainage group (SMD − 2.2 days, [95% CI: -14.5;10.07, p = 0.2622]) (Fig. 4 ). There was severe heterogeneity across the studies (I 2 = 89.7%). Hospital length of stay Length of hospital stay in days post-operatively was reported in two studies against controls (n = 74). A common effects model is used for the meta-analysis. The data showed a statistically significant difference between the digital chest drainage group and the traditional chest drainage group (SMD − 0.63 days, [95% CI: -1.1;-0.16, p = < 0.01]) (Fig. 5 ). There was low heterogeneity across the studies (I 2 = 0%). Number of chest x-rays performed Number of chest x-rays performed before drain removal was reported in two studies (n = 74). A common effects model is used for the meta-analysis. The data showed a statistically significant difference between the digital chest drainage group and the traditional chest drainage group (SMD − 1.2 x-rays, [95% CI: -1.7;-0.7, p = < 0.0001]) (Fig. 6 ). There was low heterogeneity across the studies (I 2 = 0%). Pulmonary complications Prolonged air leak, pneumothorax, and pneumonia were reported in two studies (n = 74). Overall, there was one pneumothorax, one respiratory failure, one pneumonia, and three prolonged air leaks in the electronic chest drain group compared with one pneumothorax and six prolonged air leaks in traditional chest drain group. A common effects model is used for the meta-analysis. The data did not show a statistically significant difference between the two groups (p = 0.8392) (Fig. 7 ). There was low heterogeneity across the studies (I 2 = 0%). Discussion The use of digital chest drainage after thoracic surgery gained popularity in clinical practice with the emergence of the Thopaz Chest Drain System, Medela, Switzerland in 2007 ( 5 ). They act as a compact and closed portable system connected to the chest tube from the patient with an in-built motorised vacuum giving negative pressure to the pleural cavity to promote drainage. Many high quality randomised controlled trials have been performed in adults to evaluate benefits of digital drainage ( 6 , 12 ). These have established a series of practical advantages for patients and healthcare staff such as objective air leak and fluid drainage measurements, improved mobilisation, and reduced cost. By contrast to the adult population, there has been little research regarding digital chest drain use in the paediatric population after thoracic surgery. In addition to the benefits established in adults, it would stand to reason that digital drains may offer unique advantages for measuring air leaks in infants or young children, particularly those who are non-compliant with manoeuvres commonly employed to assess for an air leak, such as voluntary coughing. Thus far, there have been no randomised controlled trials or prospectively controlled clinical trials conducted to investigate the use of digital chest drains in children. This systematic review of three observational studies included 86 patients aged < 18 who underwent lung resection (segmentectomy and/or lobectomy) and were managed with digital chest drains post operatively until drain removal ( 8 , 13 , 14 ). Two of these observational studies (n = 74) had historical control groups and formed the SMD meta-analysis. The meta-analysis showed a statistically significant reduction in hospital length of stay (SMD − 0.63 days, [95% CI: -1.1;-0.16, p = < 0.01]) and number of chest x-rays performed (SMD − 1.2 x-rays, [95% CI: -1.7;-0.7, p = < 0.0001]) in the digital drainage group compared to the traditional drainage group. Although a reduction in duration of drainage was seen in the digital drainage group, this was not found to be statistically significant (SMD − 2.2 days, [95% CI: -14.5;10.07, p = 0.2622]). There were no significant differences in development of pulmonary complications between the digital and traditional drainage groups (p = 0.8392). Our confidence in our findings were limited by concerns in risk of bias and heterogeneity, particularly in the duration of drainage. To our knowledge, this is the first systematic review and meta-analysis that examines the role of digital drainage after pulmonary resection in the paediatric population. Our results are generally in agreement with previous meta-analyses performed in adults, demonstrating a reduction in length of stay ( 6 , 12 ). It was essential to use an SMD meta-analysis due to differences in practice between the two centres. As a consequence in the absence of high-quality evidence to inform guidelines, the management of chest drains following lung resection varies dramatically from centre to centre ( 15 ). For example, Frediani et al had a mean drainage duration of 7.35 days and 15.67 days for the digital and traditional groups, respectively. By comparison, Pérez et al had a mean drainage duration of only 1.69 days and 5.38 days for digital and traditional groups, respectively. There is a general consensus that a chest x-ray showing a fully expanded lung should be performed before drain removal ( 15 ), and all three studies abide by this in their management protocols. There is poor concordance between centres on the threshold for air leak and drainage volumes before drain removal ( 16 , 17 ). Among the studies included in this review, both Costa et al and Pérez et al use an air leak of < 10ml/min recorded on digital drainage as the threshold for drain removal ( 13 , 14 ). Frediani et al does not report an air leak threshold for drain removal ( 8 ). None of the studies included report a minimum drainage volume to be achieved before drain removal. All studies included used the Thopaz Chest Drain System, Medela, Switzerland. Repeated meta-analyses and high-quality randomised controlled trials performed in recent years have shown reduced drainage time and reduced hospital length of stay in the adult demographic ( 6 , 12 ). Other studies have found reduced rates of pulmonary complications such as pneumothorax ( 6 ). The foremost explanation for this is the objective measurement of air leak, providing supporting evidence for the decision to remove a chest drain early. This standardisation in decision making yielded by digital drainage is particularly useful considering the intervariability in the subjective assessment of air leak in traditional chest drains reported in the literature ( 18 ). Furthermore, increased patient, nurse, and clinician satisfaction have been reported when using digital drainage systems with adults ( 7 ). Patients have reported an improved ability to mobilise with digital drains, likely due to their portable on-suction function and compact and closed build. Considering this improved mobility and the reduced drainage duration associated with them, early recovery after thoracic surgery protocols often suggest the use of digital drainage systems ( 19 ). Recently, the National Institute for Health and Care Excellence (NICE) guidelines have also supported the transition to digital drains, reporting a £111.33 saving per patient post pulmonary resection secondary to shortened length of stay ( 20 ). Our study faces a number of limitations. The evidence on the effectiveness in use of digital chest drains following pulmonary resection surgery in paediatrics is limited by the small number of studies and small sample size included. This weakened the power of our statistical analysis, and it was not possible to ascertain an association between pulmonary complications and type of chest drain. Furthermore, there was heterogeneity between studies in post-operative protocol, such as the indication for chest drain removal. Future randomised controlled studies would be beneficial in overcoming these limitations. There is at least one randomised controlled trial underway in the United States to evaluate the benefit of digital drainage systems in children ( 20 ). Additionally, the development of standardised guidelines for chest drain management following lung resection in children would aid in reducing the heterogeneity between studies for future pooled analysis. In conclusion, digital chest drain systems demonstrated a significant reduction in hospital length of stay and reduction in number of chest x-rays performed in the paediatric population. There was no reduction in duration of drainage and no reduction in post-operative pulmonary complications in this cohort. Our confidence in our results is limited by the small number of studies and sample size included. Well-established benefits including reduction in inpatient stay, reduction in duration of drainage, and cost-saving found in the adult population will likely be consistent in a paediatric population. Additionally, digital drainage offers distinct advantages that are particularly relevant in paediatrics such as the objective measurement of air leak in non-compliant patients and the reduction in radiation exposure from early drain removal and the fewer chest x-rays performed. While the absence of controlled prospective studies limits our meta-analysis, it also highlights a gap in the literature and the opportunity for further research to provide more robust evidence and inform future guidelines. Abbreviations PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses SMD, standard mean difference, NICE, National Institute for Health and Care Excellence Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials The search strategies used in this systematic review and meta-analysis have been submitted as supplementary material. Competing interests Not applicable. Funding Not applicable. Authors' contributions RA performed title, abstract, and full-text screening, data extraction, risk of bias assessment and was the major contributor in writing of the manuscript. AD performed title, abstract, and full-text screening, data extraction and risk of bias assessment. DH settled conflicts that arose in study in screening of studies and risk of bias assessment and supervised the writing of the manuscript. All authors participated in the development of the search strategy in conjunction with a research librarian from our hospital. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Annunziata F, Bush A, Borgia F, Raimondi F, Montella S, Poeta M, et al. Congenital lung malformations: unresolved issues and unanswered questions. Front Pead. 2019;7:239. Baird R, Puligandla PS, Laberge J-M, editors. Congenital lung malformations: informing best practice. Seminars in pediatric surgery. Elsevier; 2014. Beres A, Aspirot A, Paris C, Berube D, Bouchard S, Laberge J-M, et al. A contemporary evaluation of pulmonary function in children undergoing lung resection in infancy. J Pediatr Surg. 2011;46(5):829–32. Leblanc C, Baron M, Desselas E, Phan MH, Rybak A, Thouvenin G, et al. Congenital pulmonary airway malformations: state-of-the-art review for pediatrician’s use. Eur J Pediatrics. 2017;176:1559–71. Cerfolio RJ, Bryant AS. The benefits of continuous and digital air leak assessment after elective pulmonary resection: a prospective study. Ann Thorac Surg. 2008;86(2):396–401. Zhou L, Guo K, Shang X, Xu EF, Wu M. 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. Gen Thorac Cardiovasc Surg. 2023;71(1):1–11. Pompili C, Detterbeck F, Papagiannopoulos K, Sihoe A, Vachlas K, Maxfield MW, et al. Multicenter international randomized comparison of objective and subjective outcomes between electronic and traditional chest drainage systems. Ann Thorac Surg. 2014;98(2):490–7. Frediani S, Romano G, Pardi V, Aloi IP, Bertocchini A, Accinni A et al. Benefits of using digital thoracic drainage systems for post-operative treatment in pediatric populations: personal experience and review of literature. Front Pead. 2023;11. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372. Dernevik L, Belboul A, Rådberg G. Initial experience with the world’s first digital drainage system. The benefits of recording air leaks with graphic representation. Eur J Cardiothorac Surg. 2007;31(2):209–13. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355. Comacchio GM, Marulli G, Mendogni P, Andriolo LG, Guerrera F, Brascia D, et al. Comparison between electronic and traditional chest drainage systems: a multicenter randomized study. Ann Thorac Surg. 2023;116(1):104–9. Pérez-Egido L, García-Casillas MA, Simal I, Fanjul M, Cañizo A, Cerdá JA, et al. Digital thoracic drainage: a new system to monitor air leaks in pediatric population. J Pediatr Surg. 2019;54(4):693–5. Costa AD, Bachichi T, Holanda C, Rizzo LA. An initial experience with a digital drainage system during the postoperative period of pediatric thoracic surgery. 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Gonfiotti A, Viggiano D, Voltolini L, Bertani A, Bertolaccini L, Crisci R, et al. Enhanced recovery after surgery and video-assisted thoracic surgery lobectomy: the Italian VATS Group surgical protocol. J Thorac disease. 2018;10(Suppl 4):S564. Nct. Digital Chest Tube Drainage System (Thopaz+) Versus Analog in Pediatric Patients. https://clinicaltrialsgov/ct2/show/NCT05511987 . 2022. Tables Table 1 Author Year Country Study Design Population Intervention Control Type of Surgery Participants Coste et al 2016 Brazil Prospective cohort study Patients undergoing lung resection Digital chest drainage (Thopaz Chest Drain System, Medela, Switzerland) No control Lobectomy (82%) and segmentectomy (18%) 11 (intervention) 0 (control) Pérez et al 2019 Spain Prospective cohort study Patients undergoing lung resection Digital chest drainage (Thopaz Chest Drain System, Medela, Switzerland) Historical control group Lobectomy (46%) and segmentectomy (54%) 13 (intervention) 13 (control) Frediani et al 2023 Italy Retrospective cohort study Patients undergoing lung resection Digital chest drainage (Thopaz Chest Drain System, Medela, Switzerland) Historical control group 23 (intervention) 25 (control) Additional Declarations No competing interests reported. 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4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":219176,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eForest plot summarizing individual study estimates and overall estimates of duration of drainage (days).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage4.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5422732/v1/c156d7b72395547c2c1e7737.jpeg\"},{\"id\":71798984,\"identity\":\"5a988954-814b-4a81-9dab-294184f53de2\",\"added_by\":\"auto\",\"created_at\":\"2024-12-18 16:29:59\",\"extension\":\"jpeg\",\"order_by\":5,\"title\":\"Figure 5\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":251468,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eForest plot summarizing individual study estimates and overall estimates of hospital length of stay (days).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage5.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5422732/v1/d8808af7534256615a81cf76.jpeg\"},{\"id\":71797711,\"identity\":\"22c3c28e-53ea-4a1f-b6c9-653b2e2aa6fb\",\"added_by\":\"auto\",\"created_at\":\"2024-12-18 16:21:59\",\"extension\":\"jpeg\",\"order_by\":6,\"title\":\"Figure 6\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":277966,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eForest plot summarizing individual study estimates and overall estimates of number of chest x-rays performed.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage6.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5422732/v1/aec009dde9dd5cc3e29e1cfa.jpeg\"},{\"id\":71797712,\"identity\":\"fa9d5285-7407-490a-a802-04a3b56b5d99\",\"added_by\":\"auto\",\"created_at\":\"2024-12-18 16:21:59\",\"extension\":\"jpeg\",\"order_by\":7,\"title\":\"Figure 7\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":245259,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eForest plot summarizing individual study estimates and overall estimates of pulmonary complications.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage7.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5422732/v1/8504288a6ccd9416d3a97abf.jpeg\"},{\"id\":83836065,\"identity\":\"c0c16292-4f93-4648-8bfe-8774c15ed396\",\"added_by\":\"auto\",\"created_at\":\"2025-06-03 13:09:05\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2725145,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5422732/v1/b69ce13e-e979-4aa3-9957-0e7950eb4980.pdf\"},{\"id\":71797710,\"identity\":\"d85ad099-a644-4ba4-93ac-5d6aea88b89c\",\"added_by\":\"auto\",\"created_at\":\"2024-12-18 16:21:59\",\"extension\":\"docx\",\"order_by\":10,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":14598,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryFile1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5422732/v1/55c8c37a84d4bddd5839d4dd.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Digital chest drainage versus traditional chest drainage in children after pulmonary resection: A systematic review and meta-analysis\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003ePulmonary resection including wedge resection, segmentectomy, and lobectomy are commonly performed procedures in paediatric thoracic surgery (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). This is most often used as curative treatment for congenital disorders such as congenital pulmonary airway malformations, bronchopulmonary sequestration, or congenital lobar emphysema. There are no clear guidelines in the management of congenital lung lesions and practice can vary considerably across centres (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). Many experts favour early elective resection of lesions rather than delay and develop complications such as malignancy or recurrent infection. Surgery is often completed in infancy to allow compensatory growth of remaining lung tissue and research has shown that this tends to have little to no effect on a patient\\u0026rsquo;s pulmonary function in adulthood (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). The number of pulmonary resections indicated in children are increasing with higher incidence and diagnosis of these congenital disorders secondary to higher quality and improved access to imaging (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eIn concert with this increase, the use of digital chest drains such as the Thopaz Chest Drain System, Medela, has risen rapidly since their introduction in 2007 (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). These systems offer an electronic recording of the volume of air leak which would otherwise be measured subjectively by the clinician by the presence or absence of air bubbles in the traditional water seal drainage system. The presence of air leak is clinically valuable information in the decision for drain removal, which is otherwise a barrier to discharge. The argument for the use of electronic drains is strengthened when considering that inter-observer variability in identifying air leaks is a well-recognised phenomenon, even among experienced clinicians (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). An objective reading confirming the absence of an air leak may expedite drain removal and this is thought to be the primary factor that can result in a shortened length of stay for patients compared to their peers (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e). Many randomised controlled trials have been conducted in the adult population demonstrating advantages of digital drainage systems over their traditional counterparts following pulmonary resection (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). Digital chest drainage has been associated with a reduced drainage duration, reduced length of stay, and reduced cost when compared to traditional chest drainage (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). They also allow the continuous recording of air leakage to better inform decision making in chest drain management compared to the snapshot that clinicians would normally see at the bedside with traditional drainage. The large evidence base for these findings, particularly that of improved patient satisfaction, outcomes, and cost provides sound reasoning to expand the usage of digital drainage systems globally (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eBy contrast to the adult population, there is a relative paucity of information in children, both on digital chest drainage and in post-operative chest drain management as a whole. Considering the success found in adults, it would be reasonable to believe that digital chest drainage systems would lead to similar improvements for children. This provided the rationale for our systematic review, and to our knowledge, this is the first meta-analysis of this topic. The aim of this systematic review was to assess the post-operative outcomes in a paediatric population undergoing pulmonary resection who were managed with digital chest drains post-operatively. Randomised controlled studies or observational studies that were included and identified to have a traditional drainage control group were to be included for a meta-analysis to assess post-operative outcomes such as hospital length of stay, number of chest x-rays performed, and post-operative pulmonary complications.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eReview protocol and search strategy\\u003c/h2\\u003e \\u003cp\\u003eThis systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). A protocol was designed and registered at PROSPERO (574095). All authors participated in the development of the search strategy, which was developed in conjunction with a research librarian from Children\\u0026rsquo;s Health Ireland, Crumlin. The structured search strategy included natural language and Medical Subject Headings, grouped into three concepts: electronic chest drain, thoracic surgery, and paediatrics. Structured searches (Supplementary Table\\u0026nbsp;1) were conducted in PubMed, Cochrane Central Register of Controlled Trials (Cochrane CENTRAL), EMBASE, and SCOPUS for studies from the 1st of January 2008 up to 20th of July 2024. These dates were chosen as electronic chest drains were introduced into adult clinical practice in 2007 (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). There were no language restrictions.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eStudy selection and data extraction\\u003c/h3\\u003e\\n\\u003cp\\u003eStudies meeting the below PICO criteria were included:\\u003c/p\\u003e \\u003cp\\u003e \\u003col\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003ePopulation: All studies involving patients aged less than eighteen years old who had undergone lung resection surgery (wedge resection, segmentectomy, lobectomy, and pneumonectomy) were included. Studies with patients over eighteen years old were excluded.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eIntervention: Patients who had electronic chest drainage systems (Thopaz, DigiVent, etc.) placed during their surgery until they were removed post-operatively.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eOutcomes:\\u003c/p\\u003e \\u003cp\\u003e \\u003col style=\\\"list-style-type: lower-roman;\\\"\\u003e\\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003ePrimary outcomes were time to chest drain removal (days) and hospital length of stay (days). Studies that did not report these were excluded.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eSecondary: Number of chest x-rays performed, duration of air leak (days), rate of prolonged air leaks (days), hospital readmission, and severe complications (Clavien-Dindo\\u0026thinsp;\\u0026ge;\\u0026thinsp;3).\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eStudy design: randomised controlled trials, quasi-experimental studies, and observational studies were included.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003cp\\u003eTitle, abstract, and full-text screening were performed independently by two authors using the COVIDENCE online software with conflicts settled by a third author. Once the relevant studies were included, data extraction was performed independently by two reviewers using a data extraction template based on our selected outcomes.\\u003c/p\\u003e\\n\\u003ch3\\u003eRisk of bias assessment\\u003c/h3\\u003e\\n\\u003cp\\u003eRisk of bias was assessed for all studies included. For observational studies, the Cochrane Collaboration\\u0026rsquo;s ROBINS-I tool was used (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). This is a domain based critical evaluation tool which considers bias because of selection, confounding, classification, deviations from intended interventions, missing outcome data, and in measurement of the outcome and selective reporting. If all questions were considered to have low risk of bias, the paper was considered to have low risk of bias overall. If one or more domains were considered to have moderate risk of bias, the paper was considered to have moderate risk of bias overall. If one or more domains were considered to have serious risk of bias, the paper was considered to have serious risk of bias overall. If one or more domains were considered to have critical risk of bias or multiple domains were considered to have serious risk of bias, the study was considered to have critical risk of bias. Two authors conducted the risk of bias for all studies. Disagreements were settled by a third author.\\u003c/p\\u003e\\n\\u003ch3\\u003eSynthesis of results\\u003c/h3\\u003e\\n\\u003cp\\u003eMeta-analysis was performed on outcomes in which two or more observational studies presented comparable data. For the meta-analysis of standardised mean differences (SMD) and the meta-analysis of proportions, a common effects model was used if the heterogeneity was 0%, and a random effects model used if the heterogeneity was greater than this to create a points estimate summary of the analysed studies. Heterogeneity was assessed with the I\\u003csup\\u003e2\\u003c/sup\\u003e statistic with homogeneity defined as I\\u003csup\\u003e2\\u003c/sup\\u003e of 0%, low heterogeneity defined as an I\\u003csup\\u003e2\\u003c/sup\\u003e of less than 50%, moderate heterogeneity defined as an I\\u003csup\\u003e2\\u003c/sup\\u003e of 50\\u0026ndash;70%, and severe heterogeneity by an I\\u003csup\\u003e2\\u003c/sup\\u003e over 70%. The chi-squared test was used to test for homogeneity, with a p-value of \\u0026lt;\\u0026thinsp;0.1 being significant. Results were presented as means with standard mean difference (SMD) with 95% CI for continuous outcomes and as proportions with odds ratio (OR) with 95% confidence intervals (CI) for dichotomous outcomes. All analyses were conducted with the \\u0026lsquo;meta\\u0026rsquo; packages using R software (R version 4.4.1).\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA total of 162 articles were identified with 7 duplicates removed by the software (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). A total of 155 titles and abstracts were screened and a total of 6 full texts were reviewed. Of the texts reviewed, one was excluded because of wrong study type, one was excluded because of wrong study population, and one was excluded because of duplicate publication. In total 3 studies were included, with no randomised controlled trials and three observational studies. The characteristics of each study is summarised (Table\\u0026nbsp;1). Two of these studies had historical controls whereas one study had no control.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDescriptive characteristics of the included studies\\u003c/h2\\u003e \\u003cp\\u003eTable\\u0026nbsp;1 shows the study details of the three included observational studies published in 2016, 2019, and 2023 including population and outcomes reported. The trials evaluated 85 patients in total, with 47 patients allocated to intervention groups and 38 patients retrieved from historical control groups. The average age of participants per study ranged from 18 months to 10.7 years old. The indication for drain removal varied between studies, generally defined as an air leak of less than 10ml/min for 6 and 24 hours with a fully expanded lung on chest x-ray. Surgeries performed across studies included segmentectomy and/or lobectomy. The data for each of these distinct surgeries were reported as one group in each study.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eRisk of bias assessment\\u003c/h3\\u003e\\n\\u003cp\\u003eOut of the three studies, we considered one to be at critical risk of bias and two to be at moderate risk of bias overall (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). \\u003cem\\u003eCosta et al\\u003c/em\\u003e was considered to be at critical risk of bias due to confounding and reporting bias. \\u003cem\\u003eP\\u0026eacute;rez et al\\u003c/em\\u003e was considered to be at moderate risk of bias because of confounding, classification of intervention, and reporting bias. \\u003cem\\u003eFrediano et al\\u003c/em\\u003e was considered to be at moderate risk of bias because of confounding, selection, and reporting bias. Confounding bias was primarily related to weak historical control groups or no control group at all.\\u003c/p\\u003e\\n\\u003ch3\\u003eDuration of chest drainage\\u003c/h3\\u003e\\n\\u003cp\\u003eDuration of drainage in days post-operatively until drain removal was reported in two studies against controls (n\\u0026thinsp;=\\u0026thinsp;74). A random effects model is used for the meta-analysis with Knapp-Hartung adjustments because of the small number of studies included. The data showed no statistically significant difference between the digital chest drainage group and the traditional chest drainage group (SMD \\u0026minus;\\u0026thinsp;2.2 days, [95% CI: -14.5;10.07, p\\u0026thinsp;=\\u0026thinsp;0.2622]) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e). There was severe heterogeneity across the studies (I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;89.7%).\\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eHospital length of stay\\u003c/h2\\u003e \\u003cp\\u003eLength of hospital stay in days post-operatively was reported in two studies against controls (n\\u0026thinsp;=\\u0026thinsp;74). A common effects model is used for the meta-analysis. The data showed a statistically significant difference between the digital chest drainage group and the traditional chest drainage group (SMD \\u0026minus;\\u0026thinsp;0.63 days, [95% CI: -1.1;-0.16, p\\u0026thinsp;=\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01]) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e). There was low heterogeneity across the studies (I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;0%).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eNumber of chest x-rays performed\\u003c/h2\\u003e \\u003cp\\u003eNumber of chest x-rays performed before drain removal was reported in two studies (n\\u0026thinsp;=\\u0026thinsp;74). A common effects model is used for the meta-analysis. The data showed a statistically significant difference between the digital chest drainage group and the traditional chest drainage group (SMD \\u0026minus;\\u0026thinsp;1.2 x-rays, [95% CI: -1.7;-0.7, p\\u0026thinsp;=\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.0001]) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig6\\\" class=\\\"InternalRef\\\"\\u003e6\\u003c/span\\u003e). There was low heterogeneity across the studies (I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;0%).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePulmonary complications\\u003c/h2\\u003e \\u003cp\\u003eProlonged air leak, pneumothorax, and pneumonia were reported in two studies (n\\u0026thinsp;=\\u0026thinsp;74). Overall, there was one pneumothorax, one respiratory failure, one pneumonia, and three prolonged air leaks in the electronic chest drain group compared with one pneumothorax and six prolonged air leaks in traditional chest drain group. A common effects model is used for the meta-analysis. The data did not show a statistically significant difference between the two groups (p\\u0026thinsp;=\\u0026thinsp;0.8392) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig7\\\" class=\\\"InternalRef\\\"\\u003e7\\u003c/span\\u003e). There was low heterogeneity across the studies (I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;0%).\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThe use of digital chest drainage after thoracic surgery gained popularity in clinical practice with the emergence of the Thopaz Chest Drain System, Medela, Switzerland in 2007 (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). They act as a compact and closed portable system connected to the chest tube from the patient with an in-built motorised vacuum giving negative pressure to the pleural cavity to promote drainage. Many high quality randomised controlled trials have been performed in adults to evaluate benefits of digital drainage (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). These have established a series of practical advantages for patients and healthcare staff such as objective air leak and fluid drainage measurements, improved mobilisation, and reduced cost. By contrast to the adult population, there has been little research regarding digital chest drain use in the paediatric population after thoracic surgery. In addition to the benefits established in adults, it would stand to reason that digital drains may offer unique advantages for measuring air leaks in infants or young children, particularly those who are non-compliant with manoeuvres commonly employed to assess for an air leak, such as voluntary coughing. Thus far, there have been no randomised controlled trials or prospectively controlled clinical trials conducted to investigate the use of digital chest drains in children.\\u003c/p\\u003e \\u003cp\\u003eThis systematic review of three observational studies included 86 patients aged\\u0026thinsp;\\u0026lt;\\u0026thinsp;18 who underwent lung resection (segmentectomy and/or lobectomy) and were managed with digital chest drains post operatively until drain removal (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). Two of these observational studies (n\\u0026thinsp;=\\u0026thinsp;74) had historical control groups and formed the SMD meta-analysis. The meta-analysis showed a statistically significant reduction in hospital length of stay (SMD \\u0026minus;\\u0026thinsp;0.63 days, [95% CI: -1.1;-0.16, p\\u0026thinsp;=\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01]) and number of chest x-rays performed (SMD \\u0026minus;\\u0026thinsp;1.2 x-rays, [95% CI: -1.7;-0.7, p\\u0026thinsp;=\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.0001]) in the digital drainage group compared to the traditional drainage group. Although a reduction in duration of drainage was seen in the digital drainage group, this was not found to be statistically significant (SMD \\u0026minus;\\u0026thinsp;2.2 days, [95% CI: -14.5;10.07, p\\u0026thinsp;=\\u0026thinsp;0.2622]). There were no significant differences in development of pulmonary complications between the digital and traditional drainage groups (p\\u0026thinsp;=\\u0026thinsp;0.8392). Our confidence in our findings were limited by concerns in risk of bias and heterogeneity, particularly in the duration of drainage.\\u003c/p\\u003e \\u003cp\\u003e To our knowledge, this is the first systematic review and meta-analysis that examines the role of digital drainage after pulmonary resection in the paediatric population. Our results are generally in agreement with previous meta-analyses performed in adults, demonstrating a reduction in length of stay (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). It was essential to use an SMD meta-analysis due to differences in practice between the two centres. As a consequence in the absence of high-quality evidence to inform guidelines, the management of chest drains following lung resection varies dramatically from centre to centre (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e). For example, \\u003cem\\u003eFrediani et al\\u003c/em\\u003e had a mean drainage duration of 7.35 days and 15.67 days for the digital and traditional groups, respectively. By comparison, \\u003cem\\u003eP\\u0026eacute;rez et al\\u003c/em\\u003e had a mean drainage duration of only 1.69 days and 5.38 days for digital and traditional groups, respectively. There is a general consensus that a chest x-ray showing a fully expanded lung should be performed before drain removal (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e), and all three studies abide by this in their management protocols. There is poor concordance between centres on the threshold for air leak and drainage volumes before drain removal (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). Among the studies included in this review, both \\u003cem\\u003eCosta et al\\u003c/em\\u003e and \\u003cem\\u003eP\\u0026eacute;rez et al\\u003c/em\\u003e use an air leak of \\u0026lt;\\u0026thinsp;10ml/min recorded on digital drainage as the threshold for drain removal (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). \\u003cem\\u003eFrediani et al\\u003c/em\\u003e does not report an air leak threshold for drain removal (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e). None of the studies included report a minimum drainage volume to be achieved before drain removal. All studies included used the Thopaz Chest Drain System, Medela, Switzerland.\\u003c/p\\u003e \\u003cp\\u003eRepeated meta-analyses and high-quality randomised controlled trials performed in recent years have shown reduced drainage time and reduced hospital length of stay in the adult demographic (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). Other studies have found reduced rates of pulmonary complications such as pneumothorax (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). The foremost explanation for this is the objective measurement of air leak, providing supporting evidence for the decision to remove a chest drain early. This standardisation in decision making yielded by digital drainage is particularly useful considering the intervariability in the subjective assessment of air leak in traditional chest drains reported in the literature (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eFurthermore, increased patient, nurse, and clinician satisfaction have been reported when using digital drainage systems with adults (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). Patients have reported an improved ability to mobilise with digital drains, likely due to their portable on-suction function and compact and closed build. Considering this improved mobility and the reduced drainage duration associated with them, early recovery after thoracic surgery protocols often suggest the use of digital drainage systems (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). Recently, the National Institute for Health and Care Excellence (NICE) guidelines have also supported the transition to digital drains, reporting a \\u0026pound;111.33 saving per patient post pulmonary resection secondary to shortened length of stay (\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eOur study faces a number of limitations. The evidence on the effectiveness in use of digital chest drains following pulmonary resection surgery in paediatrics is limited by the small number of studies and small sample size included. This weakened the power of our statistical analysis, and it was not possible to ascertain an association between pulmonary complications and type of chest drain. Furthermore, there was heterogeneity between studies in post-operative protocol, such as the indication for chest drain removal. Future randomised controlled studies would be beneficial in overcoming these limitations. There is at least one randomised controlled trial underway in the United States to evaluate the benefit of digital drainage systems in children (\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). Additionally, the development of standardised guidelines for chest drain management following lung resection in children would aid in reducing the heterogeneity between studies for future pooled analysis.\\u003c/p\\u003e \\u003cp\\u003eIn conclusion, digital chest drain systems demonstrated a significant reduction in hospital length of stay and reduction in number of chest x-rays performed in the paediatric population. There was no reduction in duration of drainage and no reduction in post-operative pulmonary complications in this cohort. Our confidence in our results is limited by the small number of studies and sample size included. Well-established benefits including reduction in inpatient stay, reduction in duration of drainage, and cost-saving found in the adult population will likely be consistent in a paediatric population. Additionally, digital drainage offers distinct advantages that are particularly relevant in paediatrics such as the objective measurement of air leak in non-compliant patients and the reduction in radiation exposure from early drain removal and the fewer chest x-rays performed. While the absence of controlled prospective studies limits our meta-analysis, it also highlights a gap in the literature and the opportunity for further research to provide more robust evidence and inform future guidelines.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003ePRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses\\u003c/p\\u003e\\n\\u003cp\\u003eSMD, standard mean difference,\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eNICE, National Institute for Health and Care Excellence\\u003cbr\\u003e\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe search strategies used in this systematic review and meta-analysis have been submitted as supplementary material.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eRA performed title, abstract, and full-text screening, data extraction, risk of bias assessment and was the major contributor in writing of the manuscript. AD performed title, abstract, and full-text screening, data extraction and risk of bias assessment. DH settled conflicts that arose in study in screening of studies and risk of bias assessment and supervised the writing of the manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors participated in the development of the search strategy in conjunction with a research librarian from our hospital.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u0026nbsp;\\u003cbr\\u003e\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eAnnunziata F, Bush A, Borgia F, Raimondi F, Montella S, Poeta M, et al. Congenital lung malformations: unresolved issues and unanswered questions. Front Pead. 2019;7:239.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBaird R, Puligandla PS, Laberge J-M, editors. Congenital lung malformations: informing best practice. Seminars in pediatric surgery. Elsevier; 2014.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBeres A, Aspirot A, Paris C, Berube D, Bouchard S, Laberge J-M, et al. A contemporary evaluation of pulmonary function in children undergoing lung resection in infancy. J Pediatr Surg. 2011;46(5):829\\u0026ndash;32.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLeblanc C, Baron M, Desselas E, Phan MH, Rybak A, Thouvenin G, et al. Congenital pulmonary airway malformations: state-of-the-art review for pediatrician\\u0026rsquo;s use. Eur J Pediatrics. 2017;176:1559\\u0026ndash;71.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCerfolio RJ, Bryant AS. The benefits of continuous and digital air leak assessment after elective pulmonary resection: a prospective study. Ann Thorac Surg. 2008;86(2):396\\u0026ndash;401.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZhou L, Guo K, Shang X, Xu EF, Wu M. 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. Gen Thorac Cardiovasc Surg. 2023;71(1):1\\u0026ndash;11.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePompili C, Detterbeck F, Papagiannopoulos K, Sihoe A, Vachlas K, Maxfield MW, et al. Multicenter international randomized comparison of objective and subjective outcomes between electronic and traditional chest drainage systems. Ann Thorac Surg. 2014;98(2):490\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFrediani S, Romano G, Pardi V, Aloi IP, Bertocchini A, Accinni A et al. Benefits of using digital thoracic drainage systems for post-operative treatment in pediatric populations: personal experience and review of literature. Front Pead. 2023;11.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDernevik L, Belboul A, R\\u0026aring;dberg G. Initial experience with the world\\u0026rsquo;s first digital drainage system. The benefits of recording air leaks with graphic representation. Eur J Cardiothorac Surg. 2007;31(2):209\\u0026ndash;13.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSterne JA, Hern\\u0026aacute;n MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eComacchio GM, Marulli G, Mendogni P, Andriolo LG, Guerrera F, Brascia D, et al. Comparison between electronic and traditional chest drainage systems: a multicenter randomized study. Ann Thorac Surg. 2023;116(1):104\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eP\\u0026eacute;rez-Egido L, Garc\\u0026iacute;a-Casillas MA, Simal I, Fanjul M, Ca\\u0026ntilde;izo A, Cerd\\u0026aacute; JA, et al. Digital thoracic drainage: a new system to monitor air leaks in pediatric population. J Pediatr Surg. 2019;54(4):693\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCosta AD, Bachichi T, Holanda C, Rizzo LA. An initial experience with a digital drainage system during the postoperative period of pediatric thoracic surgery. Jornal brasileiro de pneumologia: publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 2016;42(6):444\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eThet MS, Han KP, Hlwar KE, Thet KS, Oo AY. Efficacy of chest X-rays after drain removal in adult and pediatric patients undergoing cardiac and thoracic surgery: A systematic review. J Card Surg. 2022;37(12):5320\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSchnuck JK, Javid PJ, Riehle KJ, Rothstein DH. Chest Tube Management following Lung Resection in Pediatric Patients: A Retrospective Analysis. J Pediatr Surg. 2023;58(7):1227\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSchnuck JK, Acker SN, Kelley-Quon LI, Lee JH, Shew SB, Fialkowski E et al. Decision-Making in Pleural Drainage Following Lung Resection in Children: A Western Pediatric Surgery Research Consortium Survey. J Pediatr Surg. 2024.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVarela G, Jim\\u0026eacute;nez MF, Novoa NM, Aranda JL. Postoperative chest tube management: measuring air leak using an electronic device decreases variability in the clinical practice. Eur J Cardiothorac Surg. 2009;35(1):28\\u0026ndash;31.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGonfiotti A, Viggiano D, Voltolini L, Bertani A, Bertolaccini L, Crisci R, et al. Enhanced recovery after surgery and video-assisted thoracic surgery lobectomy: the Italian VATS Group surgical protocol. J Thorac disease. 2018;10(Suppl 4):S564.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNct. Digital Chest Tube Drainage System (Thopaz+) Versus Analog in Pediatric Patients. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://clinicaltrialsgov/ct2/show/NCT05511987\\u003c/span\\u003e\\u003cspan address=\\\"https://clinicaltrialsgov/ct2/show/NCT05511987\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. 2022.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTable 1\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"946\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 103px;\\\"\\u003e\\n \\u003cp\\u003eAuthor\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003eYear\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eCountry\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eStudy Design\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 123px;\\\"\\u003e\\n \\u003cp\\u003ePopulation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eIntervention\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eControl\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 116px;\\\"\\u003e\\n \\u003cp\\u003eType of Surgery\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 121px;\\\"\\u003e\\n \\u003cp\\u003eParticipants\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 103px;\\\"\\u003e\\n \\u003cp\\u003eCoste et al\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e2016\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eBrazil\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eProspective cohort study\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 123px;\\\"\\u003e\\n \\u003cp\\u003ePatients undergoing lung resection\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eDigital chest drainage (Thopaz Chest Drain System, Medela, Switzerland)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eNo control\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 116px;\\\"\\u003e\\n \\u003cp\\u003eLobectomy (82%) and segmentectomy (18%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 121px;\\\"\\u003e\\n \\u003cp\\u003e11 (intervention)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0 (control)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 103px;\\\"\\u003e\\n \\u003cp\\u003eP\\u0026eacute;rez et al\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e2019\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eSpain\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eProspective cohort study\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 123px;\\\"\\u003e\\n \\u003cp\\u003ePatients undergoing lung resection\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eDigital chest drainage (Thopaz Chest Drain System, Medela, Switzerland)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eHistorical control group\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 116px;\\\"\\u003e\\n \\u003cp\\u003eLobectomy (46%) and segmentectomy (54%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 121px;\\\"\\u003e\\n \\u003cp\\u003e13 (intervention)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e13 (control)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 103px;\\\"\\u003e\\n \\u003cp\\u003eFrediani et al\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e2023\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eItaly\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eRetrospective cohort study\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 123px;\\\"\\u003e\\n \\u003cp\\u003ePatients undergoing lung resection\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eDigital chest drainage (Thopaz Chest Drain System, Medela, Switzerland)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eHistorical control group\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 116px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 121px;\\\"\\u003e\\n \\u003cp\\u003e23 (intervention)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e25 (control)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Lung cancer, pulmonary resection, digital chest drain, paediatrics\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5422732/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5422732/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003ePulmonary resection is commonly performed as curative treatment for congenital thoracic malformations. There is a plethora of high-quality evidence showing improved outcomes with digital chest drainage systems compared to traditional water-seal systems in adults. By contrast, there is a relative paucity of research with children and therefore much uncertainty in post-operative chest drain management in paediatrics.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eA systematic review and meta-analysis was conducted to assess the effect of digital chest drainage systems in paediatric patients after pulmonary resection. Data sources included PubMed, Cochrane Central Register of Controlled Trials, EMBASE, and SCOPUS, with information from 1 January 2007 to 20 July 2024. The qualitative analysis included three observational studies. The quantitative analysis included 74 patients across two observational studies that compared digital and traditional chest drainage systems. A fixed effects model was used to produce a pooled estimate for a meta-analysis of means if the studies were homogenous, otherwise a random effects model was used.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eThe meta-analysis showed a statistically significant reduction in hospital length of stay (SMD \\u0026minus;\\u0026thinsp;0.63 days, [95% CI: -1.1;-0.16, p\\u0026thinsp;=\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01]) and number of chest x-rays performed (SMD \\u0026minus;\\u0026thinsp;1.2 x-rays, [95% CI: -1.7;-0.7, p\\u0026thinsp;=\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.0001]) in the digital group compared to the traditional group. Although a reduction in chest tube duration was seen in the digital group, this was not statistically significant (SMD \\u0026minus;\\u0026thinsp;2.2 days, [95% CI: -14.5;10.07, p\\u0026thinsp;=\\u0026thinsp;0.2622]). There were no significant differences in development of pulmonary complications between the digital and traditional drainage groups (p\\u0026thinsp;=\\u0026thinsp;0.8392).\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThe use of digital chest drainage systems demonstrated a shortened hospital length of stay and quantity of chest x-rays performed in paediatric patients following pulmonary resection. The overall certainty of these findings is limited by the low quality of the available evidence.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Digital chest drainage versus traditional chest drainage in children after pulmonary resection: A systematic review and meta-analysis\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-12-18 16:21:54\",\"doi\":\"10.21203/rs.3.rs-5422732/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"748d6891-2234-4ab1-9790-0fa1b54ba8ee\",\"owner\":[],\"postedDate\":\"December 18th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-06-03T13:08:33+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-12-18 16:21:54\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5422732\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5422732\",\"identity\":\"rs-5422732\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}