Application of Improved Indwelling Double Chest Tubes in High-Risk Air Leak Patients Undergoing Single-Port Thoracoscopic Pulmonary Segmentectomy

Application of Improved Indwelling Double Chest Tubes in High-Risk Air Leak Patients Undergoing Single-Port Thoracoscopic Pulmonary Segmentectomy | 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 Application of Improved Indwelling Double Chest Tubes in High-Risk Air Leak Patients Undergoing Single-Port Thoracoscopic Pulmonary Segmentectomy Zhaowang Zhu, Fangqing Wang, Binkui Wang, Gang Chen, Weimin Ruan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8069853/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Backgroun d : For patients with high-risk factors such as pleural adhesions, emphysema, or complex pulmonary segment resection, the use of traditional single chest tube drainage post-operatively can lead to increased pain and delayed recovery. This study aims to explore the application value of the improved dual chest tube indwelling drainage method in reducing pain and improving recovery in such patients. Methods: A prospective randomized controlled trial design was employed, enrolling 90 patients who underwent single-port thoracoscopic pulmonary segmentectomy in the Department of Thoracic Surgery at Tongling People's Hospital, affiliated with Wannan Medical College, from June 2023 to March 2025. Patients were divided into a control group (n=50, conventional 28 Fr chest tube placed through the original incision) and an observation group (n=40, improved dual tube drainage method: one 28 Fr chest tube placed in front of the incision, and a negative pressure drainage ball tube placed behind the incision). The primary endpoint was post-operative pain score (VAS), analyzed using a linear mixed-effects model. Secondary endpoints included drainage time, drainage volume, post-operative hospital stay, and related post-operative complications. Results: The VAS scores demonstrated a significant main effect of time (P<0.001), and there was a significant interaction effect between group and time (P<0.01), indicating that the observation group experienced a faster decrease in post-operative pain. On postoperative day 3 (95% CI=-0.53, P=0.045) and day 5 (95% CI=-1.30, P<0.001), the VAS scores in the observation group were significantly lower than those in the control group. In terms of secondary outcomes, the drainage time in the observation group was significantly shorter than that in the control group (3.26 ± 1.74 days vs. 5.50 ± 2.26 days, P<0.001), with a lower total drainage volume (691.45 ± 365.58 ml vs. 895.53 ± 722.08 ml, P = 0.002) and a shorter postoperative hospital stay (9 [8–11] days vs. 13 [9–16] days, P0.05). Conclusion: The improved dual chest tube indwelling drainage method shows potential advantages in reducing postoperative pain and shortening drainage and hospital stay times for high-risk air leak patients following single-port thoracoscopic pulmonary segmentectomy, with no observed trend of increased complications, indicating its feasibility and potential clinical value. Single-port thoracoscopy lung cancer negative pressure drainage ball closed thoracic drainage rapid recovery Figures Figure 1 Figure 2 Figure 3 1 Introduction Lung cancer is the most common malignant tumor [ 1 ] ,and single-port thoracoscopic surgery is the mainstream surgical method for lung cancer treatment [ 2 ] .To observe for active bleeding in the thoracic cavity and to drain any air leaks or effusions, a thicker chest drainage tube is typically inserted [ 3 ] .However, due to the limitations of the incision location in single-port thoracoscopic surgery, post-operative drainage effectiveness can be poor, and pain associated with the drainage tube can adversely affect the patient's recovery time and quality of life [ 4 ] .For certain patients with emphysema [ 5 ] ,pleural adhesions [ 6 ] or those undergoing complex segmentectomy [ 7 ] ,the condition of their pulmonary function is often poor. Intraoperative dissection of adhesions and the handling of multiple inter-segmental planes can result in significant damage to lung tissue, often leading to persistent air leaks post-operatively. Managing these patients in the same manner as other "normal" patients can lead to a significantly prolonged duration of chest tube placement for this group. Currently, there are still no effective management methods for these patients, and long-term retention of a single chest tube is commonly used, increasing patient pain and reducing post-operative satisfaction. The project team classifies those meeting one or more of the following criteria as having high-risk factors for post-operative air leaks: a)Preoperative chest CT scan of the target lobe showed moderate or severe emphysema, defined as a Goddard score ≥ 2 (more than 25% of the lung field involved); b)Moderate or severe pleural adhesions identified intraoperatively, defined as adhesion grade ≥ 4, requiring dissection with energy devices; c)Resection of a complex segment, involving dissection across multiple intersegmental planes. The project team has proposed an improved dual chest tube indwelling drainage method for high-risk air leak patients. This method involves placing two drainage tubes of different diameters through the same incision, optimizing the placement of the chest tubes, early removal of the thicker tube while retaining the thinner one, among other strategies. This approach aims to shorten the duration of placement for the thicker tube and reduce patient pain while ensuring effective drainage. Compared to traditional single-tube drainage methods, this has certain advantages, which are reported as follows. 2 Methods 2.1 Randomization and blinding A total of 90 patients who underwent single-port thoracoscopic lung cancer surgery at Tongling People's Hospital, affiliated with Wannan Medical College, from June 2024 to March 2025 were selected. Random numbers were generated using computer software (IBM SPSS Statistics 26.0), and based on whether the random number was greater than 0.5, participants were assigned to the observation group (n = 40) or the control group (n = 50). The allocation sequence was concealed in opaque, sealed envelopes labeled sequentially. After obtaining informed consent, the operating room nurse opened the next envelope immediately before the surgery to determine the group assignment. Due to the significant differences in the type and number of chest drainage tubes, blinding of the surgeons and patients was not feasible. To minimize bias, outcome assessments (including VAS scores, duration of air leaks, total drainage volume, duration of drainage, and length of hospital stay) were conducted by ward nurses who were unaware of the group allocation, and data analysis was performed by a statistician who also was not aware of the assignment. 2.2 Patient selection Inclusion criteria: ① patients who underwent single-port segmentectomy; ② patients aged 20-80 years old, male or female; ③ patients assessed as having a high risk of postoperative air leakage, defined as meeting one or more of the following conditions: a) the target lobe of the resected segment showed moderate or severe emphysema on preoperative chest CT, defined as a Goddard score ≥2 (more than 25% of the lung field involved); b) moderate or severe pleural adhesions were observed intraoperatively, defined as adhesion grade ≥4, requiring dissection with energy devices (e.g., electrocautery); c) the resected segment was a complex segment, involving dissection across multiple intersegmental planes. Exclusion criteria: 1) .preoperative combination of lung infection, tuberculosis, and tumors in other parts of the body; 2) .combination of other major organ dysfunction and psychiatric diseases, cognitive communication disorders; 3). massive air leakage from the expanding lungs during the operation; 4). blockage of closed chest drains; 5) .imperfect clinical data; 6) .death or loss of visits. 2.2 Patient selection Inclusion criteria: ①patients who underwent single-port thoracoscopic segmental lung resection; ②patients aged 20-80 years old, male or female;③patients assessed as having a high risk of postoperative air leakage, defined as meeting one or more of the following conditions: a) the target lobe of the resected segment showed moderate or severe emphysema on preoperative chest CT, defined as a Goddard score ≥2 (more than 25% of the lung field involved); b) moderate or severe pleural adhesions were observed intraoperatively, defined as adhesion grade ≥4, requiring dissection with energy devices (e.g., electrocautery); c) the resected segment was a complex segment, involving dissection across multiple intersegmental planes. Exclusion criteria: 1) .preoperative combination of lung infection, tuberculosis, and tumors in other parts of the body; 2) .combination of other major organ dysfunction and psychiatric diseases, cognitive communication disorders; 3). massive air leakage from the expanding lungs during the operation; 4). blockage of closed chest drains; 5) .imperfect clinical data; 6) .death or loss of visits. 2.3 Catheterization Method All patients were positioned in the lateral decubitus position under general anesthesia with double-lumen endotracheal intubation. A surgical incision approximately 3 cm long was made in the 4th or 5th intercostal space along the anterior axillary line or mid-axillary line, followed by pulmonary segmentectomy according to the size of the primary tumor. Routine mediastinal lymphadenectomy was performed during the surgery. Prior to closing the chest, suctioning and lung inflation were carried out. Observation Group: An 28 Fr closed chest drain was placed at the anterior aspect of the original incision, approximately 12 cm deep in the thorax. A single negative pressure drainage ball (200 ml, diameter 4.8 mm, maximum negative pressure -10 cm H2O, manufacturer: Huacheng Medical Equipment Co.) was inserted as a drainage ball tube behind the original incision, traversing the posterior chest and positioned at the apex of the thorax to avoid being inserted into the interlobar fissures. Care was taken to have multiple side holes on both tubes, with the last side hole approximately 3 cm from the chest wall, secured with sutures. See Fig.1-2. Control Group: A single 28 Fr closed chest drain was placed above the original incision, also approximately 12 cm deep in the thorax, with the last side hole about 3 cm from the chest wall, and secured with sutures at the incision site. 2.4 Chest Tube Management 2.4.1 Observation Group: The thick chest tube is removed when there are no or only a small number of air bubbles (air leak grade 1) and the chest drainage volume is less than 300 mL. The negative pressure drainage ball tube is removed when there is no significant drainage fluid (less than 100 mL) and the ball remains collapsed. See Fig.3. 2.4.2 Control Group: Indications for chest tube removal: 1) Follow-up chest X-ray shows complete re-expansion of the remaining lung (with no residual cavity in the thoracic cavity) and no signs of pleural effusion or pneumothorax; 2) No air bubbles overflow from the drainage bottle when the patient coughs; 3) The drainage fluid at the time of tube removal is non-bloody, non-chylous, and non-purulent; 4) Chest drainage volume ≤200 mL/24h. Nurses observe and record the negative pressure ball drainage every 2 hours and maintain the ball in a state of maximum negative pressure. Postoperatively, patients are encouraged to actively cough and expectorate and to engage in early ambulation. Postoperative pain management is performed using an electronic analgesic pump by the anesthesiology department (effective for 48 hours). If necessary, postoperative adjuvant pain medications (e.g., flurbiprofen ester, tramadol) are used. 2.5 Observational Indicators and Evaluation Criteria 2.5.1 Collection of pain scores, chest tube indwelling time, drainage volume, hospitalization time, and postoperative complications, including pneumothorax, pleural effusion, subcutaneous emphysema, pulmonary infection, incision infection, and incision hernia. Postoperative follow-up is conducted within two weeks after surgery through outpatient chest X-ray examination and telephone follow-up by nursing staff to monitor recovery and detect potential complications. 2.5.2 Evaluation of Emphysema is conducted using the subjective visual Goddard scoring method for emphysema [8 ,9] :Patients were included if the Goddard score was ≥2 in the lung field of the lobe containing the segment to be resected, as assessed on preoperative chest CT images.(Table 1). Table 1. Goddard Scoring Table Goddard score Emphysema as a proportion of this transected anatomical level (emphysema %) 0 0% 1 0%< Emphysema %≤25% 2 25%< Emphysema %≤50% 3 50%< Emphysema %≤75% 4 75%< Emphysema %≤100% Note: Typically, three transverse anatomical levels of both lungs are selected for evaluation — the upper lung level at the aortic arch, the middle lung level at the carina, and the lower lung level approximately 1 cm above the top of the right diaphragm. In total, the two lungs are divided into six anatomical levels, each scored from 0 to 4, yielding a total score range of 0–24. Mild emphysema is defined as a total score ≤8, moderate as 8 16. 2.5.3 Pleural Adhesion Grading.Based on the studies by Oncel [10] and Li [11] the grading criteria are as follows:Grade 0: No pleural adhesions;Grade 1: Loose and thin pleural adhesions that can be separated with traction;Grade 2: Pleural adhesions requiring blunt dissection;Grade 3: Pleural adhesions requiring sharp dissection;Grade 4: Pleural injury during the separation of adhesions;Grade 5: Subpleural tissue injury during the separation of adhesions. 2.5.4 Definition of Complex Segmentectomy [12] :A surgical procedure that involves handling more than two intersegmental planes, including single complex pulmonary segmentectomy (right S1, S2, S3, S4, S7, S8, S9, S10; left S1+2, S3, S7, S8, S9, S10) and combined pulmonary segmentectomy (any combination of the aforementioned complex segments). 2.5.5 Pain Assessment Pain is assessed using the Visual Analog Scale (VAS) [13] ,with a total score range from 0 to 10. A score of 0 represents no pain, 1-3 indicates mild pain, 4-7 indicates moderate pain, and above 7 indicates severe pain. 2.5.6 Air Leak GradingAir leaks are graded based on severity, combining previous studies [14 ,15] ，and are categorized according to the patient’s respiratory status and the presence of bubbles in the drainage bottle:Grade 0: No bubbles after three consecutive coughs;Grade 1: At least one instance of bubbles during three consecutive coughs;Grade 2: Continuous bubbles during active coughing;Grade 3: Small, persistent bubbles during quiet breathing;Grade 4: Large, persistent air leak during quiet breathing.To minimize subjectivity, air leak grades for each patient are independently assessed by three senior thoracic surgeons. The final grading is determined by consensus among the assessors to ensure consistency and reliability in the evaluations. 2.6 Statistical Analysis Data were processed using SPSS 26.0 statistical software. A linear mixed-effects model (LMM) was used to analyze the changes in VAS scores over time and between groups. The model was set with patient identification as a random intercept, and group (observation group vs. control group), time (postoperative days 1, 2, 3, and 5), and the group × time interaction as fixed effects. The covariance structure used was autoregressive AR(1), and the parameter estimation method was restricted maximum likelihood (REML). All tests were two-tailed, and P < 0.05 was considered statistically significant. For data following a normal distribution, t-tests were used, with continuous variables presented as x ± s. Categorical data were presented as frequency/percentage (%) and analyzed using the chi-square test. P < 0.05 was considered statistically significant. For skewed distributions, non-parametric tests (e.g., Mann-Whitney U test) were used. 3 Results A total of 90 patients were included, with 40 patients in the observation group and 50 patients in the control group. The difference in the number of participants between the groups resulted from simple randomization. However, no significant differences were found in baseline characteristics such as age, gender, and BMI between the two groups (p > 0.05, Table 2). Table 2. General Information Item Observation Group Control Group P Value Male/Female (n, %) 17(42.5%)/23(57.5%) 28(56%)/22(44%) 0.203 Age (years) 61.05±10.19 62.76±12.73 0.516 BMI(kg/m2) 23.04±3.716 24.07±8.58 0.546 3.2 Primary Endpoint Results Table 3. Fixed Effects Parameter Estimates of the Linear Mixed-Effects Model Fixed Effects β Estimate Standard Error (SE) 95%-CI z-Value P-Value Intercept (Control Group, Day 1) 3.978 0.153 3.679–4.277 26.07 <0.001 Observation Group vs Control Group 0.193 0.230 -0.258–0.644 0.84 0.402 Time (Day 2 vs Day 1) -0.681 0.174 -1.022–-0.340 -3.91 <0.001 Time (Day 3 vs Day 1) -0.908 0.174 -1.249–-0.567 -5.22 <0.001 Time (Day 5 vs Day 1) -0.682 0.174 -1.023–-0.341 -3.92 <0.001 Group × Time (Day 2) -0.315 0.262 -0.829–0.200 -1.20 0.230 Group × Time (Day 3) -0.526 0.262 -1.041–-0.012 -2.01 0.045* Group × Time (Day 5) -1.301 0.262 -1.816–-0.787 -4.96 <0.001** Table 4. Model-Adjusted Mean (Marginal Mean) VAS Scores for Each Group at Each Time Point Time (Days) Control Group Estimated Mean (95% -CI) Observation Group Estimated Mean (95% -CI) Intergroup P Value Day 1 3.98 (3.68–4.28) 4.17 (3.89–4.45) 0.40 Day 2 3.30 (3.00–3.60) 3.20 (2.90–3.50) 0.23 Day 3 3.07 (2.77–3.37) 2.55 (2.25–2.85) 0.045* Day 5 3.30 (3.00–3.60) 2.00 (1.70–2.30) <0.001** Table 5. Differences in VAS Scores Between the Two Groups at Each Time Point (Observation Group - Control Group) Time (Days) Difference Estimate (95%CI) Z -Value P -Value Day 1 +0.19 (-0.26–0.64) 0.84 0.402 Day 2 -0.32 (-0.83–0.20) -1.20 0.230 Day 3 -0.53 (-1.04–-0.01) -2.01 0.045* Day 5 -1.30 (-1.82–-0.79) -4.96 <0.001** Note: The reference category is the control group on postoperative day 1; P < 0.05; *P < 0.01. The LMM showed a significant main effect of time (P < 0.001), with VAS scores gradually decreasing over time post-surgery. The main effect of group was not significant (P = 0.402), but the group × time interaction effect was significant (P < 0.01) (Table 3). Specifically, there was no statistically significant difference in VAS scores between the two groups on postoperative days 1 and 2; however, on day 3 (95% CI = -0.53, P = 0.045) and day 5 (95% CI = -1.30, P < 0.001), the VAS score in the observation group was significantly lower than that in the control group (Tables 4 and 5). These results suggest that the observation group effectively reduced pain in the later stages of postoperative recovery. 3.3 Secondary Endpoint Results Table 6. Secondary Endpoint Results Item Observation Group（ ±SD） Control Group（ ±SD） T-Value P-Value Thick Tube Drainage Time (days) 3.26±1.74 5.50±2.26 4.188 ＜0.001 Thin Tube Drainage Time (days) 4.66±2.00 Total Drainage Time (days) 4.66±2.00 5.50±2.26 1.485 0.142 Thick Tube Drainage Volume (ml) 490.79±264.94 895.53±722.08 3.244 0.002 Thin Tube Drainage Volume (ml) 201.18±117.69 Total Drainage Volume (ml) 691.45±365.58 895.53±722.08 0.124 Surgical Time 151.41±40.10 150.24±47.38 0.005 0.907 Blood Loss 27.95±7.58 33.29±16.45 1.949 0.070 Table 7. Length of Hospital Stay Group Case（n） Length of Hospital Stay(day) P-Value Observation Group 40 9（8-11） ＜0.001 Control Group 50 13（9-16） Table 8.Incidence of Complications Item Observation group/case Control group/case P-value Subcutaneous emphysema 3 2 0.679 Pleural effusion 1 1 1.000 Pneumothorax 0 0 - Lung infection 1 3 0.318 Incisional hernia 0 0 - Puncture tube placement 1 1 1.000 Chest tube blockage 0 0 - Total 6 7 0.841 Regarding the secondary outcome indicators, for the thick tube (28 Fr), the observation group had a significantly shorter drainage time (3.26 ± 1.74 days vs. 5.50 ± 2.26 days, P < 0.001), and the thick tube drainage volume was significantly reduced in both groups (490.79 ± 264.94 mL vs. 895.53 ± 722.08 mL, P = 0.002) (Table 6). Postoperative hospital stay was also shorter (median 9 days [IQR 8-11] vs. 13 days [IQR 9-16], P 0.05). 3.4 Complications Patients who were readmitted due to pneumothorax, massive pleural effusion, or pulmonary infection within 30 days were recorded as unplanned readmissions. Several patients in this study experienced unplanned readmissions. Both groups had cases of subcutaneous emphysema (3/40 (7.5%) vs. 2/50 (4%), P = 0.679), which improved with negative pressure suction treatment, and follow-up chest X-rays showed no significant pneumothorax. Each group had one patient who developed pleural effusion after discharge, which was managed with puncture and drainage. The incidence of thoracic infections in both groups(2.5% (1/40) vs. 6% (3/50), P = 0.318)(Table 8). No cases of drainage tube-related infections or dislocations were observed in either group. During the follow-up period, no cases of re-intervention or long-term recurrence were observed. 4 Discussion Patients with pleural adhesions, emphysema, and complex segmentectomy are considered high-risk groups for persistent air leaks after segmentectomy [ 16 , 17 , 18 ] .These patients tend to have slower recovery, longer chest tube retention, and prolonged pain duration, thus requiring more refined postoperative management. The mechanisms leading to postoperative air leaks vary among these patients; pleural adhesions can complicate surgical exposure, leading to pleural injury, longer operation times, and increased postoperative drainage, thereby elevating the risk of air leaks [ 19 ] . In patients with emphysema, particularly elderly smokers, the risk of postoperative air leaks is significantly heightened due to the fragility of lung tissue and poor healing capacity [ 20 , 21 ] .Complex segmentectomy involve addressing multiple intersegmental planes, making the surgical procedure intricate and increasing the risk of parenchymal tear and air leak due to the length of sutures [ 22 ] ,Given these high-risk factors, conventional postoperative drainage methods often struggle to meet the dual needs of pain relief and early tube removal. Several studies [ 23 , 24 ] have found that the volume of pleural effusion in lung cancer patients typically peaks on the first day after pulmonary resection, and subsequently decreases as wound exudation and pleural cavity absorption occur. Retaining only a thin tube might not achieve adequate drainage due to its smaller diameter [ 25 ] .In this study, we employed an improved dual-tube drainage system to achieve sufficient drainage early on through the thick chest tube, and once the pleural effusion peaks, we utilized the thin tube for drainage, thereby reducing the retention time of the thick tube and alleviating patient pain. The advantage of single-port thoracoscopy is the smaller surgical incision, which reduces muscle damage and intercostal nerve compression [ 26 ] ,Intercostal nerve injury can lead to postoperative pain, and the compression of the intercostal nerves by postoperative drainage tubes can exacerbate this pain [ 27 ] .Some studies have shown [ 28 ] , that the placement of thick chest tubes or multiple chest tubes can easily lead to compression of the intercostal nerves, increasing postoperative pain. However, in this study, no significant main effect was found in the VAS scores between the two patient groups, indicating that the overall average VAS scores of both groups did not differ at any postoperative time point. This finding suggests that the dual-tube indwelling method used in this study does not significantly increase patient pain, possibly due to both groups receiving patient-controlled analgesia pumps during the early postoperative period (days 1–2), which may have attenuated the differences in early pain intensity. Previous studies have shown that postoperative intravenous analgesia pumps can significantly reduce pain and promote patient coughing and early ambulation [ 29 ] .As postoperative time progresses, pain gradually decreases in both groups, and VAS scores decrease as recovery progresses. However, the observation group showed a faster and more significant reduction in pain. By removing the thick chest tube first and the negative pressure drainage ball tube afterward, the observation group had a significantly shorter duration of thick tube retention compared to the control group (3.26 ± 1.74 days vs. 5.50 ± 2.26 days, P < 0.001). No significant differences in VAS scores were observed between the two groups on postoperative days 1 and 2, but on day 3 (difference = − 0.53, P = 0.045) and day 5 (difference = − 1.30, P < 0.001), the VAS scores of the observation group were significantly lower than those of the control group. This suggests that the improved dual-tube drainage method may be more effective in alleviating pain during the recovery phase, offering a potential advantage in reducing late postoperative pain. Early removal of the thick tube is the core of this approach. Currently, most clinicians are gradually relaxing the threshold for drainage volume before tube removal, from 150 mL to 200 mL, and even up to 400 mL, believing that drainage volume is no longer a limiting factor for tube removal. However, they still adhere to the principle that the chest bottle should not have air leaks (bubbles) before removing the drainage tube [ 30 , 31 ] .High-risk air leak patients often experience postoperative air leaks. If the practice of removing the drainage tube only when there are no air leaks in the chest bottle is maintained, this will increase the duration of chest tube retention, which contradicts the current concept of fast-track recovery surgery [ 32 ] .In this study, two drainage tubes were inserted, and the thick tube was removed early in cases of minimal air leakage, while the thin tube was retained. The observation group had a significantly shorter drainage time for the thick tube compared to the control group (3.26 ± 1.74 days vs. 5.50 ± 2.26 days, P < 0.001). Given that early removal of the thick tube in the observation group might result in intrathoracic air, negative pressure created by the drainage ball was used for drainage. The drainage volume of the thick tube in the observation group was significantly reduced compared to the control group (490.79 ± 264.94 mL vs. 895.53 ± 722.08 mL, P = 0.002), but there was no significant difference in total drainage volume between the two groups (691.45 ± 365.58 mL vs. 895.53 ± 722.0 mL, P = 0.124), suggesting that the thin tube can take over the task of gas and fluid drainage after the thick tube is removed. Regarding complications, both groups experienced subcutaneous emphysema, a common complication after thoracic surgery for lung cancer, which can be treated with negative pressure suction or skin incision for gas drainage. The longer the chest tube is retained, the higher the risk of infection and tube displacement, especially with multiple chest tubes [ 33 ] ,In this study, the project team minimized these risks by adhering to strict surgical aseptic procedures and using sterilized water to irrigate the incision after muscle layer suturing, reducing the retention of free fat particles, and preventing fat liquefaction at the incision and subsequent incision or drainage tube infections. Postoperative standardized care and patient education were provided to prevent tube displacement. The observation group had a shorter retention time for the thick tube and only retained one thin tube afterward. No significant differences in postoperative complications were observed between the two groups, suggesting that the improved dual-tube drainage strategy may have potential safety advantages. This study still needs to address the following limitations. It is a single-center, small-sample randomized controlled trial, with an uneven sample size between groups. Differences in patient sources, surgeon experience, and postoperative management may affect the applicability of the conclusions to other institutions or populations. Current research investigating postoperative air leaks includes spraying biological glue on the wound to prevent leaks [ 34 ] and using a thoracic drainage monitoring system [ 35 ] ,for real-time feedback on draining gas and fluid. Due to institutional constraints, we could not compare the improved dual-tube drainage strategy with other drainage techniques (such as digital drainage systems or surgical sealant applications). Due to procurement policies of the institution, the drainage ball tubes used in this study were all supplied by a single manufacturer (Huacheng Medical Devices), which may introduce potential device-related bias. Limited by the sample size, we grouped patients with emphysema, pleural adhesions, or complex segmentectomies into the same group. The combined analysis of these high-risk factors may overlook differences in their effects on postoperative outcomes; thus, subgroup analyses are needed to clarify the extent of their influence. Moreover, due to the nature of the intervention, it was not possible to implement blinding for patients and healthcare personnel, which may introduce potential bias, particularly in the more subjective outcome measures (such as pain scores). The pain scores obtained in this study should be viewed as subjective evaluations influenced by certain psychological and behavioral factors. Finally, the follow-up period was relatively short, limited to outpatient reexaminations and telephone follow-ups within two weeks post-surgery. Therefore, we were unable to assess long-term prognosis indicators such as recurrence of pleural effusion, chronic pain, and quality of life. In future research, we plan to employ block randomization to ensure balanced sample sizes between groups and conduct multicenter studies with larger sample sizes covering multiple drainage modes to further validate the findings and elucidate the comparative advantages of this method. Detailed subgroup analyses will be carried out on high-risk air leak patients to clarify the specific impacts of each high-risk factor on surgical outcomes, with an extended follow-up period to explore the effects on long-term quality of life, recurrence of effusions, or chronic pain and other long-term indicators. 5 Conclusion the improved dual chest tube indwelling drainage method shows potential advantages in reducing postoperative pain and shortening drainage and hospital stay times for high-risk air leak patients following single-port thoracoscopic segmentectomy, with no observed trends of increased complications. This approach demonstrates certain feasibility and potential clinical value. These results indicate that the improved dual-tube drainage strategy offers potential benefits, which should be validated through multicenter studies in the future. Declarations Acknowledgements Not applicable. Author contributions ZZW-Experimental design, Data collection,analysis and Writing the paper. WFQ-Experimental design,Surgical implementation, Revising the paper.WBK-Data collection,analysis.CG-Surgical implementation RWM-Surgical implementation.All the authors critically reviewed the manuscript and approved the final version. All authors read and approved the final manuscript. Funding This study was supported by This study was supported by the Tongling City Science and Technology Plan Project (20230203052). Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate The study strictly adhered to the relevant provisions of the Declaration of Helsinki.It has been reviewed and approved by the Ethics Committee of Tongling People's Hospita（2024-KY014Y）. and the clinical trial was registered in the Chinese Clinical Trial Registry (No: MR-34-25-068342, 01/06/2024). All methods were conducted in accordance with the guidelines and regulations of the institutional review board. Prior to the start of the study, all participants were informed and their written informed consent was obtained.Patient participation in the research was entirely voluntary, and participants may withdraw at any time without affecting their routine treatment. All patient information remains strictly confidential, with research data used solely for academic purposes. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Author details 1 Tongling People's Hospital,Wannan Medical College. 2 The Department of Cardiothoracic Surgery, Tongling People's Hospital. 3 Tongling People's Hospital,Wannan Medical College. 4 The Department of Cardiothoracic Surgery, Tongling People's Hospital. 5 The Department of Cardiothoracic Surgery, Tongling People's Hospital. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–49. https://doi:10.3322/caac.21660 . Rodriguez GR, Kucera J, Antevil JL, Mullenix PS, Trachiotis GD. Contemporary video-assisted thoracoscopic lobectomy for early-stage lung cancer. J Laparoendosc Adv Surg Tech A. 2024;34(9):798–807. https://doi:10.1089/lap.2024.0281 . Lyons NB, Abdelhamid MO, Collie BL, Ramsey WA, O’Neil CF, Delamater JM, et al. 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Prospective randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg. 2001;71(5):1613–7. https://doi:10.1016/S0003-4975(01)02474-2 . Amore D, Caterino U, Casazza D, Ievoli R, Imitazione P, Saglia A, et al. Persistent alveolar air leak following pulmonary lobectomy: an old problem in a modern era. Monaldi Arch Chest Dis. 2023;93(4):2474. https://doi:10.4081/monaldi.2023.2474 . Kagimoto A, Ishida M, Mimura T. Significance of the Goddard score in predicting complications related to air leak after lobectomy. Ann Thorac Surg. 2024;118(1):233–9. https://doi:10.1016/j.athoracsur.2023.10.010 . Okubo Y, Yoshida Y, Yotsukura M, et al. Complex segmentectomy is not a complex procedure relative to simple segmentectomy. Eur J Cardiothorac Surg. 2021;61(1):100–7. http://doi:10.1093/ejcts/ezab367 . Ma Q, Tarabrin EA, Berikkhanov ZG, Ivanova MY, et al. Risk factors and clinical impact of prolonged air leak following video-assisted thoracoscopic surgery: a retrospective cohort study. Front Med (Lausanne). 2025;12:1549765. http://doi:10.3389/fmed.2025.1549765 . Pischik VG, Maslak OS, Obornev AD, Zinchenko EI, Kovalenko AI. Risk factors and outcomes of prolonged air leak after pulmonary resections. Indian J Thorac Cardiovasc Surg. 2019;35(4):564–8. http://doi:10.1007/s12055-019-00827-w . Murakami J, Ueda K, Tanaka T, et al. Grading of Emphysema Is Indispensable for Predicting Prolonged Air Leak After Lung Lobectomy. Ann Thorac Surg. 2018;105(4):1031–7. http://doi:10.1016/j.athoracsur.2017.11.053 . Gooseman MR, Brunelli A, Chaudhuri N, Milton R, Tcherveniakov P, Papagiannopoulos K, et al. Prolonged air leak after segmentectomy: incidence and risk factors. J Thorac Dis. 2023;15(2):858–65. http://doi:10.21037/jtd-22-623 . Adachi H, Wakimoto S, Ando K, Yamamoto T, Saito Y, Shiono S, et al. Optimal Chest Drainage Method After Anatomic Lung Resection: A Prospective Observational Study. Ann Thorac Surg. 2023;115(4):845–52. 10.1016/j.athoracsur.2022.06.042 . http://doi . Gioutsos K, Ehrenreich L, Azenha LF, Quapp CS, Kocher GJ, Lutz JA, et al. Randomized Controlled Trial of Thresholds for Drain Removal After Anatomic Lung Resection. Ann Thorac Surg. 2024;117(6):1103–9. http://doi:10.1016/j.athoracsur.2023.09.011 . Anderson D, Chen SA, Godoy LA, Brown LM, Cooke DT. Comprehensive Review of Chest Tube Management: A Review. JAMA Surg. 2022;157(3):269–74. 10.1001/jamasurg.2021.7050 . http://doi . Abouarab AA, Rahouma M, Kamel M, Ghaly G, Mohamed A. Single Versus Multi-Incisional Video-Assisted Thoracic Surgery: A Systematic Review and Meta-analysis. J Laparoendosc Adv Surg Tech A. 2018;28(2):174–85. 10.1089/lap.2017.0446 . http://doi . Bach K, Volberg C, Wiesmann T, Wulf H, Schubert AK. Perioperative Schmerztherapie bei minimal-invasiver Thoraxchirurgie. Anaesthesiologie. 2023;72(10):726–36. http://doi:10.1007/s00101-023-01329-6 . You J, Zhang H, Li W, Dai N, Zheng Z. Single versus double chest drains after pulmonary lobectomy: a systematic review and meta-analysis. World J Surg Oncol. 2020;18(1):175. http://doi:10.1186/s12957-020-01945 . Xu J, Pu M, Xu X, Xiang J, Rong X. The postoperative analgesic effect of intercostal nerve block and intravenous patient-controlled analgesia on patients undergoing lung cancer surgery. Am J Transl Res. 2021;13(8):9790–5. PMID: 34540111. Gao S, Zhang Z, Aragón J, Brunelli A, Cassivi S, Chai Y, et al. The Society for Translational Medicine: clinical practice guidelines for the postoperative management of chest tube for patients undergoing lobectomy. J Thorac Dis. 2017;9(9):3255–64. http://doi:10.21037/jtd.2017.08.165 . Homma T. A series of experiences with TissuePatch™ for alveolar air leak after pulmonary resection. Gen Thorac Cardiovasc Surg. 2023;71(10):570–6. http://doi:10.1007/s11748-023-01921-y . Yang D, Zheng X. Enhanced recovery after surgery program focusing on chest tube management improves surgical recovery after video-assisted thoracoscopic surgery. J Cardiothorac Surg. 2024;19(1):253. http://doi:10.1186/s13019-024-02762-3 . Kawaguchi Y. Preferred management of post-operative chest tube placement after lung resection. J Thorac Dis. 2024;16(8):5480–3. http://doi:10.21037/jtd-24-1046 . Homma T. A series of experiences with TissuePatch™ for alveolar air leak after pulmonary resection. Gen Thorac Cardiovasc Surg. 2023;71(10):570–6. http://doi:10.1007/s11748-023-01921-y . Embalabala A, Mitzman B, Crabtree T. Digital pleural versus analog drainage devices for postoperative management of patients after pulmonary resection. Eur J Cardiothorac Surg. 2025;67(Supplement1):i31–40. http://doi:10.1093/ejcts/ezae215 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 05 Apr, 2026 Reviews received at journal 10 Feb, 2026 Reviews received at journal 08 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers invited by journal 22 Jan, 2026 Editor assigned by journal 11 Nov, 2025 Submission checks completed at journal 11 Nov, 2025 First submitted to journal 09 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8069853","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578812034,"identity":"a6b8ff28-881b-4c5e-b2a1-b4e6498190d8","order_by":0,"name":"Zhaowang Zhu","email":"","orcid":"","institution":"Wannan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Zhaowang","middleName":"","lastName":"Zhu","suffix":""},{"id":578812035,"identity":"2974456b-be16-4719-91c3-057482080f1e","order_by":1,"name":"Fangqing 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1","display":"","copyAsset":false,"role":"figure","size":1359965,"visible":true,"origin":"","legend":"\u003cp\u003eChest Tube Placement\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8069853/v1/e2ff7ace082ac1ae9a3c6203.png"},{"id":101172102,"identity":"a5f349ca-0d92-4dad-b273-d30de8cae8c3","added_by":"auto","created_at":"2026-01-27 00:12:21","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":82879,"visible":true,"origin":"","legend":"\u003cp\u003ePlacement Completed, Sutured and Secured\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8069853/v1/6de832fa35d467f1362a9232.jpeg"},{"id":101172105,"identity":"63a8356c-601f-4baf-b5ca-ae97cc887e70","added_by":"auto","created_at":"2026-01-27 00:12:21","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":39762,"visible":true,"origin":"","legend":"\u003cp\u003eRemoval of the Drainage Tube\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8069853/v1/514f76c08cd3ee8e621b330f.jpeg"},{"id":101208440,"identity":"43a9fb15-6a5f-45f8-a814-98a2de855813","added_by":"auto","created_at":"2026-01-27 10:10:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2567494,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8069853/v1/673f36b5-5c2f-446c-81a5-0301676db45a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of Improved Indwelling Double Chest Tubes in High-Risk Air Leak Patients Undergoing Single-Port Thoracoscopic Pulmonary Segmentectomy","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eLung cancer is the most common malignant tumor\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e,and single-port thoracoscopic surgery is the mainstream surgical method for lung cancer treatment \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.To observe for active bleeding in the thoracic cavity and to drain any air leaks or effusions, a thicker chest drainage tube is typically inserted \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.However, due to the limitations of the incision location in single-port thoracoscopic surgery, post-operative drainage effectiveness can be poor, and pain associated with the drainage tube can adversely affect the patient's recovery time and quality of life\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.For certain patients with emphysema\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e,pleural adhesions\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003eor those undergoing complex segmentectomy\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e,the condition of their pulmonary function is often poor. Intraoperative dissection of adhesions and the handling of multiple inter-segmental planes can result in significant damage to lung tissue, often leading to persistent air leaks post-operatively. Managing these patients in the same manner as other \"normal\" patients can lead to a significantly prolonged duration of chest tube placement for this group. Currently, there are still no effective management methods for these patients, and long-term retention of a single chest tube is commonly used, increasing patient pain and reducing post-operative satisfaction.\u003c/p\u003e \u003cp\u003eThe project team classifies those meeting one or more of the following criteria as having high-risk factors for post-operative air leaks:\u003c/p\u003e \u003cp\u003ea)Preoperative chest CT scan of the target lobe showed moderate or severe emphysema, defined as a Goddard score\u0026thinsp;\u0026ge;\u0026thinsp;2 (more than 25% of the lung field involved);\u003c/p\u003e \u003cp\u003eb)Moderate or severe pleural adhesions identified intraoperatively, defined as adhesion grade\u0026thinsp;\u0026ge;\u0026thinsp;4, requiring dissection with energy devices;\u003c/p\u003e \u003cp\u003ec)Resection of a complex segment, involving dissection across multiple intersegmental planes.\u003c/p\u003e \u003cp\u003eThe project team has proposed an improved dual chest tube indwelling drainage method for high-risk air leak patients. This method involves placing two drainage tubes of different diameters through the same incision, optimizing the placement of the chest tubes, early removal of the thicker tube while retaining the thinner one, among other strategies. This approach aims to shorten the duration of placement for the thicker tube and reduce patient pain while ensuring effective drainage. Compared to traditional single-tube drainage methods, this has certain advantages, which are reported as follows.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003e2.1 Randomization and blinding\u003c/p\u003e\n\u003cp\u003eA total of 90 patients who underwent single-port thoracoscopic lung cancer surgery at Tongling People\u0026apos;s Hospital, affiliated with Wannan Medical College, from June 2024 to March 2025 were selected. Random numbers were generated using computer software (IBM SPSS Statistics 26.0), and based on whether the random number was greater than 0.5, participants were assigned to the observation group (n = 40) or the control group (n = 50). The allocation sequence was concealed in opaque, sealed envelopes labeled sequentially. After obtaining informed consent, the operating room nurse opened the next envelope immediately before the surgery to determine the group assignment. Due to the significant differences in the type and number of chest drainage tubes, blinding of the surgeons and patients was not feasible. To minimize bias, outcome assessments (including VAS scores, duration of air leaks, total drainage volume, duration of drainage, and length of hospital stay) were conducted by ward nurses who were unaware of the group allocation, and data analysis was performed by a statistician who also was not aware of the assignment.\u003c/p\u003e\n\u003cp\u003e2.2 Patient selection\u003c/p\u003e\n\u003cp\u003eInclusion criteria: ① patients who underwent single-port segmentectomy; ② patients aged 20-80 years old, male or female; ③ patients assessed as having a high risk of postoperative air leakage, defined as meeting one or more of the following conditions:\u003cbr\u003e\u0026nbsp;a) the target lobe of the resected segment showed moderate or severe emphysema on preoperative chest CT, defined as a Goddard score \u0026ge;2 (more than 25% of the lung field involved);\u003cbr\u003e\u0026nbsp;b) moderate or severe pleural adhesions were observed intraoperatively, defined as adhesion grade \u0026ge;4, requiring dissection with energy devices (e.g., electrocautery);\u0026nbsp; c) the resected segment was a complex segment, involving dissection across multiple intersegmental planes.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: 1) .preoperative combination of lung infection, tuberculosis, and tumors in other parts of the body; 2) .combination of other major organ dysfunction and psychiatric diseases, cognitive communication disorders; 3). massive air leakage from the expanding lungs during the operation; 4). blockage of closed chest drains; 5) .imperfect clinical data; 6) .death or loss of visits.\u003c/p\u003e\n\u003cp\u003e2.2 Patient selection\u003c/p\u003e\n\u003cp\u003eInclusion criteria: ①patients who underwent single-port thoracoscopic segmental lung resection; ②patients aged 20-80 years old, male or female;③patients assessed as having a high risk of postoperative air leakage, defined as meeting one or more of the following conditions:\u003cbr\u003e\u0026nbsp;a) the target lobe of the resected segment showed moderate or severe emphysema on preoperative chest CT, defined as a Goddard score \u0026ge;2 (more than 25% of the lung field involved);\u003cbr\u003eb) moderate or severe pleural adhesions were observed intraoperatively, defined as adhesion grade \u0026ge;4, requiring dissection with energy devices (e.g., electrocautery); c) the resected segment was a complex segment, involving dissection across multiple intersegmental planes.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: 1) .preoperative combination of lung infection, tuberculosis, and tumors in other parts of the body; 2) .combination of other major organ dysfunction and psychiatric diseases, cognitive communication disorders; 3). massive air leakage from the expanding lungs during the operation; 4). blockage of closed chest drains; 5) .imperfect clinical data; 6) .death or loss of visits.\u003c/p\u003e\n\u003cp\u003e2.3 Catheterization Method\u003c/p\u003e\n\u003cp\u003eAll patients were positioned in the lateral decubitus position under general anesthesia with double-lumen endotracheal intubation. A surgical incision approximately 3 cm long was made in the 4th or 5th intercostal space along the anterior axillary line or mid-axillary line, followed by pulmonary segmentectomy according to the size of the primary tumor. Routine mediastinal lymphadenectomy was performed during the surgery. Prior to closing the chest, suctioning and lung inflation were carried out.\u003c/p\u003e\n\u003cp\u003eObservation Group: An 28 Fr closed chest drain was placed at the anterior aspect of the original incision, approximately 12 cm deep in the thorax. A single negative pressure drainage ball (200 ml, diameter 4.8 mm, maximum negative pressure -10 cm H2O, manufacturer: Huacheng Medical Equipment Co.) was inserted as a drainage ball tube behind the original incision, traversing the posterior chest and positioned at the apex of the thorax to avoid being inserted into the interlobar fissures. Care was taken to have multiple side holes on both tubes, with the last side hole approximately 3 cm from the chest wall, secured with sutures. See Fig.1-2.\u003c/p\u003e\n\u003cp\u003eControl Group: A single 28 Fr closed chest drain was placed above the original incision, also approximately 12 cm deep in the thorax, with the last side hole about 3 cm from the chest wall, and secured with sutures at the incision site.\u003c/p\u003e\n\u003cp\u003e2.4 Chest Tube Management\u003c/p\u003e\n\u003cp\u003e2.4.1 Observation Group: The thick chest tube is removed when there are no or only a small number of air bubbles (air leak grade 1) and the chest drainage volume is less than 300 mL. The negative pressure drainage ball tube is removed when there is no significant drainage fluid (less than 100 mL) and the ball remains collapsed. See Fig.3.\u003c/p\u003e\n\u003cp\u003e2.4.2 Control Group: Indications for chest tube removal: 1) Follow-up chest X-ray shows complete re-expansion of the remaining lung (with no residual cavity in the thoracic cavity) and no signs of pleural effusion or pneumothorax; 2) No air bubbles overflow from the drainage bottle when the patient coughs; 3) The drainage fluid at the time of tube removal is non-bloody, non-chylous, and non-purulent; 4) Chest drainage volume \u0026le;200 mL/24h.\u003c/p\u003e\n\u003cp\u003eNurses observe and record the negative pressure ball drainage every 2 hours and maintain the ball in a state of maximum negative pressure.\u003c/p\u003e\n\u003cp\u003ePostoperatively, patients are encouraged to actively cough and expectorate and to engage in early ambulation. Postoperative pain management is performed using an electronic analgesic pump by the anesthesiology department (effective for 48 hours). If necessary, postoperative adjuvant pain medications (e.g., flurbiprofen ester, tramadol) are used.\u003c/p\u003e\n\u003cp\u003e2.5 Observational Indicators and Evaluation Criteria\u003c/p\u003e\n\u003cp\u003e2.5.1 Collection of pain scores, chest tube indwelling time, drainage volume, hospitalization time, and postoperative complications, including pneumothorax, pleural effusion, subcutaneous emphysema, pulmonary infection, incision infection, and incision hernia. Postoperative follow-up is conducted within two weeks after surgery through outpatient chest X-ray examination and telephone follow-up by nursing staff to monitor recovery and detect potential complications.\u003c/p\u003e\n\u003cp\u003e2.5.2 Evaluation of Emphysema is conducted using the subjective visual Goddard scoring method for emphysema \u003csup\u003e[8\u003c/sup\u003e\u003csup\u003e,9]\u003c/sup\u003e:Patients were included if the Goddard score was \u0026ge;2 in the lung field of the lobe containing the segment to be resected, as assessed on preoperative chest CT images.(Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1. Goddard Scoring Table\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eGoddard score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eEmphysema as a proportion of this transected anatomical level (emphysema %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e0%\u0026lt; Emphysema %\u0026le;25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e25%\u0026lt; Emphysema %\u0026le;50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e50%\u0026lt; Emphysema %\u0026le;75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e75%\u0026lt; Emphysema %\u0026le;100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Typically, three transverse anatomical levels of both lungs are selected for evaluation \u0026mdash; the upper lung level at the aortic arch, the middle lung level at the carina, and the lower lung level approximately 1 cm above the top of the right diaphragm. In total, the two lungs are divided into six anatomical levels, each scored from 0 to 4, yielding a total score range of 0\u0026ndash;24. Mild emphysema is defined as a total score \u0026le;8, moderate as 8 \u0026lt; total score \u0026le;16, and severe as total score \u0026gt;16.\u003c/p\u003e\n\u003cp\u003e2.5.3 Pleural Adhesion Grading.Based on the studies by Oncel\u003csup\u003e[10]\u003c/sup\u003eand Li\u003csup\u003e[11]\u003c/sup\u003ethe grading criteria are as follows:Grade 0: No pleural adhesions;Grade 1: Loose and thin pleural adhesions that can be separated with traction;Grade 2: Pleural adhesions requiring blunt dissection;Grade 3: Pleural adhesions requiring sharp dissection;Grade 4: Pleural injury during the separation of adhesions;Grade 5: Subpleural tissue injury during the separation of adhesions.\u003c/p\u003e\n\u003cp\u003e2.5.4 Definition of Complex Segmentectomy\u003csup\u003e[12]\u003c/sup\u003e:A surgical procedure that involves handling more than two intersegmental planes, including single complex pulmonary segmentectomy (right S1, S2, S3, S4, S7, S8, S9, S10; left S1+2, S3, S7, S8, S9, S10) and combined pulmonary segmentectomy (any combination of the aforementioned complex segments).\u003c/p\u003e\n\u003cp\u003e2.5.5 Pain Assessment\u003c/p\u003e\n\u003cp\u003ePain is assessed using the Visual Analog Scale (VAS)\u003csup\u003e[13]\u003c/sup\u003e,with a total score range from 0 to 10. A score of 0 represents no pain, 1-3 indicates mild pain, 4-7 indicates moderate pain, and above 7 indicates severe pain.\u003c/p\u003e\n\u003cp\u003e2.5.6 Air Leak GradingAir leaks are graded based on severity, combining previous studies\u003csup\u003e[14\u003c/sup\u003e\u003csup\u003e,15]\u003c/sup\u003e，and are categorized according to the patient\u0026rsquo;s respiratory status and the presence of bubbles in the drainage bottle:Grade 0: No bubbles after three consecutive coughs;Grade 1: At least one instance of bubbles during three consecutive coughs;Grade 2: Continuous bubbles during active coughing;Grade 3: Small, persistent bubbles during quiet breathing;Grade 4: Large, persistent air leak during quiet breathing.To minimize subjectivity, air leak grades for each patient are independently assessed by three senior thoracic surgeons. The final grading is determined by consensus among the assessors to ensure consistency and reliability in the evaluations.\u003c/p\u003e\n\u003cp\u003e2.6 Statistical Analysis\u003c/p\u003e\n\u003cp\u003eData were processed using SPSS 26.0 statistical software. A linear mixed-effects model (LMM) was used to analyze the changes in VAS scores over time and between groups. The model was set with patient identification as a random intercept, and group (observation group vs. control group), time (postoperative days 1, 2, 3, and 5), and the group \u0026times; time interaction as fixed effects. The covariance structure used was autoregressive AR(1), and the parameter estimation method was restricted maximum likelihood (REML). All tests were two-tailed, and P \u0026lt; 0.05 was considered statistically significant. For data following a normal distribution, t-tests were used, with continuous variables presented as x \u0026plusmn; s. Categorical data were presented as frequency/percentage (%) and analyzed using the chi-square test. P \u0026lt; 0.05 was considered statistically significant. For skewed distributions, non-parametric tests (e.g., Mann-Whitney U test) were used.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003eA total of 90 patients were included, with 40 patients in the observation group and 50 patients in the control group. The difference in the number of participants between the groups resulted from simple randomization. However, no significant differences were found in baseline characteristics such as age, gender, and BMI between the two groups (p \u0026gt; 0.05, Table 2).\u003c/p\u003e\n\u003cp\u003eTable 2. General Information\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003eObservation Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;P Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eMale/Female (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e17(42.5%)/23(57.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e28(56%)/22(44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.203\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e61.05\u0026plusmn;10.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e62.76\u0026plusmn;12.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.516\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eBMI(kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e23.04\u0026plusmn;3.716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e24.07\u0026plusmn;8.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.546\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e3.2 Primary Endpoint Results\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 3. Fixed Effects Parameter Estimates of the Linear Mixed-Effects Model\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFixed Effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026beta; Estimate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eStandard Error (SE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e95%-CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ez-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eIntercept (Control Group, Day 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e3.978\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e3.679\u0026ndash;4.277\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e26.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eObservation Group vs Control Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.230\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-0.258\u0026ndash;0.644\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.402\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eTime (Day 2 vs Day 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-0.681\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-1.022\u0026ndash;-0.340\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-3.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eTime (Day 3 vs Day 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-0.908\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-1.249\u0026ndash;-0.567\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-5.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eTime (Day 5 vs Day 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-0.682\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-1.023\u0026ndash;-0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-3.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eGroup \u0026times; Time (Day 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-0.829\u0026ndash;0.200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.230\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eGroup \u0026times; Time (Day 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-1.041\u0026ndash;-0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.045*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eGroup \u0026times; Time (Day 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-1.301\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-1.816\u0026ndash;-0.787\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-4.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026lt;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 4. Model-Adjusted Mean (Marginal Mean) VAS Scores for Each Group at Each Time Point\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eTime (Days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eControl Group Estimated Mean (95% -CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eObservation Group Estimated Mean (95% -CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eIntergroup P Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDay 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.98 (3.68\u0026ndash;4.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e4.17 (3.89\u0026ndash;4.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDay 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.30 (3.00\u0026ndash;3.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.20 (2.90\u0026ndash;3.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDay 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.07 (2.77\u0026ndash;3.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e2.55 (2.25\u0026ndash;2.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.045*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDay 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.30 (3.00\u0026ndash;3.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e2.00 (1.70\u0026ndash;2.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026lt;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 5. Differences in VAS Scores Between the Two Groups at Each Time Point (Observation Group - Control Group)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eTime (Days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDifference Estimate (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eZ -Value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eP -Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDay 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e+0.19 (-0.26\u0026ndash;0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.402\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDay 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-0.32 (-0.83\u0026ndash;0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.230\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDay 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-0.53 (-1.04\u0026ndash;-0.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.045*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDay 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-1.30 (-1.82\u0026ndash;-0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-4.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026lt;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: The reference category is the control group on postoperative day 1; P \u0026lt; 0.05; *P \u0026lt; 0.01.\u003c/p\u003e\n\u003cp\u003eThe LMM showed a significant main effect of time (P \u0026lt; 0.001), with VAS scores gradually decreasing over time post-surgery. The main effect of group was not significant (P = 0.402), but the group \u0026times; time interaction effect was significant (P \u0026lt; 0.01) (Table 3). Specifically, there was no statistically significant difference in VAS scores between the two groups on postoperative days 1 and 2; however, on day 3 (95% CI = -0.53, P = 0.045) and day 5 (95% CI = -1.30, P \u0026lt; 0.001), the VAS score in the observation group was significantly lower than that in the control group (Tables 4 and 5). These results suggest that the observation group effectively reduced pain in the later stages of postoperative recovery.\u003c/p\u003e\n\u003cp\u003e3.3 Secondary Endpoint Results\u003c/p\u003e\n\u003cp\u003eTable 6. Secondary Endpoint Results\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eObservation Group（\u003cimg width=\"7\" height=\"17\" src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img1769176873.gif\" alt=\"image\"\u003e\u0026plusmn;SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eControl Group（\u003cimg width=\"7\" height=\"17\" src=\"https://myfiles.space/user_files/127393_c7e80a1c9bb65875/127393_custom_files/img1769176873.gif\" alt=\"image\"\u003e\u0026plusmn;SD）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eT-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eThick Tube Drainage Time (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e3.26\u0026plusmn;1.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e5.50\u0026plusmn;2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e4.188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eThin Tube Drainage Time (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e4.66\u0026plusmn;2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\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: 108px;\"\u003e\n \u003cp\u003eTotal Drainage Time (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e4.66\u0026plusmn;2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e5.50\u0026plusmn;2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e1.485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eThick Tube Drainage Volume (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e490.79\u0026plusmn;264.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e895.53\u0026plusmn;722.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e3.244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eThin Tube Drainage Volume (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e201.18\u0026plusmn;117.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\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: 108px;\"\u003e\n \u003cp\u003eTotal Drainage Volume (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e691.45\u0026plusmn;365.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e895.53\u0026plusmn;722.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eSurgical Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e151.41\u0026plusmn;40.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e150.24\u0026plusmn;47.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.907\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eBlood Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e27.95\u0026plusmn;7.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e33.29\u0026plusmn;16.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e1.949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 7. Length of Hospital Stay\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCase（n）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eLength of Hospital Stay(day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eObservation Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e9（8-11）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e13（9-16）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\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\u003eTable 8.Incidence of Complications\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"570\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eObservation group/case\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eControl group/case\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eSubcutaneous emphysema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003ePleural effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003ePneumothorax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eLung infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e0.318\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eIncisional hernia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003ePuncture tube placement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eChest tube blockage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e0.841\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eRegarding the secondary outcome indicators, for the thick tube (28 Fr), the observation group had a significantly shorter drainage time (3.26 \u0026plusmn; 1.74 days vs. 5.50 \u0026plusmn; 2.26 days, P \u0026lt; 0.001), and the thick tube drainage volume was significantly reduced in both groups (490.79 \u0026plusmn; 264.94 mL vs. 895.53 \u0026plusmn; 722.08 mL, P = 0.002) (Table 6). Postoperative hospital stay was also shorter (median 9 days [IQR 8-11] vs. 13 days [IQR 9-16], P \u0026lt; 0.001)(Table 7). No significant differences were observed between the two groups in total drainage time, total drainage volume, surgical time, and intraoperative blood loss (P \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e3.4 Complications\u003c/p\u003e\n\u003cp\u003ePatients who were readmitted due to pneumothorax, massive pleural effusion, or pulmonary infection within 30 days were recorded as unplanned readmissions. Several patients in this study experienced unplanned readmissions. Both groups had cases of subcutaneous emphysema (3/40 (7.5%) vs. 2/50 (4%), P = 0.679), which improved with negative pressure suction treatment, and follow-up chest X-rays showed no significant pneumothorax. Each group had one patient who developed pleural effusion after discharge, which was managed with puncture and drainage. The incidence of thoracic infections in both groups(2.5% (1/40) vs. 6% (3/50), P = 0.318)(Table 8). No cases of drainage tube-related infections or dislocations were observed in either group. During the follow-up period, no cases of re-intervention or long-term recurrence were observed.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003ePatients with pleural adhesions, emphysema, and complex segmentectomy are considered high-risk groups for persistent air leaks after segmentectomy \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e.These patients tend to have slower recovery, longer chest tube retention, and prolonged pain duration, thus requiring more refined postoperative management. The mechanisms leading to postoperative air leaks vary among these patients; pleural adhesions can complicate surgical exposure, leading to pleural injury, longer operation times, and increased postoperative drainage, thereby elevating the risk of air leaks\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. In patients with emphysema, particularly elderly smokers, the risk of postoperative air leaks is significantly heightened due to the fragility of lung tissue and poor healing capacity \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e.Complex segmentectomy involve addressing multiple intersegmental planes, making the surgical procedure intricate and increasing the risk of parenchymal tear and air leak due to the length of sutures \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e,Given these high-risk factors, conventional postoperative drainage methods often struggle to meet the dual needs of pain relief and early tube removal. Several studies\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003ehave found that the volume of pleural effusion in lung cancer patients typically peaks on the first day after pulmonary resection, and subsequently decreases as wound exudation and pleural cavity absorption occur. Retaining only a thin tube might not achieve adequate drainage due to its smaller diameter \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e.In this study, we employed an improved dual-tube drainage system to achieve sufficient drainage early on through the thick chest tube, and once the pleural effusion peaks, we utilized the thin tube for drainage, thereby reducing the retention time of the thick tube and alleviating patient pain.\u003c/p\u003e \u003cp\u003eThe advantage of single-port thoracoscopy is the smaller surgical incision, which reduces muscle damage and intercostal nerve compression\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e,Intercostal nerve injury can lead to postoperative pain, and the compression of the intercostal nerves by postoperative drainage tubes can exacerbate this pain\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e.Some studies have shown\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e, that the placement of thick chest tubes or multiple chest tubes can easily lead to compression of the intercostal nerves, increasing postoperative pain. However, in this study, no significant main effect was found in the VAS scores between the two patient groups, indicating that the overall average VAS scores of both groups did not differ at any postoperative time point. This finding suggests that the dual-tube indwelling method used in this study does not significantly increase patient pain, possibly due to both groups receiving patient-controlled analgesia pumps during the early postoperative period (days 1\u0026ndash;2), which may have attenuated the differences in early pain intensity. Previous studies have shown that postoperative intravenous analgesia pumps can significantly reduce pain and promote patient coughing and early ambulation\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e.As postoperative time progresses, pain gradually decreases in both groups, and VAS scores decrease as recovery progresses. However, the observation group showed a faster and more significant reduction in pain. By removing the thick chest tube first and the negative pressure drainage ball tube afterward, the observation group had a significantly shorter duration of thick tube retention compared to the control group (3.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74 days vs. 5.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26 days, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant differences in VAS scores were observed between the two groups on postoperative days 1 and 2, but on day 3 (difference\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.53, P\u0026thinsp;=\u0026thinsp;0.045) and day 5 (difference\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.30, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), the VAS scores of the observation group were significantly lower than those of the control group. This suggests that the improved dual-tube drainage method may be more effective in alleviating pain during the recovery phase, offering a potential advantage in reducing late postoperative pain.\u003c/p\u003e \u003cp\u003eEarly removal of the thick tube is the core of this approach. Currently, most clinicians are gradually relaxing the threshold for drainage volume before tube removal, from 150 mL to 200 mL, and even up to 400 mL, believing that drainage volume is no longer a limiting factor for tube removal. However, they still adhere to the principle that the chest bottle should not have air leaks (bubbles) before removing the drainage tube\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e.High-risk air leak patients often experience postoperative air leaks. If the practice of removing the drainage tube only when there are no air leaks in the chest bottle is maintained, this will increase the duration of chest tube retention, which contradicts the current concept of fast-track recovery surgery\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e.In this study, two drainage tubes were inserted, and the thick tube was removed early in cases of minimal air leakage, while the thin tube was retained. The observation group had a significantly shorter drainage time for the thick tube compared to the control group (3.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74 days vs. 5.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26 days, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Given that early removal of the thick tube in the observation group might result in intrathoracic air, negative pressure created by the drainage ball was used for drainage. The drainage volume of the thick tube in the observation group was significantly reduced compared to the control group (490.79\u0026thinsp;\u0026plusmn;\u0026thinsp;264.94 mL vs. 895.53\u0026thinsp;\u0026plusmn;\u0026thinsp;722.08 mL, P\u0026thinsp;=\u0026thinsp;0.002), but there was no significant difference in total drainage volume between the two groups (691.45\u0026thinsp;\u0026plusmn;\u0026thinsp;365.58 mL vs. 895.53\u0026thinsp;\u0026plusmn;\u0026thinsp;722.0 mL, P\u0026thinsp;=\u0026thinsp;0.124), suggesting that the thin tube can take over the task of gas and fluid drainage after the thick tube is removed. Regarding complications, both groups experienced subcutaneous emphysema, a common complication after thoracic surgery for lung cancer, which can be treated with negative pressure suction or skin incision for gas drainage. The longer the chest tube is retained, the higher the risk of infection and tube displacement, especially with multiple chest tubes \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e,In this study, the project team minimized these risks by adhering to strict surgical aseptic procedures and using sterilized water to irrigate the incision after muscle layer suturing, reducing the retention of free fat particles, and preventing fat liquefaction at the incision and subsequent incision or drainage tube infections. Postoperative standardized care and patient education were provided to prevent tube displacement. The observation group had a shorter retention time for the thick tube and only retained one thin tube afterward. No significant differences in postoperative complications were observed between the two groups, suggesting that the improved dual-tube drainage strategy may have potential safety advantages.\u003c/p\u003e \u003cp\u003eThis study still needs to address the following limitations. It is a single-center, small-sample randomized controlled trial, with an uneven sample size between groups. Differences in patient sources, surgeon experience, and postoperative management may affect the applicability of the conclusions to other institutions or populations. Current research investigating postoperative air leaks includes spraying biological glue on the wound to prevent leaks\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003eand using a thoracic drainage monitoring system\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e,for real-time feedback on draining gas and fluid. Due to institutional constraints, we could not compare the improved dual-tube drainage strategy with other drainage techniques (such as digital drainage systems or surgical sealant applications). Due to procurement policies of the institution, the drainage ball tubes used in this study were all supplied by a single manufacturer (Huacheng Medical Devices), which may introduce potential device-related bias. Limited by the sample size, we grouped patients with emphysema, pleural adhesions, or complex segmentectomies into the same group. The combined analysis of these high-risk factors may overlook differences in their effects on postoperative outcomes; thus, subgroup analyses are needed to clarify the extent of their influence. Moreover, due to the nature of the intervention, it was not possible to implement blinding for patients and healthcare personnel, which may introduce potential bias, particularly in the more subjective outcome measures (such as pain scores). The pain scores obtained in this study should be viewed as subjective evaluations influenced by certain psychological and behavioral factors. Finally, the follow-up period was relatively short, limited to outpatient reexaminations and telephone follow-ups within two weeks post-surgery. Therefore, we were unable to assess long-term prognosis indicators such as recurrence of pleural effusion, chronic pain, and quality of life. In future research, we plan to employ block randomization to ensure balanced sample sizes between groups and conduct multicenter studies with larger sample sizes covering multiple drainage modes to further validate the findings and elucidate the comparative advantages of this method. Detailed subgroup analyses will be carried out on high-risk air leak patients to clarify the specific impacts of each high-risk factor on surgical outcomes, with an extended follow-up period to explore the effects on long-term quality of life, recurrence of effusions, or chronic pain and other long-term indicators.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003ethe improved dual chest tube indwelling drainage method shows potential advantages in reducing postoperative pain and shortening drainage and hospital stay times for high-risk air leak patients following single-port thoracoscopic segmentectomy, with no observed trends of increased complications. This approach demonstrates certain feasibility and potential clinical value. These results indicate that the improved dual-tube drainage strategy offers potential benefits, which should be validated through multicenter studies in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZZW-Experimental design, Data collection,analysis and Writing the paper. WFQ-Experimental design,Surgical implementation, Revising the paper.WBK-Data collection,analysis.CG-Surgical implementation RWM-Surgical implementation.All the authors critically reviewed the manuscript and approved the final version. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by This study was supported by the Tongling City Science and Technology Plan Project (20230203052).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study strictly adhered to the relevant provisions of the Declaration of Helsinki.It has been reviewed and approved by the Ethics Committee of Tongling People\u0026apos;s Hospita（2024-KY014Y）. and the clinical trial was registered in the Chinese Clinical Trial Registry (No:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMR-34-25-068342, 01/06/2024). All methods were conducted in accordance with the guidelines and regulations of the institutional review board. Prior to the start of the study, all participants were informed and their written informed consent was obtained.Patient participation in the research was entirely voluntary, and participants may withdraw at any time without affecting their routine treatment. All patient information remains strictly confidential, with research data used solely for academic purposes.\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\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eTongling People\u0026apos;s Hospital,Wannan Medical College.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eThe Department of Cardiothoracic Surgery, Tongling People\u0026apos;s Hospital.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eTongling People\u0026apos;s Hospital,Wannan Medical College.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eThe Department of Cardiothoracic Surgery, Tongling People\u0026apos;s Hospital.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003eThe Department of Cardiothoracic Surgery, Tongling People\u0026apos;s Hospital.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. 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Digital pleural versus analog drainage devices for postoperative management of patients after pulmonary resection. Eur J Cardiothorac Surg. 2025;67(Supplement1):i31\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://doi:10.1093/ejcts/ezae215\u003c/span\u003e\u003cspan address=\"http://doi:10.1093/ejcts/ezae215\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Single-port thoracoscopy, lung cancer, negative pressure drainage ball, closed thoracic drainage, rapid recovery","lastPublishedDoi":"10.21203/rs.3.rs-8069853/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8069853/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackgroun\u003c/strong\u003ed\u003cstrong\u003e:\u003c/strong\u003e For patients with high-risk factors such as pleural adhesions, emphysema, or complex pulmonary segment resection, the use of traditional single chest tube drainage post-operatively can lead to increased pain and delayed recovery. This study aims to explore the application value of the improved dual chest tube indwelling drainage method in reducing pain and improving recovery in such patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A prospective randomized controlled trial design was employed, enrolling 90 patients who underwent single-port thoracoscopic pulmonary segmentectomy in the Department of Thoracic Surgery at Tongling People's Hospital, affiliated with Wannan Medical College, from June 2023 to March 2025. Patients were divided into a control group (n=50, conventional 28 Fr chest tube placed through the original incision) and an observation group (n=40, improved dual tube drainage method: one 28 Fr chest tube placed in front of the incision, and a negative pressure drainage ball tube placed behind the incision). The primary endpoint was post-operative pain score (VAS), analyzed using a linear mixed-effects model. Secondary endpoints included drainage time, drainage volume, post-operative hospital stay, and related post-operative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The VAS scores demonstrated a significant main effect of time (P\u0026lt;0.001), and there was a significant interaction effect between group and time (P\u0026lt;0.01), indicating that the observation group experienced a faster decrease in post-operative pain. On postoperative day 3 (95% CI=-0.53, P=0.045) and day 5 (95% CI=-1.30, P\u0026lt;0.001), the VAS scores in the observation group were significantly lower than those in the control group. In terms of secondary outcomes, the drainage time in the observation group was significantly shorter than that in the control group (3.26 ± 1.74 days vs. 5.50 ± 2.26 days, P\u0026lt;0.001), with a lower total drainage volume (691.45 ± 365.58 ml vs. 895.53 ± 722.08 ml, P = 0.002) and a shorter postoperative hospital stay (9 [8–11] days vs. 13 [9–16] days, P\u0026lt;0.001). There were no statistically significant differences in surgical time, intraoperative bleeding volume, and complications between the two groups (P\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe improved dual chest tube indwelling drainage method shows potential advantages in reducing postoperative pain and shortening drainage and hospital stay times for high-risk air leak patients following single-port thoracoscopic pulmonary segmentectomy, with no observed trend of increased complications, indicating its feasibility and potential clinical value.\u003c/p\u003e","manuscriptTitle":"Application of Improved Indwelling Double Chest Tubes in High-Risk Air Leak Patients Undergoing Single-Port Thoracoscopic Pulmonary Segmentectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 00:12:16","doi":"10.21203/rs.3.rs-8069853/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-05T08:40:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T06:00:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T23:14:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302716724302768604049411663123999882479","date":"2026-02-08T11:24:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20525624091030291407145885211552275310","date":"2026-02-02T12:19:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-22T07:08:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-11T14:44:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-11T14:44:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-11-09T14:47:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d3a67313-5fa3-470b-97aa-7cfe37062933","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-05T08:54:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 00:12:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8069853","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8069853","identity":"rs-8069853","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}