A Novel Technique to Remove Iatrogenic Pulmonary Parenchymal Chest Tube (PPcT): A Retrospective Analysis From a Tertiary Care Thoracic Surgery Centre

Overview

Iatrogenic Pulmonary Parenchymal chest Tube (PPcT) placement is a recognized but underreported complication of tube thoracostomy, described both in the subcontinent and worldwide. This complication occurs when the chest tube inadvertently traverses the pleural cavity and penetrates the lung parenchyma. Patients with underlying lung pathology are at increased risk of having iatrogenic pulmonary parenchymal chest tube. In this study we describe the safe and minimally invasive technique to remove the PPcT without the need of video assisted thoracic surgery (VATS) or thoracotomy.

Patients with reduced pulmonary compliance, underlying lung consolidation, or dense pleural adhesions are particularly vulnerable because these conditions limit the normal displacement of the lung away from the chest wall, predisposing it to injury during tube placement. Diagnosing PPcT is often challenging because the clinical presentation and radiographic findings are nonspecific, and the condition may be overlooked, particularly in patients with pre-existing pulmonary disease. Computed tomography (CT) of the chest remains the gold standard for accurate diagnosis. At our institution, we have developed and successfully implemented a stepwise, minimally invasive technique for the safe removal of PPcT over the last 19 years (since 2006), thereby avoiding thoracotomy or other invasive procedures. Once PPcT is confirmed by CT scan-while carefully differentiating true parenchymal tube placement from tubes merely located within fissures-we adopt a three-stage removal strategy: Initial healing phase: The tube is left in situ for approximately two weeks to allow for local fibrosis and healing around the injured parenchyma, which reduces the risk of bleeding and air leak during subsequent manipulation. Gradual staged retraction: After this period, the tube is retracted by approximately 2 cm and secured again. In cases where the tube is tightly adherent, it is rotated 360° along its axis to release any fibrous adhesions. The patient is then observed for 24 hours, with close monitoring for hemodynamic instability, hemorrhage, or air leak, and a chest radiograph is obtained to confirm tube position. Subsequent retractions: If the patient remains stable, they are discharged and readmitted at 7-day intervals for further staged retractions of approximately 2 cm each. This process continues until the fenestrations ("eyes") of the tube exit the pleural cavity, at which point the tube is safely removed. In many cases, the tube can be removed after the first or second stage if the fenestrations have already cleared the pleural space, thereby preventing pneumothorax. This technique has consistently yielded excellent results in our experience, allowing safe removal of PPcT while minimizing morbidity and eliminating the need for thoracotomy or video-assisted thoracoscopic surgery (VATS) for tube retrieval.