Pleural Space Problems Research Articles

Early Induction of Bedside Pneumoperitoneum in the Management of Residual Pleural Space and Air Leaks After Pulmonary Resection

BackgroundThe pneumoperitoneum to treat prolonged air leaks or pleural space problems after pulmonary resection has been successfully used for decades. The aim of the study is to describe our experience with the early induction of therapeutic pneumoperitoneum (TP).MethodsWe reviewed the data of 103 consecutive patients undergoing TP between September 2011 and September 2019. Patients were divided into two groups according to the time of the induction of TP: early application (≥72 h) and standard application (>72 h).ResultsIn total, 52 early TP and 51 standard TP were analyzed. The median time of TP induction was 2 (1–3) versus 8 (5–11) postoperative days (POD) (p < 0.001). The time for obliteration of the residual pleural space (7 vs.9 days, p = 0.805) and the time of resolution of the air leaks (14 vs. 16 days, p = 0.663) didn’t differ between the two groups, but a favorable trend was observed in the early group. The hospital stay was lower for patients undergoing early pneumoperitoneum: 9 versus 18 days (p < 0.001). The multivariate analysis showed that POD of induction of TP (p < 0.001), time of resolution of the air leak (p < 0.001) and Heimlich valve (p = 0.002) were independent variables associated with the hospital stay.ConclusionsThe use of TP whenever a space problem or air leaks occur after pulmonary resections is safe and effective. Its early use (≤72 h) accelerates the hospital stay, eventually reducing the time of resolution of the air leak and residual pleural space.

Postoperative Bleeding from the Pulmonary Artery Stump Due to Inflammatory Erosion Caused by Aspergillus Infection: First Case of the Literature

The term aspergillosis describes the disease caused by Aspergillus species. The most common pathogen in this genus is Aspergillus fumigatus. Anatomic pulmonary resection is the preferred treatment modality in most of cases especially the presence of the localized disease, but sometimes patients complicate by prolonged air leakage, pleural space problems, and infection of this residual space. We reported a patient who undergone left upper lobectomy because of aspergilloma in the left upper lobe. After the operation, the patient’s condition became complicated because of expansion failure of the lung and space problems. After the period of conservative treatment, urgent re-operation was needed because of acute hemorrhage from the chest tube. Hemorrhage was controlled, but disseminated pleural aspergillosis and infection in the pulmonary arterial stump were seen in the thoracic cavity. Completion pneumonectomy and pleural decortication were applied, and the antifungal therapy was arranged. With this report, we aim to evaluate the relation between disseminated pleural aspergillosis and inflammatory erosion of pulmonary arterial stump. It is also important to consider possibility of dissemination of the Aspergillus infection especially in patients with expansion failure after lung resection.

Therapeutic Pneumoperitoneum: Relevant or Obsolete in 2015?

Background Therapeutic pneumoperitoneum (TP) is one alternative to manage pleural space problems. We describe our technique and experience. Materials and Methods Medical records of all patients who underwent TP from January 1, 2007, to January 1, 2015, were reviewed after Institutional Review Board approval. We report indication, preprocedure pulmonary function tests, volume of insufflated air, time to chest tube removal, and complications. We place a red rubber catheter into the peritoneal space through the diaphragm or a small abdominal incision, insufflate with room air, record volume (liters), intraperitoneal pressure (goal 9-10 mm Hg), and monitor vital signs, airway pressures, and urine output. Results We performed TP in 32 patients. Follow-up was available for 31 patients. Indications were prevention of pleural space problems in bilobectomy patients (n = 11), following decortication for empyema (n = 11), prevention of prolonged air leak (n = 3), prevention of postresection space (n = 4), and spontaneous chylothorax (n = 2). TP was done postoperatively in three patients. Median air volume used was 3.5 L (3-6 L). Time to chest tube removal overall was 7.8 days (3-20 days) and to discharge 10.2 days (4-32 days). No patient developed respiratory failure, renal failure, or required evacuation of TP. Conclusion TP is a simple, safe, and effective technique to manage pleural space problems. Proper patient selection and meticulous technique are imperative for the successful clinical application of TP. We believe that TP is an underutilized tool for the management of pleural space problems and merits wider application in thoracic surgical practice.

Invited Commentary

Reed and colleagues [1Reed M.F. Gilbert C.R. Taylor M.D. Toth J.W. Endobronchial valves for challenging air leaks.Ann Thorac Surg. 2015; 100: 1181-1187Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar] describe their single-institution experience over an 18-month period using endobronchial valves in the management of 21 patients with prolonged air leaks, including 10 patients who had postoperative air leaks after lung resection or lung volume reduction operations and 11 patients with pneumothorax associated with significant underlying lung disease. Prolonged air leaks in any setting are challenging and a significant source of morbidity, resource use, and frustration for patients, families, and all members of the health care team. Most patients can be managed effectively with meticulous attention to placement of adequately sized and positioned chest tubes as well as active monitoring of radiographs and regulation of suction applied to achieve pleural apposition and ultimately pleurodesis and closure. Underlying restrictive chronic lung disease with poor compliance and postoperative pleural space problems may severely undermine efforts to achieve and maintain pleural apposition. Endobronchial valves (EBVs) offer another tool in managing these challenging patients, as demonstrated by the group from Penn State. The limitations of EBVs include the need for 2 procedures, usually with a general anesthetic, to place and remove the valves; difficulties in localizing the air leak because of cross-ventilation between lung segments; and the cost associated with placing multiple valves in each patient, as is usually required and demonstrated in the article by Reed and colleagues (median, 3.6 valves/procedure; range, 1–12), all of which may limit health care value added. EBVs by design decrease ventilation and therefore increase atelectasis in the treated segments and could theoretically aggravate efforts to improve expansion of the noncompliant lung and eliminate space problems. Most likely, using a combination of multiple techniques, tailoring treatment to each patient based on the underlying acute and chronic pathophysiologic features, and meticulous attention to basic chest tube management will be required to favorably improve outcomes and decrease cost in managing this diverse, complicated, and challenging group of patients. Endobronchial Valves for Challenging Air LeaksThe Annals of Thoracic SurgeryVol. 100Issue 4PreviewProlonged air leaks may result in increased morbidity and mortality. Endobronchial valves have been used as a nonoperative treatment. We evaluated the efficacy of endobronchial valves at achieving chest tube removal and hospital discharge for air leaks resulting from varied etiologies. Full-Text PDF

Optimizing Control of the Pleural Space

Pleural space problems can create formidable treatment dilemmas for thoracic surgeons. Most arise as iatrogenic sequelae of lung resections, although some occur as late consequences of infection, hemothorax, or systemic inflammatory disease. Regardless of etiology, a central theme in the development and perpetuation of chronic pleural space problems is that there has been a loss of parietal-visceral pleural apposition, and this has allowed for development of an obligate space. A variety of surgical strategies aimed at reestablishment of pleural apposition and obliteration of pleural space are reviewed.

Surgery for aspergilloma: time trend towards improved results?

Surgery of aspergilloma has been renowned to be technically challenging and has a high complication rate. We have already demonstrated an improved outcome as a result of a reduction in complex cases related to history of tuberculosis. In this paper we will evaluate whether this time trend has continued during recent years. Initial presentation and postoperative outcome of 33 patients who underwent surgical treatment between 1998 and 2009 were reviewed and compared with two previous reports (group 1: 55 patients from 1974 to 1991; group 2: 12 patients from 1992 to 1997). Underlying disease was tuberculosis in 15% of patients (57% in group 1, 17% in group 2), and 12% of patients had complex aspergillomas (80% in group 1, 41% in group 2). Postoperatively, there was no mortality (5% in group 1, 0% in group 2). Morbidity decreased progressively in terms of bleeding (44% in group 1, 9% in group 2, and 6% in recently, accrued patients), of pleural space problems (47%, 18% and 12%, respectively), and of prolonged hospital stay (32%, 8% and 6%, respectively). With a decreased postoperative complications rate after resection, contemporary surgery of aspergilloma is safe and offers satisfactory early and long-term results.

Treatment of Recalcitrant Air Leaks

Pleural space problems after lung resection and persistent air leaks are among the commonest challenges posed to thoracic surgeons. Surgical repair of air leaks are indicated when conventional tube thoracostomy has failed to solve the problem. We would like to propose the novel application of the combined latissimus dorsi-serratus anterior transposition flap for selected cases of air leaks that are recalcitrant to conventional treatment. We discuss its indications and the surgical technique. Five patients underwent the procedure between 2004 and 2007. They were male patients aged between 32 and 70 years. Four patients had alveolar-pleural fistulas resulting in persistent air leaks while the fifth patient had, in addition, a space problem following lung volume reduction surgery. All patients had prolonged treatment with chest drains without success. With the patient in a lateral decubitus position, a lazy-S incision was used to expose the entire latissimus dorsi and the proximal slips of the serratus anterior muscles. They were raised as pedicled flaps and transferred in tandem. The latissimus dorsi was introduced into the pleural cavity via a thoracic window and used to reinforce the fistula repair. The serratus anterior muscle closed the rib window. In all cases, the lungs reexpanded and chest drains were removed within 5 days post surgery. There were no recurrent air leaks at 1-year follow-up with all patients. Conservative treatment in all our patients was unsuccessful. The dual flap technique has the advantage of allowing normal ventilation while providing a seal over the alveolar-pleural fistula. The muscle bulk of the latissimus dorsi fills the pleural dead space and the serratus anterior muscle seals the axilla preventing subcutaneous emphysema. There was minimal morbidity associated with the use of this dual muscle flap technique. This technique is an effective treatment option for recalcitrant air leaks.

The Removal of Chest Tubes Despite an Air Leak or a Pneumothorax

The presence of an air leak is currently a contraindication for removal of a chest tube. The objective of this series was to evaluate the safety of chest tube removal in patients with an air leak. This study was a retrospective cohort study of a prospective database. Patients who underwent elective pulmonary resection and were discharged home with a chest tube were eligible. Between July 2000 and July 2007, 6,038 patients underwent elective pulmonary resection by one general thoracic surgeon. One hundred and ninety-nine patients (3.8%) with a persistent air leak had their chest tubes placed to a suctionless portable drainage device and were discharged home. One hundred ninety-four patients (97%) returned to our clinic (median, postdischarge day 16). One hundred thirty-seven patients had no air leak, and 57 patients still had an air leak. All 137 patients (including 26 with a nonexpanding pneumothorax) had their chest tubes removed. In addition, all 57 patients (including 19 who had pneumothorax as well) had their chest tubes removed without sequela (9 after provocative clamping). At 3 months' follow-up, all patients were asymptomatic without evidence of pleural space problems, except 3 (all in the persistent air leak group) in whom an empyema developed. Patients with air leaks can be safely discharged home with their chest tubes. These tubes can be safely removed even if the patients have a pneumothorax, if the following criteria are met: the patients have been asymptomatic, have no subcutaneous emphysema after 14 days on a portable device at home, and the pleural space deficit has not increased in size.

A single 24F Blake drain after wedge resection or lobectomy: a study on 100 consecutive cases

To evaluate the results of chest drainage using one 24F Blake drain after standard thoracic operations (wedge resection and lobectomy). In 2005, 100 consecutive patients underwent drainage of their pleural cavity following lobectomy or wedge resection(s). There were 70 men and 30 women, with a mean age of 55 years (17-83). There were 47 lobectomies (23 upper, 5 middle, 19 lower), 3 bilobectomies (2 right upper and middle, 1 right lower and middle), and 2 anatomical segmentectomies. All these anatomical resections were performed by standard thoracotomy, mainly for cancer diseases (45 cases). Furthermore, 48 atypical resections by single or multiple wedge(s) were realized, 20 of them by VATS. They included 14 various benign diseases, 16 malignant diseases, 8 significant emphysema bullous, and 10 blebs. Chest X rays were performed regularly in the postoperative period to detect residual pleural effusion or pneumothorax necessitating additional drainage or reoperation. Patients were controlled one month after discharge. One patient with pleural carcinosis died of pulmonary embolus on day 8. Neither replacement of chest tube nor reoperation was necessary for pleural space problems. Median duration of drainage was 5 days (3-15), 6 days after lobectomy and 4 days after wedge resection. In 15 cases, the duration of drainage was more than 8 days: 11 persistent air leaks and 4 drainages exceeding 150-200 cm3 daily. Ninety percent of patients were discharged the day following the drain removal. Postoperative courses after standard thoracic procedures using a single 24F Blake drainage appear similar to that accounting after a classical semi-rigid drainage. Such single drainage may appear now as an acceptable option. The flexible quality of the drain, its reduced caliber, and the character unique of the drainage, may contribute to improve comfort of the operated patients.

Pleural Space Problems After Living Lobar Transplantation

We reviewed our experience with adult living lobar lung transplant (LL) recipients to assess whether size and shape mismatch of the donor organ to the recipient pre-disposes to the development of pleural space problems (PSP). Eighty-seven LL were performed on 84 adult recipients from 1993 through 2003. Seventy-six patients had cystic fibrosis. Patient records were examined for PSP, defined as air leak or bronchopleural fistula for more than 7 days; pneumothorax, loculated pleural effusions, or empyema in 68 patients for which complete data were available. There were 24 PSP identified for an overall incidence of 35%. The most common PSP was air leak/bronchopleural fistula, accounting for 38% of PSP. The second most common PSP was loculated pleural effusion (21% of PSP). Empyema was uncommon (2 patients, 3% of total patients) in our series of patients despite the large population of cystic fibrosis patients. In 4 of these patients, computed tomography-guided drainage was used for loculated effusions after chest tube removal. Three LL patients underwent surgery for persistent air leak and required muscle flap repair. One of these required subsequent omental transfer. Two LL patients required decortication for empyema. Many patients with PSP could be managed without further surgical intervention (14/24 patients). Donor-recipient height mismatch was not significantly different between PSP and non-PSP patients (p = 0.53). The incidence of PSP in LL recipients is similar to that reported in the literature on cadaveric transplant recipients. The relatively small lobe in the potentially contaminated chest cavity of cystic fibrosis recipients does not significantly pre-dispose to development of empyema despite immunosuppression. Many PSP can be managed non-operatively, although early aggressive intervention for large air leaks and judicious chest tube management are essential for a good outcome.

Diaphragmatic elevation of a patient with chronic obstructive pulmonary disease after left upper lobectomy

Among postoperative pleural space problems after pulmonary resections, it is more difficult and troublesome to manage this space after left upper lobectomy in patients with chronic obstructive pulmonary disease (COPD). We performed a retrospective study focusing on the elevation of ipsilateral hemidiaphragm of the 36 patients with or without COPD after left upper lobectomies, by measuring diaphragmatic dome length (DDL) with a plain posteroanterior roentgenogram. They were divided into two groups: group I (forced expiratory volume in 1 s (FEV1) % predicted < 70%, n = 5); and group II (FEV1) % predicted > or = 70%, n = 31). Of each group, we investigated the trend of both left and right DDLs perioperatively, calculating DDL index (DDL divided by height, DDLI), and also analyzed several perioperative parameters. The trend of left DDLI after surgery was different in the two groups (P=0.012). In group I, left DDLI became larger gradually in proportion to the postoperative weeks, while in group II it became the largest 2 weeks after surgery and decreased gradually. Left DDLI in group I was smaller than that in group II 2 weeks after surgery (P=0.007). We found that the diaphragm of COPD patients does not elongate easily after left upper lobectomy.

Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections

Background. The use of pneumoperitoneum to treat prolonged air leaks or space problems, or both, after pulmonary resection has been recently resurrected and used successfully. Methods. During the last 3 years, 14 patients experienced short-term pleural space problems associated with prolonged air leaks after pulmonary resection for lung cancer. All patients, under sedation and local anesthesia, had a mean of 2,100 mL of air injected under the diaphragm, using a Veres needle after a mean time of 7 days (range, 5 to 10 days) from the operation. In 3 patients talc slurry was added to help control the air leak. Results. No patients experienced complications during the induction of the pneumoperitoneum. No patients complained of dyspnea, although blood gas analysis showed a slight increment of carbon dioxide partial pressure ( p < 0,0004). Obliteration of the pleural space was observed in all cases after a mean time of 4 days (range, 1 to 7 days). Air leaks stopped in all patients after a mean time of 8 days (range, 4 to 12 days). The mean postoperative hospital stay after lung resection was 18 days (range, 14 to 22 days). No patients had significant complications or long-term sequelae. We found that patients who had undergone induction chemotherapy had longer air leak durations than observed in noninduction patients ( p = 0.03). Conclusions. Our experience supports the use of postoperative pneumoperitoneum whenever a space problem associated with prolonged air leaks is present. The procedure is effective, safe, and easy to perform.

Pleuropulmonary aspergilloma: Clinical spectrum and results of surgical treatment

From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.

Neodymiumi:yttrium-aluminum garnet laser-assisted pulmonary resections

The neodymium:yttrium-aluminum garnet laser is a new approach to limited pulmonary resection. It avoids distortion of surrounding pulmonary tissue and potential pleural space problems, which can occur with mechanical stapler resections. We have recently used this laser to manage 39 pulmonary lesions in 20 patients. There were no major postoperative complications, and air leak after resection was minimal. Neodymium:yttrium-aluminum garnet laser excision is a useful method that may have an advantage over mechanical stapling techniques for the limited resection of many pulmonary lesions.

Thoracoscopy and talc poudrage for pneumothoraces and effusions

The indications, technique, and results of thoracoscopic talc poudrage in the two clinical settings of pneumothorax and recurrent pleural effusion in chronically ill patients are reported. Forty patients underwent this treatment between May 1982 and September 1989. The patients ranged in age from 10 months to 78 years. Of the 20 patients who underwent treatment of pneumothorax, 9 had cystic fibrosis, 7 had severe chronic obstructive pulmonary disease, 2 had spontaneous pneumothoraces, and 2 had postoperative parenchymal bronchopleural fistulas. Nineteen patients (95%) had successful treatment. Of the 20 patients who underwent treatment of chronic effusions, 14 had malignant etiologies, 3 had chylothoraces, and 3 had other miscellaneous effusions. Eighteen patients (90%) in this group had successful treatment. There were two hospital deaths related to the underlying disease processes after the pleural space problems were successfully treated. This study suggests that proper selection of patients and full exploitation of the capabilities of thoracoscopy and talc poudrage will result in effective treatment with low morbidity and mortality.