Invited Commentary

Abstract

Prolonged air leak (PAL) is one of the most frustrating complications for both surgeons and patients after pulmonary surgery. This is especially true after surgery for spontaneous pneumothorax, in which a persistent air leak is most often the indication for surgery in the first place. Prolonged air leak has a variety of associated costs including increased length of stay, higher risk of empyema, and longer time required for patients to return to work. Although generally small, the mortality rate in patients with PAL, which was 3.6% in this study, is not insignificant. Being able to reliably predict which patients are at increased risk for PAL is very appealing to thoracic surgeons. In this cohort of over 2,000 spontaneous pneumothorax patients with well-accepted indications for surgery, the authors found that the risk of PAL was related to increasing age, higher American Society of Anesthesiologists (ASA) score, the performance of bilateral procedures, and bullae diameter. Analyses of risk factors for PAL after lobectomy have similarly demonstrated the effect of age. In these studies, poor lung function and the presence of adhesions have also been associated with an increased risk of PAL. The risk associated with higher ASA score in this study may reasonably be assumed to be a surrogate for these conditions. Interestingly, only half of the patients in this study received some form of pleurodesis. In addition, buttressing of staples lines was not employed. Application of these adjunctive maneuvers may have further decreased the 9.7% incidence of PAL that the authors report. Although not specifically designed to analyze outcomes in patients with secondary spontaneous pneumothorax (SSP), the inclusion of 492 such patients in this study offers important insights into the management of this challenging condition. Even when lung expansion is achieved and the initial air leak resolves after chest tube placement, recurrence rates for these patients approximate 50%. In this study [1Jiang L. Jiang G. Zhu Y. Hao W. Zhang L. Risk factors predisposing to prolonged air leak after video-assisted thoracoscopic surgery for spontaneous pneumothorax.Ann Thorac Surg. 2014; 97: 1008-1014Google Scholar], the incidence of PAL in patients with SSP was 31%. A closer look at these numbers reveals that older, more debilitated patients have even higher risks. The incidence of PAL in patients with chronic obstructive pulmonary disease was 44%. For patients older than 70 years (who presumably also had SSP), the rate was 50%. Perhaps most telling, PAL occurred in 94% of ASA 3 patients. As the authors discuss, numerous issues must be thoughtfully considered prior to operating on patients with SSP. These include the need to reinforce staple lines with pericardial strips, the extensiveness of pneumolysis, the type of pleurodesis to perform, and the influence of preoperative steroid use. It is tempting to resect all significant bullae, as the authors did in this study, even if they are not culprit lesions. This may, however, lead to additional space and air leak problems. Recent reports suggest improved outcomes for high-risk patients when the operation is performed without general anesthesia [2Noda M. Okada Y. Maeda S. et al.Is there a benefit of awake thoracoscopic surgery in patients with secondary spontaneous pneumothorax?.J Thorac Cardiovasc Surg. 2012; 143: 613-616Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar]. Postoperatively, the amount and duration of suction are important factors related to the duration of postoperative air leaks. Finally, identifying patients in whom surgical risk is prohibitive and who should instead be offered bedside pleurodesis when possible will be critical. Future studies are needed to more thoroughly address these issues as thoracic surgeons will be called upon more frequently to care for patients with SSP as our population continues to age. Risk Factors Predisposing to Prolonged Air Leak After Video-Assisted Thoracoscopic Surgery for Spontaneous PneumothoraxThe Annals of Thoracic SurgeryVol. 97Issue 3PreviewThe goal of this prospective study was to determine risk factors for prolonged air leak (PAL) for patients who underwent video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax. Full-Text PDF