Prolonged Air Leak Following Radical Upper Lobectomy: An Analysis of Incidence and Possible Risk Factors

doi:10.1378/chest.113.6.1507

Chest

Volume 113, Issue 6, June 1998, Pages 1507-1510

https://doi.org/10.1378/chest.113.6.1507 Get 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.

References (16)

NagasakiF et al.
Complications of surgery in the treatment of carcinoma of the lung.
Chest
(1982)
KeagyB et al.
Elective pulmonary lobectomy: factors associated with morbidity and operative mortality.
Ann Thorac Surg
(1985)
BuschE et al.
Pulmonary complications in patients undergoing thoracotomy for lung carcinoma.
Chest
(1994)
DeslauriersJ et al.
Prospective assessment of 30-day operative morbidity for surgical resections in lung cancer.
Chest
(1994)
HazelriggSR et al.
Video assisted thoracic surgery study group data.
Ann Thorac Surg
(1993)
JuettnerFM et al.
Reinforced staple line in severely emphysematous lungs.
J Thorac Cardiovasc Surg
(1989)
VaughnCC et al.
Prevention of air leaks after pulmonary wedge resection.
Ann Thorac Surg
(1997)
McCarthyPM et al.
The effectiveness of fibrin glue sealant for reducing experimental pulmonary air leak.
Ann Thorac Surg
(1988)

There are more references available in the full text version of this article.

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An air leak lasting more than 5–7 days (persistent air leak, PAL) can complicate up to 40% of patients with secondary spontaneous pneumothorax. Chronic obstructive pulmonary disease is the most common cause of secondary spontaneous pneumothorax, and early surgical intervention has been recommended for patients with PAL. Bullectomy or blebectomy with concomitant mechanical pleurodesis by medical thoracoscopy or video assisted thoracoscopic surgery is considered definitive therapy. Unfortunately, the perioperative course following lung resection can also be complicated by air leaks leading to worse clinical outcomes. Post lung resection air leak can be pressure independent or pressure dependent (also known as drainage-related air leak). The distinction between these two entities is crucial as the management varies drastically. Pleural manometry may play an important role in the early diagnosis of pressure-dependent PAL preventing further unnecessary surgical procedures from being performed.
Risk factors for prolonged air leak after pulmonary surgery: A systematic review and meta-analysis
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Our meta-analysis also found that lower ratio of FEV1 and FVC (FEV1/FVC%) could be conducive to the increased PAL risk. The pooled results were, by variable type: binary variables in 7 studies,18,20–22,37,41,43 OR 1.99, 95%CrI 1.22 to 3.33, P = 0.005; continuous variables in 5 studies,18,20,24,30,36 MD -5.67, 95%CrI -7.50 to -3.83, P<0.001. However, no significant results were noticed in forced vital capacity percent of predicted (FVC%) (P = 0.072).
This study aimed to comprehensively identify risk factors for the occurrence of prolonged air leak (PAL) in patients undergoing pulmonary surgery. Studies were retrieved from 3 databases, including PubMed, Web of Science, and EmBase up to 13 May 2020. We performed meta-analysis using Bayesian random effect models through divergence restricting conditional tessellation (DIRECT) algorithm. The effect size was expressed as odds ratio (OR) or mean difference (MD), each with 95% credible interval (CrI). The evidence quality was evaluated. Subgroup analyses and sensitivity analyses were conducted. Thirty-nine studies with 89006 patients were finally included. Pooled PAL incidence was 15%. Of 30 risk factors, 22 were significantly associated with increased PAL incidence. Five risk factors were ultimately selected with high evidence quality: smoking history (OR 1.84, 95%CrI 1.45 to 2.31, P<0.001), preoperative steroid use (OR 1.51, 95%CrI 0.87 to 2.65, P = 0.031), lower ratio of forced expiratory volume in 1 s and forced vital capacity (OR 1.99, 95%CrI 1.22 to 3.33, P = 0.005), non-fissureless technique (OR 2.14, 95%CrI 1.31 to 3.66, P = 0.003), and pathological TNM stage III/IV (OR 1.50, 95%CrI 1.07 to 2.12, P = 0.003). Regarding the negative impact of PAL on the personal cost and postoperative recovery, the verification of previous proposed factors and investigation of recently discovered ones both implied directions for risk stratification and the establishment of an applicable prediction model.
Air leaks: Stapling affects porcine lungs biomechanics
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During thoracic operations, surgical staplers resect cancerous tumors and seal the spared lung. However, post-operative air leaks are undesirable clinical consequences: staple legs wound lung tissue. Subsequent to this trauma, air leaks from lung tissue into the pleural space. This affects the lung's physiology and patients' recovery.
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Air bubbles originated at staple holes of inner row from exposed porcine lung tissue due to torn pleural on costal surface. Compared during inflation, left upper or lower lobe resections have similar compliance (slope of the pressure vs volume curve), which are 9% lower than healthy lung compliance. However, lower lobes statistically burst at lower pressures than upper lobes (p-value<0.046) in ex vivo conditions confirming previous clinical in vivo studies. In parallel, the lung deformed mostly in the vicinity of staple holes and presented maximum shear strain near the observed leak location. To conclude, a novel technique DIC provided concrete evidence of the post-operative air leaks biomechanics. Further studies could investigate causal relationships between the mechanical parameters and the development of an air leak.
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Citation Excerpt :
Prolonged air leaks (PALs) after lung resections are one of the most common complications in thoracic surgery. The overall incidence of postoperative complications is approximately 3.4% to 8.5%, whereas the rate of air leaks after lung resections is up to 26%.1,2 While several definitions of prolonged air leakage are in use, the most current definition describes an increased length of hospital stay compared with an otherwise uncomplicated postoperative course.3,4
Prolonged air leaks (PALs) after lung resection are one of the most common complications in thoracic surgery. Several options are available to treat PALs. The autologous blood patch pleurodesis is commonly used but has not been thoroughly investigated.
We conducted a prospective randomized study including all consecutive patients with PALs after pulmonary resections. Patients were randomized to either having received pleurodesis by injecting 100 mL autologous blood at d 5 and 6 (Group A) or being placed under observation (Group B). Patients from either group undergoing revisions were further investigated by a post hoc analysis and formed Group C.
A total of 24 patients were included: 10 patients were randomized to group A and 14 to group B. Six patients (3 from each group) underwent surgical revision and were included in Group C. Groups A and B did not differ in baseline characteristics. The median time to drainage removal was 9 d (range: 5-23 d) in Group A; 9 d (range: 2-20 d) in Group B; and 6 d in Group C (range: 3-10 d), (A/B versus C, P < 0.04; A versus B was not significant).
There is no evidence indicating a benefit for blood patch pleurodeses in patients undergoing lung resections and presenting with postoperative PALs for more than 5 d. An early operative closure of postoperative air leakage seems to be more effective.

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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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Chest

Clinical Investigations: SurgeryProlonged Air Leak Following Radical Upper Lobectomy: An Analysis of Incidence and Possible Risk Factors†,

Study objectives

Design

Setting

Patients

Measurements

Results

Conclusion

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

CONCLUSION

Chest

Ann Thorac Surg

Chest

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Clinical Investigations: Surgery
Prolonged Air Leak Following Radical Upper Lobectomy: An Analysis of Incidence and Possible Risk Factors†,