Chest
Volume 113, Issue 6, June 1998, Pages 1507-1510
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Clinical Investigations: Surgery
Prolonged Air Leak Following Radical Upper Lobectomy: An Analysis of Incidence and Possible Risk Factors,

https://doi.org/10.1378/chest.113.6.1507Get rights and content

Study objectives

To examine the incidence and clinical significance of prolonged air leak (PAL) in patients undergoing radical upper lobectomy and to determine potential risk factors for PAL in this group of patients.

Design

Retrospective review of a prospective database.

Setting

Experience of one thoracic surgeon at a tertiary care cancer center.

Patients

One hundred consecutive patients undergoing right upper lobectomy and mediastinal lymph node dissection for non-small cell lung cancer over an 11-year period.

Measurements

PAL was defined as an air leak lasting >7 days. Preoperative, intraoperative, and postoperative clinical data were collected and analyzed to determine the factors associated with PAL.

Results

PAL was the most prevalent postoperative complication, comprising 25.5% of all complications seen, and lasting an average of 12.1 ±5.3 days. In 21 of the 26 patients with PAL, this complication was the only morbidity identified. There was no statistically significant difference in patient age, gender, preoperative FEV1 and diffusion of carbon monoxide, exposure to neoadjuvant chemotherapy, status of pulmonary fissures, or pathologic stage between the PAL group vs the remaining 74 patients without this complication. A significantly greater proportion of patients with PAL had FEV1/FVC ratio ≤50% (6/26 vs 5/74; p=0.02). Patients with PAL had significantly longer median length of hospital stay (11 vs 7 days; p=0.0001). Moreover, PAL was the single most common reason for an extended length of hospitalization (21/58, 36% of all causes).

Conclusion

PAL is an alarmingly common postoperative complication and is the most frequent cause of an extended length of hospital stay in patients undergoing radical upper lobectomy. Severe obstructive pulmonary disease predisposes patients to the development of this complication.

Section snippets

MATERIALS AND METHODS

The records of 100 consecutive patients, retrieved from a prospective database, who had undergone a right upper lobectomy for NSCLC by the same surgeon (M.B.) at Memorial Sloan-Kettering Cancer Center from September 1988 through May 1996 were examined retrospectively. Patients with Pancoast tumors and tumors requiring bilobectomy, pneumonectomy, or chest wall resection were excluded. A PAL was defined as an air leak requiring >7 days of postoperative chest tube drainage. A chest tube required

RESULTS

Thirty-eight women and 62 men, with a median age of 66 years (range, 41 to 81 years), were included in this analysis. All resections were performed through a standard posterolateral thoracotomy and included a complete mediastinal lymph node dissection. In 10 patients, a concomitant right lower lobe superior segmentectomy or wedge resection was performed. All patients were extubated either in the operating room or immediately after transfer to the recovery room.

The postoperative course was

DISCUSSION

Pulmonary lobectomies frequently require division across the lung parenchyma and, therefore, inherently create a potential source for parenchymal air leaks. In most instances, the air leak seals rapidly when the visceral pleura becomes adherent to the chest wall, and the chest tube is removed uneventfully. However, upper lobectomies often result in large apical air spaces with poor visceral-parietal pleural apposition, and thus, frequently predispose these patients to longer pulmonary air leaks.

CONCLUSION

PAL represents a major source of morbidity and is the most frequent cause of an extended length of hospitalization in patients undergoing upper lobectomy for NSCLC. It behooves thoracic surgeons to be cognizant of this iatrogenic complication and actively participate in developing more effective strategies to prevent it.

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Deceased.

Reprint requests: Ari Brooks, MD, Memorial Sloan-Kettering Cancer Center, Thoracic Service, Department of Surgery, 1275 York Ave, New York, NY 10021

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