Routine Immediate Postoperative Chest Radiography After Minimally Invasive Pulmonary Lobectomy Has a Low Impact on Clinical Management: A Value-Based Imaging Analysis

Background/Objectives: Despite the widespread adoption of minimally invasive video-assisted thoracoscopic surgery (VATS) for pulmonary lobectomy and Enhanced Recovery After Surgery (ERAS) protocols, routine chest X-rays (CXRs) in the Post-Anesthesia Care Unit (PACU) after VATS pulmonary lobectomy remain common. Evidence questioning their clinical utility in asymptomatic patients is growing. This study aimed to evaluate the therapeutic yield of routine PACU CXRs following VATS lobectomy, in a homogeneous cohort (PACU time point). Methods: This single-center retrospective cohort study included 554 consecutive patients who underwent elective VATS lobectomy (2014–2025). The primary endpoint was the therapeutic yield of routine PACU CXRs, defined as the proportion directly leading to a documented change in postoperative management. Secondary outcomes included the yield of post-drain-removal CXRs, radiographic findings, and the yield in patients with intraoperative complications. Results: Among 554 routine PACU CXRs, only 12 (2.2%; 95% CI: 1.1–3.7) led to a management change; surgical re-intervention was required in 1 patient and chest tube reinsertion in 5 patients. By contrast, 93 post-drain-removal CXRs (16.8%; 95% CI: 13.7–20.0) led to a change (p < 0.001). The most frequent abnormal findings were pneumothorax (5.8%), atelectasis (4.5%), and pleural effusion (2.0%). Routine PACU imaging generated an estimated cost of €16.620 and a cumulative radiation exposure of 27.7 mSv. Conclusions: Routine PACU CXR after VATS lobectomy has a very low therapeutic yield and rarely changes management in asymptomatic patients. These findings support a selective, symptom-driven imaging strategy, although further prospective studies are needed to confirm safety and effectiveness.