Leak Duration Research Articles

Clinical usefulness of free subcutaneous fat pad for reduction of intraoperative air leakage during thoracoscopic pulmonary resection in lung cancer cases.

Intraoperative alveolar air leaks remain a significant problem in thoracoscopic surgery (TS) cases. We examined the usefulness of covering damaged lung tissue with a subcutaneous fat pad for preventing postoperative air leakage in patients with non-small cell lung cancer (NSCLC). Patients with NSCLC underwent a thoracoscopic lobectomy or segmentectomy. When alveolar air leakage from the superficial pulmonary parenchyma was found, fibrin glue in combination with an absorbable mesh sheet was applied (S group; n = 100). When leakage originated from deep within the pulmonary parenchyma, a subcutaneous fat pad about 2 × 2 cm in size was harvested from the utility incision and placed on the damaged lung tissue with fibrin glue and sutures (F group; n = 66). Patient characteristics, air leak duration, and chest-tube removal time were analyzed. The homogeneity of each group was consistent, with no statistical differences for age, respiratory function, surgical procedures, pathologic stage, and histological type. The air leak duration was significantly shorter (p = 0.015), and the chest tube was removed significantly earlier (p = 0.002) in patients in the F group. Use of a free subcutaneous fat pad during pulmonary resection for TS patients with NSCLC reduced the duration of air leakage and chest tube drainage. The present method is easy, safe, and effective for repairing an air leak from remaining lung tissues in such cases.

Multicenter International Randomized Comparison of Objective and Subjective Outcomes Between Electronic and Traditional Chest Drainage Systems

The aim of this study was to assess the impact of digital versus traditional drainage devices on chest tube removal and patient satisfaction. A randomized trial of digital versus traditional devices after lobectomy/segmentectomy was conducted at 4 international centers (United Kingdom, Europe, Asia, United States). Patients were managed with overnight suction followed by gravity drainage. Chest tubes were removed when an air leak was not evident anymore and the drained fluid was less than 400 mL/d. The groups (digital, 191 patients; traditional, 190 patients) were well matched for baseline and surgical characteristics. There were 325 lobectomies/bilobectomies and 56 segmentectomies, 308 of which were performed by video-assisted thoracic surgery (VATS). Patients randomized to digital systems had a significantly shorter air leak duration (1.0 versus 2.2 days; p=0.001), duration of chest tube placement (3.6 versus 4.7 days; p=0.0001), and postoperative length of stay (4.6 versus 5.6 days; p<0.0001). Subjective end points revealed a perceived improved ability to arise from bed (p=0.008), system convenience for patients and personnel (p=0.02), and the potential for being comfortable when discharged home with the device (p=0.06). A mean difference of 2.6 days from air leak cessation to tube removal was observed, which was similar in the 2 groups (p=0.7). Multivariable regression analysis showed that duration of chest tube placement after air leak cessation was directly associated with the amount of fluid drained during the first 48 hours (p=0.01) and the duration of air leak (p=0.008), independent of hospital location. Patients managed with digital drainage systems experienced a shorter duration of chest tube placement, shorter hospital stays, and higher satisfaction scores compared with those managed with traditional devices. ( NCT01747889.).

Sensitivity of Energy Use to Factors in Pipe Replacement Planning for a Large Water Distribution System

Abstract A previous study completed by the authors used a life-cycle energy analysis approach to evaluate energy associated with pipe replacement schedules in a large distribution system, thereby identifying several factors that contributed to life cycle energy consumption. This paper examines the impact of parameters within the calculation of life cycle energy consumption with a sensitivity analysis. Leak duration, leak volume, break rate model coefficients, and pump efficiency were evaluated. The results of the analysis suggest that investments in improving pump efficiency are likely to yield greater energy savings than investments in leak detection or leakage volume quantification.

Does External Pleural Suction Reduce Prolonged Air Leak After Lung Resection? Results From the AirINTrial After 500 Randomized Cases

External pleural suction is used after lung resection to promote lung expansion and minimize air leak duration. Published randomized trials failed to prove this advantage but they are limited in number and underpowered in many cases. The aim of the AirINTrial study was to test the hypothesis that external pleural suction may reduce the rate of prolonged air leak in a large, randomized cohort. All candidates for lung resection (with the exception of pneumonectomy) were considered eligible for this single-center study. At the end of operation, patients were stratified by the type of resection (anatomic versus nonanatomic) and randomly allocated into the external suction arm (-15 cmH2O, group A) or into the no external suction arm (control arm, group B) in a 1:1 ratio. Chest drains were maintained for 3 days and then they were either removed or connected to an Heimlich valve, when an air leak was present. The main endpoint was to compare groups in terms of prolonged air leak (defined as the rate of patients having a chest drain still in place by postoperative day 7). Starting on February 2011, 500 patients were randomized over a 21-month period, 250 in group A and 250 in group B. Twenty-one patients in group B (8.4%) required pleural suction owing to large pneumothorax or diffuse subcutaneous emphysema. On postoperative day 7, the chest drain was still in place in 25 patients in group A and in 34 patients in group B (10% and 14%, respectively; p= 0.2). Subgroup analysis showed that external pleural suction reduced the prolonged air leak rate in thesubgroup of patients who underwent anatomic resection (n= 296, 9.6% in group A and 16.8% in group B; p=0.05). Results from the AirINTrial showed that the routine use of external suction reduces the rate of prolonged air leak after anatomic lung resection. More accurate strategies of pleural suction based on the amount of air flow and the degree of lung expansion should be probably established to improve its effectiveness.

External Suction versus Water Seal after Selective Pulmonary Resection for Lung Neoplasm: A Systematic Review

ObjectiveTo evaluate whether external suction is more advantageous than water seal in patients undergoing selective pulmonary resection (SPR) for lung neoplasm.Summary of Background DataWhether external suction should be routinely applied in postoperative chest drainage is still unclear, particularly for lung neoplasm patients. To most surgeons, the decision is based on their clinical experience.MethodsRandomized control trials were selected. The participants were patients undergoing SPR with lung neoplasm. Lung volume reduction surgery and pneumothorax were excluded. Suction versus non-suction for the intervention. The primary outcome was the incidence of persistent air leak (PAL). The definition of PAL was air leak for more than 3–7 days. The secondary outcomes included air leak duration, time of drainage, postoperative hospital stay and the incidence of postoperative pneumothorax. Studies were identified from literature collections through screening. Bias was analyzed and meta-analysis was used.ResultsFrom the 1824 potentially relevant trials, 6 randomized control trials involving 676 patients were included. There was no difference between external suction and water seal in decreasing the incidence of PAL [95% confidence interval (CI) 0.81−2.16; z = 1.10; P = 0.27]. Regarding secondary outcomes, there were no differences in time of drainage (95% CI−0.36−1.56, P = 0.22), postoperative hospital stay (95% CI -.31−.54, P = 0.87) or incidence of postoperative pneumothorax (95% CI 0.18−.02, P = 0.05) between external suction and water seal.ConclusionsFor participants, no differences are identified in terms of PAL incidence, drainage time, length of postoperative hospital stay or incidence of postoperative pneumothorax between external suction and water seal. The bias analysis should be emphasized. To the limitations of the bias and methodological differences among the included studies, we have no recommendation on whether external suction should be routinely applied after lung neoplasm SPR. More high-quality randomized controlled trials are needed.Systematic Review RegistrationNone.

Reduction of intraoperative air leaks with Progel in pulmonary resection: a comprehensive review

Intraoperative alveolar air leaks (IOALs) occur in 75% of patients during pulmonary resection. Despite routine use of sutures and stapling devices, they remain a significant problem in the daily practice of thoracic surgery. Air leaks that persist beyond postoperative day 5 often result in increased costs and complications. Several large meta-analyses have determined that sealants as a class reduce postoperative air leak duration and time to chest drain removal, but these results did not necessarily correlate with a reduction in length of postoperative hospital stay. These analyses grouped surgical sealants together of necessity, but differences in efficacy may exist due to the differing product characteristics, study protocols, surgical procedures, and study endpoints. Progel, currently the only pleural surgical sealant FDA-approved for use in lung resection, has demonstrated efficacy and safety in two controlled clinical studies and superiority over standard air leak closure methods in reducing IOALs and length of hospital stay. This paper will review these findings and report on real-world experience with this recently approved pleural sealant.

Regulated tailored suction vs regulated seal: a prospective randomized trial on air leak duration†

The objective of this study was to compare the air leak duration of two regulated chest tube modes following pulmonary lobectomy. This is a prospective randomized trial on 100 consecutive pulmonary lobectomies (2010-11) performed for lung cancer. A single 24-French chest tube was connected to an electronic system capable of maintaining the pleural pressure within preset values (regulated suction mode) or within a physiological range (regulated seal mode). Patients were randomized to two groups: Group 1, regulated individualized suction (range: -11 to -20 cmH2O, according to lobectomy type); Group 2, regulated seal (-2 cmH2O). The main endpoint was the duration of air leak (h) calculated from the end of the operation to a value consistently below 20 ml/min. Patients with prolonged air leak (>168 h) were connected to a portable device before discharge. Their air leak duration was considered as 192 h. The sample size was calculated to detect 1-day difference in air leak duration with a statistical power of 80%. The two groups were well matched for several baseline and surgical characteristics. No crossovers occurred between groups. The average air leak duration (Group 1: 28 vs Group 2: 22.2, P = 0.6), and the number of patients with prolonged air leak (Group 1: 5 vs Group 2: 4, P = 0.7) and with other complications (Group 1: 6 patients vs Group 2: 7 patients, P = 0.9) were similar between the groups. Sixteen patients of Group 1 and 21 of Group 2 had an air leak present immediately after extubation. Among them, patients of Group 2 (regulated seal) had an air leak lasting 34.5 h less than those of Group 1 (regulated suction) (52.9 vs 87.4, P = 0.07). Regulated seal is as effective and safe as regulated suction in managing chest tubes following lobectomy. This information demonstrates with objective data the non-superiority of regulated suction vs regulated seal and may assist in future investigations on regulated pleural pressure.

PP156-SUN CHYLE LEAKS AND UPPER GASTROINTESTINAL SURGERY

Rationale: Recent advances in surgery, pioneered in Japan, involve increased lymph node harvest (lymphadenectomy) in patients with upper gastrointestinal cancer. An audit was undertaken to determine if the incidence of chyle leaks had increased after changes in surgical technique; whether the length of stay differed in patients with chyle leaks; and whether the type of nutrition affected recovery time. Methods: 113 patients who underwent surgery for upper gastrointestinal cancer (oesophagectomy, total gastrectomy with Roux-en-Y and subtotal gastrectomy with Roux-en-Y) at Imperial College Healthcare NHS Trust were identified. Dietetics records were reviewed to determine chyle leak occurrence and duration, length of stay, route and type of nutrition used, and clinical course including any change in the method of nutrition support. Four records were unavailable and three patients were excluded due to insufficient information, leaving 106 for analysis. Results: The rate of chyle leaks increased from 7.8% to 22% (p = 0.06) following increasingly radical lymphadenectomy, patients with chyle leaks experienced prolonged lengths of stay 16 vs 24 days (p = 0.003). 73% of patients with chyle leaks resolved with specialized oral (27%) or enteral feeding (72%); 27% required parenteral nutrition (TPN); of which one required surgery despite conservative measures. Those on oral intake had a reduced duration of chyle leak and hospital stay. 100% of patients fed enterally received MCT feed. Conclusion: The incidence of chyle leaks has increased with increasingly radical surgery as hypothesized. Patients with chyle leaks stay longer as the leak must be resolved before building up to a normal diet and surveillance is required. The majority of patients’ leaks resolve with specialized oral or enteral nutritional measures; a very low fat or MCT diet, as previously reported. Nevertheless a minority of patients still required TPN to enable the leak to heal.

Postlobectomy Chest Radiographic Changes: A Quantitative Analysis

Purpose To provide a quantative analysis of postlobectomy chest radiographic changes and to evaluate whether the scarring from prior sternotomy affects the size of the hemithorax and the duration of air leak in patients with subsequent lobectomy. Methods In this retrospective case-controlled series, 10 consecutive patients who had a lobectomy after a prior sternotomy and 30 controls, 3 for each case, matched for lobectomy site were identified. Pre- and postoperative chest radiographs were quantitatively analysed for diaphragmic elevation, size of each hemithorax, mediastinal shift, and the presence of pneumothorax. Charts were reviewed for air-leak duration, surgical complications, and duration of hospitalization. Results There was no difference between patients with lobectomy and with and without prior sternotomy for the following variables expressed as mean (SD): hemidiaphragm elevation (1.5 ± 2.5 vs 0.5 ± 2.0 cm; P = .2), change of hemithorax size (mean transverse, 0.99 ± 0.05 vs 0.97 ± 0.07; P = .5; craniocaudal, 0.93 ± 0.08 vs 0.91 ± 0.08; P = .4) and mediastinal shift (upper, 1.2 ± 0.4 vs 1.3 ± 0.6; P = .5; lower, 1.2 ± 0.4 vs 1.2 ± 0.3; P = .8), the latter 2 were expressed as the ratio of post- to preoperative measurements. These postlobectomy radiographic findings varied, depending on the resected lobe, and became progressively more pronounced during the first 12 months after surgery. There was no difference in pneumothorax duration (mean [SD]) (9.5 ± 21 days vs 6.4 ± 7.5 days; P = .5), air leak duration (mean [SD]) (0.7 ± 0.8 days vs 1.3 ± 3.9 days; P = .6), complication rate (20% vs 30%; P = .5), or hospital stay (mean [SD]) (6.0 ± 1.7 days vs 6.9 ± 4.7 days; P = .6). Conclusion There are specific patterns of volume loss, mediastinal shift, and hemidiaphragm displacement that can be quantified on postlobectomy chest radiographs. Prior sternotomy did not affect postlobectomy radiographic changes or patient outcome.

Video-assisted thoracoscopic surgery for the treatment of primary pneumothorax: talc pleurodesis or pleural abrasion? Retrospective multicentre study

In the treatment of primary spontaneous pneumothorax (PSP) the latest guidelines recommend video-assisted thoracoscopy, but do not specify the best technique for performing pleurodesis. Indeed, there are no clinical trials comparing the effectiveness of talc pleurodesis, mechanical pleurodesis and pleurectomy. Our objective was to compare outcomes in patients who underwent surgery for primary pneumothorax with the talc procedure or with pleural abrasion using dry gauze. Patients undergoing video-assisted thoracoscopic surgery for PSP in two hospitals were retrospectively recruited between 2007 and 2008, and followed-up until December 2010. The variables measured to compare the outcomes were: recurrence, complications, and mortality, as well as the duration of air leaks and of drainage and the length of postoperative hospital stay (in days). Statistical analysis: The two groups were compared using the Chi square test for qualitative variables and nonparametric tests for continuous variables. A total of 106 interventions were carried out in 104 patients (74 in group A: pleural abrasion with dry gauze; 32 in group B: chemical pleurodesis with talc), with a mean age of 28 years (median 25) and 85.6% were male. Complications were observed in nine patients (8.5%) and there were no deaths in the 30 days after surgery; there were, however, four cases of recurrence (3.8%). The mean air leak duration was 0.78 days (median 0), the mean drainage duration 1.95 days (median 1) and the mean length of postoperative hospital stay 2.68 days (median 2). In 74 cases (69.8%), mechanical pleurodesis was performed, while 32 cases were treated with talc (30.2%). Comparing the two groups, we did not find statistically significant differences in recurrence (4.1% vs 3.1%, P=0.82), complications (6.8% vs 12.5%, P=0.45) or mortality (no cases of death). On the other hand, the mean postoperative hospital stay was lower in the mechanical pleurodesis group than in the talc group (2.2 vs 3.8 days, P=0.005). Video-assisted surgery in the treatment of PSP is a safe technique. In the mechanical pleurodesis group, we observed the same rate of recurrence, half the number of complications and a shorter hospital stay. We consider it necessary that well-designed multicentre clinical trials be carried out to compare these techniques and determine which produces the best outcomes, providing stronger scientific evidence given that the data available to date are not conclusive.

Video-assisted thoracoscopic surgery for the treatment of primary pneumothorax: talc pleurodesis or pleural abrasion? Retrospective multicentre study

In the treatment of primary spontaneous pneumothorax (PSP) the latest guidelines recommend video-assisted thoracoscopy, but do not specify the best technique for performing pleurodesis. Indeed, there are no clinical trials comparing the effectiveness of talc pleurodesis, mechanical pleurodesis and pleurectomy. Our objective was to compare outcomes in patients who underwent surgery for primary pneumothorax with the talc procedure or with pleural abrasion using dry gauze. Patients undergoing video-assisted thoracoscopic surgery for PSP in two hospitals were retrospectively recruited between 2007 and 2008, and followed-up until December 2010. The variables measured to compare the outcomes were: recurrence, complications, and mortality, as well as the duration of air leaks and of drainage and the length of postoperative hospital stay (in days). Statistical analysis: The two groups were compared using the Chi square test for qualitative variables and nonparametric tests for continuous variables. A total of 106 interventions were carried out in 104 patients (74 in group A: pleural abrasion with dry gauze; 32 in group B: chemical pleurodesis with talc), with a mean age of 28 years (median 25) and 85.6% were male. Complications were observed in nine patients (8.5%) and there were no deaths in the 30 days after surgery; there were, however, four cases of recurrence (3.8%). The mean air leak duration was 0.78 days (median 0), the mean drainage duration 1.95 days (median 1) and the mean length of postoperative hospital stay 2.68 days (median 2). In 74 cases (69.8%), mechanical pleurodesis was performed, while 32 cases were treated with talc (30.2%). Comparing the two groups, we did not find statistically significant differences in recurrence (4.1% vs 3.1%, P=0.82), complications (6.8% vs 12.5%, P=0.45) or mortality (no cases of death). On the other hand, the mean postoperative hospital stay was lower in the mechanical pleurodesis group than in the talc group (2.2 vs 3.8 days, P=0.005). Video-assisted surgery in the treatment of PSP is a safe technique. In the mechanical pleurodesis group, we observed the same rate of recurrence, half the number of complications and a shorter hospital stay. We consider it necessary that well-designed multicentre clinical trials be carried out to compare these techniques and determine which produces the best outcomes, providing stronger scientific evidence given that the data available to date are not conclusive.

Efficacy of anterior fissureless technique for right upper lobectomies: a case-matched analysis

In pulmonary lobectomy, the dissection through the fissure to gain access to the pulmonary artery may increase the risk of postoperative air leak. For several anatomic reasons, this risk is especially high after right upper lobectomies (RULs). The objective of this investigation was to verify the efficacy of an anterior fissureless lobectomy (FL) technique in reducing the incidence and duration of air leak after RUL. An observational analysis was performed of 206 consecutive patients (2002-2009) submitted to RUL for non-small-cell lung cancer. Operations were performed through a muscle-sparing lateral thoracotomy. Patients with completely developed fissures were excluded. No sealants or buttressing material were used. For group TR (traditional resection, 146 patients), RUL was performed by traditional intra-fissure dissection of the pulmonary artery; for group FL (60 patients), RUL was carried out by fissureless division of all hilar vascular structures. Several perioperative variables were used in identifying propensity score-matched pairs of patients undergoing traditional and fissureless lobectomies. The matched groups were then compared in terms of incidence of prolonged air leak, air leak duration, operation time, chest tubes duration, hospital stay and costs. Propensity score analysis yielded 58 well-matched pairs of patients operated by traditional or fissureless RUL. Compared to those in the traditional group, patients in group FL had a mean reduction in air leak duration, duration of chest tube and postoperative stay of 1.1, 1.4 and 1.2 days, respectively. This translated into an average hospital cost saving of 569 € per patient. The use of an anterior fissureless technique during RUL reduced the duration of air leak and hospital costs without increasing the surgical time. Given its simplicity and efficacy, we regard it as a useful tool for implementing fast-tracking policies and cutting hospital costs.

Optimal Technique for Primary Spontaneous Pneumothorax in Children

Surgery| March 01 2009 Optimal Technique for Primary Spontaneous Pneumothorax in Children AAP Grand Rounds (2009) 21 (3): 29. https://doi.org/10.1542/gr.21-3-29 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Optimal Technique for Primary Spontaneous Pneumothorax in Children. AAP Grand Rounds March 2009; 21 (3): 29. https://doi.org/10.1542/gr.21-3-29 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: primary spontaneous pneumothorax, thoracic surgery, video-assisted, pleurodesis, blister Source: Bialas R, Weiner T, Phillips D. Video-assisted thoracic surgery for primary spontaneous pneumothorax in children: is there an optimal technique? J Pediatr Surg. 2008;43(12):2151–2155; doi:10.1016/j.jpedsurg.2008.08.041 To assess outcomes and compare different techniques using video-assisted thoracic surgery (VATS) for the treatment of primary spontaneous pneumothorax (PSP) in children, investigators from the University of North Carolina reviewed the records of 32 children treated from 1999 to 2007 by a single group of surgeons. The indications for VATS were either presence of persistent air leak after placement of a chest tube, recurrent ipsilateral pneumothorax, or occurrence of a contralateral pneumothorax. Children with underlying lung disease (such as cystic fibrosis), trauma, or cancer were excluded. The surgical technique via thoracoscopy was determined by the operating surgeon. Bleb resection was performed using an endoscopic stapling device. Pleurodesis was done either mechanically via cautery scratch pad abrasion and/or pleural stripping, or chemically by coating the pleura with a fine dust of sterile talc powder. A chest tube was placed at the conclusion of the procedure and only removed when air leak ceased and postoperative chest radiographs showed no residual pneumothorax. The study population consisted of 32 patients who had 41 procedures. Mean age of patients in the study was 16.5 years; 25 were male. Overall the mean postoperative air leak duration was 2.7 days with a prolonged air leak of >7 days in five patients. Mean hospital length of stay after surgery was 5.0 days. The mean postoperative chest tube duration was 5.1 days. Blebs, mostly upper lobe, were identified during 95% of VATS procedures. Among the different surgical techniques, patients treated with thoracoscopic blebectomy and mechanical pleurodesis (n=31) had the shortest length of stay (mean of 4.3 days). Seven of the 32 patients (22%) subsequently developed contralateral PSP requiring VATS. Two patients developed recurrent ipsilateral PSP requiring VATS within one year of the original procedure; both were found to have blebs not originally seen and in the lower lobes. The failure rate of VATS cases in preventing future pneumothorax was 5% (2/39). Blebectomy plus mechanical pleurodesis led to five minor recurrences which did not require repeat VATS and were successfully treated non-operatively. No major or minor recurrences were seen in the group treated with blebectomy and chemical pleurodesis (n=6). The authors conclude that both chemical and mechanical pleurodesis with blebectomy are associated with acceptable patient outcomes. Dr. Cavett has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. PSP usually occurs in healthy adolescents without other lung disease.1 Recent studies have shown that rapid adolescent linear growth of the thorax compared with horizontal growth is likely to cause increase in negative pressure at the apex of the lung, which may lead to subpleural bleb formation and subsequent PSP upon rupture.1 Nonoperative treatment with observation as an inpatient includes needle aspiration and/or tube thoracostomy. This conservative therapy has been associated with a recurrence... You do not currently have access to this content.

Can tissue adhesives and glues significantly reduce the incidence and length of postoperative air leaks in patients having lung resections?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the intraoperative use of surgical adhesives in patients undergoing lung resection would reduce the incidence and length of postoperative air leaks. The reported search strategy identified 261 papers of which 12 were considered to represent the best evidence available. The author, journal, publication date, patient groups studied, study types, relevant outcomes, results and study weaknesses were tabulated. We conclude that six of the identified randomised trials found a significant reduction in air leak duration, but five found no significant difference. In contrast to significant reductions in air leak, only two studies identified a reduction in time to chest drain removal. Also, only two studies found a significant reduction in length of stay. There are multiple issues surrounding these studies ranging from identifying the optimal glue and delivery system, dealing with the learning curve of surgeons and robust protocols for chest drain removal to selection of patients suitable for surgical adhesive usage. Thus, routine usage of surgical adhesive for all operations cannot yet be recommended, although there is a wide range of adhesives available to surgeons which may be useful in selected situations.

Is there a role for therapeutic lobectomy for emphysema?☆☆☆

The feasibility of performing a standard lobectomy in patients with non-small cell lung cancer (NSCLC) and severe heterogeneous emphysema whose respiratory reserve is outside standard operability guidelines has been described [Edwards JG, Duthie DJR, Waller DA. Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema. Thorax 2001;56:791-5; Korst RJ, Ginsberg RJ, Ailawadi M, Bains MS, Downey RJ, Rusch V, Stover D. Lobectomy improves ventilatory function in selected patients with severe COPD. Ann Thorac Surg 1998;66:898-902; Carretta A, Zannini P, Puglisi A, Chiesa G, Vanzulli A, Bianchi A, Fumagalli A, Bianco S. Improvement in pulmonary function after lobectomy for non-small cell lung cancer in emphysematous patients. Eur J Cardiothorac Surg 1999;15(5):602-7]. Postoperative lung function was better than predicted, attributable to the therapeutic benefit of deflation of the hemithorax. Our aim was to determine whether the physiological benefits of this approach were superior to conventional non-anatomical lung volume reduction surgery (LVRS) in similar patients. A retrospective review of a single surgeon's experience identified 34 consecutive patients who underwent upper lobectomy for completely resected stage I-II NSCLC, and who had severe heterogeneous emphysema of apical distribution with a predicted postoperative FEV1 of less than 40%. Their perioperative characteristics, postoperative spirometry and survival of these cases were compared to 46 similar patients who underwent unilateral upper lobe LVRS during the same period. Data expressed as median (range). LVRS patients were significantly younger (59 years [39-70] vs 67 years [48-79] p<0.001), with more severe airflow obstruction (FEV(1) %pred 24 [12-60] vs 44 [17-54] p<0.001) and more heterogenous disease ('Q' score 4 [0.5-11.5] vs 7 [1-13] p=0.001) than the lobectomy group. No significant difference was found in median survival (88 vs 53 months, p=0.06). Lobectomy patients had a shorter air leak duration (5 days [2-36] vs 9 days [1-40], p=0.02) and hospital stay (8 days [3-63] vs 13 days [6-90] p=0.01). A significant correlation was found between pre-operative Q score and percentage improvement in FEV1 (r=-0.33, p=0.02). Lobectomy for lung cancer in patients in severe heterogenous chronic obstructive pulmonary disease is associated with similar improvement in airflow obstruction as conventional LVRS, but is associated with a shorter postoperative course. Lobectomy may therefore offer a therapeutic alternative to conventional LVRS in a selected population.

A prospective, randomized, controlled trial of the effectiveness of BioGlue in treating alveolar air leaks

The use of tissue glues has been advocated to reduce post-thoracotomy alveolar air leaks, but outcomes have been inconclusive. The aim of this study was to determine the effectiveness of BioGlue (CryoLife Europa Ltd, Hampshire, United Kingdom) in eliminating post-thoracotomy alveolar air leaks. A prospective, randomized, single-blind, controlled trial was conducted in which patients were stratified according to the severity of post-thoracotomy air leak that could not be controlled by conventional surgical techniques. They were allocated to a control arm (surgical treatment only) or an interventional arm (surgical treatment and BioGlue). Duration of air leak, intercostal drainage, and hospital stay comprised primary study end points. From December 2002 to January 2005, 52 patients were randomized, 29 (56%) of whom were men. The mean age was 59 +/- 15 years, and other characteristics were comparable in both groups. Indications for surgery were malignancy in 46 patients (88%), carcinoid tumor in 2 patients (4%), and infective disease in 4 patients (8%). Patients in the BioGlue arm had shorter median duration of air leaks, 1 (0-2) versus 4 (2-6) days (P < .001); intercostal chest drainage, 4 (3-4) versus 5 (4-6) days (P = .012); and hospital stay, 6 (5-7) versus 7 (7-10) days (P = .004), compared with controls. No major complications were encountered using BioGlue. This study demonstrates clear benefit from BioGlue in the treatment of alveolar air leaks through reduction of air leak duration, chest drainage time, and hospital stay. Systematic use of BioGlue may be warranted in adult thoracic surgical procedures (except pneumonectomy and decortication) when an air leak remains after all other steps to control it have failed.

Quantitative Computed Tomography Versus Spirometry in Predicting Air Leak Duration After Major Lung Resection for Cancer

Emphysema is a well-known risk factor for developing air leak or persistent air leak after pulmonary resection. Although quantitative computed tomography (CT) and spirometry are used to diagnose emphysema, it remains controversial whether these tests are predictive of the duration of postoperative air leak. Sixty-two consecutive patients who were scheduled to undergo major lung resection for cancer were enrolled in this prospective study to define the best predictor of postoperative air leak duration. Preoperative factors analyzed included spirometric variables and area of emphysema (proportion of the low-attenuation area) that was quantified in a three-dimensional CT lung model. Chest tubes were removed the day after disappearance of the air leak, regardless of pleural drainage. Univariate and multivariate proportional hazards analyses were used to determine the influence of preoperative factors on chest tube time (air leak duration). By univariate analysis, site of resection (upper, lower), forced expiratory volume in 1 second, predicted postoperative forced expiratory volume in 1 second, and area of emphysema (< 1%, 1% to 10%, > 10%) were significant predictors of air leak duration. By multivariate analysis, site of resection and area of emphysema were the best independent determinants of air leak duration. The results were similar for patients with a smoking history (n = 40), but neither forced expiratory volume in 1 second nor predicted postoperative forced expiratory volume in 1 second were predictive of air leak duration. Quantitative CT is superior to spirometry in predicting air leak duration after major lung resection for cancer. Quantitative CT may aid in the identification of patients, particularly among those with a smoking history, requiring additional preventive procedures against air leak.

Characterization and Importance of Air Leak After Lobectomy

Air leak after pulmonary resection is a common occurrence that is incompletely characterized. Our objectives were to determine prevalence of air leak and identify its risk factors, characterize its duration and discover its correlates, and evaluate its clinical importance. Air leak was studied in 319 patients undergoing isolated anatomic lobectomy between January 1998 and July 2001. Risk factors for air leak were identified by logistic regression of patient characteristics, indications for lobectomy, lobe resected, and fissure management. Factors associated with air leak duration were sought by time-related analysis. Association of complications with air leak was evaluated by propensity-matched pairs analysis. Prevalence: Air leak prevalence was 58% (186 patients). It occurred less frequently after left lower lobectomy (p < 0.0001) and later in the series (p = 0.008). It was surgeon dependent (p = 0.007) but not associated with forced expiratory volume in 1 second. The 10th, 50th, and 90th percentiles of air leak duration were 1.6, 3, and 7 days, respectively. No factors, including fissure management, were reliably associated with air leak duration. Air leak was associated with more complications (30% vs 18%, p = 0.07) and protracted hospital course (p = 0.02). Postoperative air leak is a common occurrence after lobectomy, but fortunately it is self-limiting in most patients. Air leak is independently associated with longer hospital stay and other postoperative complications. Surgical technique is important and may be the only modifiable factor.

A prospective randomized controlled trial of suction versus non-suction to the under-water seal drains following lung resection

Practice varies as to whether or not suction is applied to under-water seal drains following lung surgery. We tested the null hypothesis that there is no difference with respect to air leak duration. Patients undergoing thoracotomy or video assisted thoracoscopic surgery for lobectomy or wedge resection had either low-pressure suction or no suction applied to their underwater seal bottles postoperatively. Patients were allocated using minimization, a method of unbiased allocation ensuring balance between the arms of a trial with respect to known or suspected confounding factors. The trial was powered for duration of air leak. If an air leak persisted on the 7th post-operative day, the surgeon determined further management. Kaplan-Meier survival analysis of air leak duration and a log rank test were performed on an intention-to-treat basis, with observations censored at 144h (6 complete days). Of the 254 patients that entered the trial, data were available for analysis for 239 (123 no-suction and 116 suction). There was no significant difference in the cumulative persistence of air leaks between the two groups (P=0.62) and inspection of the Kaplan-Meier curves suggests that any difference is negligible. Applying suction to the underwater seal drains following lung surgery makes no difference in terms of air leak duration. In the light of this finding we have adopted a uniform policy of no suction being applied to the underwater seal, from the time of surgery, unless a specific clinical judgment is made to use it. The anticipated gains are that this will reduce work and cost and aid mobilization.

Invited commentary

Dr Brunelli and colleagues have presented another important study on the common problem of air leaks. This trial is well designed, performed, analyzed, and written. On the surface, their findings seem to be contrary to the ones Marshall and we have reported. However careful scrutiny of Brunelli's data actually shows that it may support the findings in those previous prospective studies. The management of chest tubes is only one way to manage air leaks. Intra-operative preventative measures rather than post-operative management are always more important for any post-operative complication. Some intra-operative techniques include: fissure-less surgery, sealants, buttressing of staple lines, pneumoperitoneum, and pleural tents. Although chest tube management is important in patients with an air leak, the advantage of one chest tube setting over another becomes weakened when air leaks are small. In this study the authors have nicely shown that when a pleural tent is used, the setting of the chest tube makes little difference. This is of little surprise. Unfortunately, the previously reported classification of air leaks and an air leak meter were not used in this study, but the natural history of the leaks in this series suggests that many were small. When one eliminates the patients who had pleural tents, which the authors essentially do for us in Table 4, their own data begin to show the advantages of water seal. The numbers may be too small to show a statistically significant difference but the air leak duration was 5.4 days compared with 7.0 days and the “air leak days/cm of staple line” was only 0.08 compared with 0.12, both favoring the water seal group. Thus, perhaps a better title for this paper may be “Pleural Tents After Upper Lobectomy Negate the Advantages of Placing Chest Tubes on Water Seal.” This finding is also not unexpected because this group has already shown the advantage of a pleural tent after upper lobectomy in a very well done prospective randomized study that was recently published. Finally, why do the authors choose to use water seal in patients who had no air leak and were excluded in this study? We prefer suction in these patients since water seal seems to offer no real advantage. Furthermore, I am perplexed as to why they conclude the paper with the statement: “Based on the results of this analysis our current practice is to use moderate suction (−10 cm H2O) overnight and water seal during the day.” The authors never even studied −10 cm of suction and found no advantage to water seal and potential harm. Why is this now their preferred protocol? We are indebted to Dr Brunelli and colleagues for once again heightening our awareness of the problem of air leaks and for a well-done prospective randomized study. Perhaps more studies are needed to examine patients who undergo lobectomy only. Their finding that water seal may lead to increased complications is provocative. It would be easy to do a prospective randomized trial that only studied patients who underwent lobectomy and to recruit enough patients in the study so one could generate the statistical power needed to fully assess the advantages and disadvantages of water seal versus suction [1Marshall M.B Deeb M.E Bleier J.I.S Suction versus water seal after pulmonary resection, a randomized prospective study.Chest. 2002; 121: 831-835Crossref PubMed Scopus (139) Google Scholar, 2Cerfolio R.J Bass C Katholi C.R A prospective randomized trial compares suction versus water seal for air leaks.Ann Thorac Surg. 2001; 71: 1613-1617Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar, 3Brunelli A Al Rafai M Monteverde M Borri A Salati M Pleural tent after upper lobectomy a randomized study of efficacy and duration of effect.Ann Thorac Surg. 2002; 74: 1958-1962Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar].