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Eur J Cardiothorac Surg 2001;20:1012-1015
© 2001 Elsevier Science NL

Pleural tenting following upper lobectomies or bilobectomies of the lung to prevent residual air space and prolonged air leak

SSK Sureyyapasa Thoracic and Cardiovascular Diseases Teaching Hospital, Istanbul, Turkey

Received 13 March 2001; received in revised form 11 July 2001; accepted 25 July 2001.

Corresponding author. 67 Ada Kardelen 4.1 D.34 Atasehir Istanbul 81120 Turkey. Tel.: +90-216-455-3538; fax: +90-212-296-1005
e-mail: erdalokur{at}hotmail.com

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Objective: Apical residual air space and prolonged air leak are not uncommon entities following resection of upper lobe of the lung. This study was carried out to observe the efficacy of pleural tenting in preventing these problems. Methods: This is a prospective randomised study. Pleural tenting after upper or upper and middle lobectomies was performed in 20 patients. In another 20 patients who underwent upper lobectomy or bilobectomy, pleural tenting was not performed. Both groups were compared in respect to durations of postoperative chest tube drainage and hospital stay, amount of total pleural drainage, and the presence of need for any additional intervention for prolonged air leak. Results: Age, sex, pathology and pulmonary function tests of two groups were similar. Duration of chest tube drainage was shorter in whom pleural tenting was performed when compared to whom pleural tenting was not performed (4.3±0.16 days versus 7.40±0.68 days, P<0.0001). Mean hospital stay was shorter in tented group (7.60±0.4 days versus 9.35±0.6 days, P=0.024). Although the mean amount of total pleural drainage was less in tented group (667.5±57.7 ml versus 802.5±83.3 ml, P=0.1911), the difference was not statistically significant. Three (15%) patients in non-tented group needed an apical chest tube insertion in postoperative period for prolonged air leak with an apical pleural space. Asymptomatic apical residual space was observed in 3 patients in tented group. There was no morbidity in patients in tented group. Conclusion: Pleural tenting following upper lobectomy or bilobectomy of the lung shortens the duration of chest tube drainage and hospital stay, and it prevents apical residual air spaces and related complications. Pleural tenting is safe and relatively simple procedure, which has no associated morbidity.

Key Words: Pleural tenting • Residual air space • Air leak • Upper lobectomy

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
By conventional radiography, 20–40% of patients who have undergone pulmonary resections will have a residual air space; of these 75% will be spontaneously obliterated in long term [1,2]. Krasna reported that pleural infections complicate approximately 5% of these spaces [3]. Air space problems are more common after upper lobectomies when compared to other type of lobar resections [4].

The changed shape of the remaining lung following pulmonary resection may not fit to the shape of the hemithorax. Additionally, inadequate volume of the remaining lung to fill the hemithorax may interfere the apposition of parietal and visceral pleural surfaces. These are the probable sites of air leaks after pulmonary lobectomy.

During the history of general thoracic surgery, plenty of methods were tried to prevent residual air spaces after lung resections. Pleural tenting, an old method, first described by Miscall [5] and Hansen [6], has recently regained popularity [7–9].

In this study, we report the results of our prospective study comparing the postoperative parameters of patients in whom pleural tenting was performed and patients in whom pleural tenting was not performed after upper or upper and middle bilobectomies of the lung.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
2.1. Study design
This prospective study was carried in 40 patients undergoing upper or upper and middle lobectomies for various reasons in our institution between November 1998 and December 1999. Patients who underwent chest wall resection, and those who had lung cancer invading parietal pleura were excluded from the study. Forty patients were randomised into two groups. Pleural tenting was performed in 20 patients whereas it was not performed in other 20 patients. Two groups were compared in respect to preoperative and postoperative variables. Preoperative variables included age, sex, side of resection, forced vital capacity (FVC) (as litre and percent of predicted) and forced expiratory volume in first second (FEV₁) (as litre and percent of predicted). Postoperative variables included durations of chest tube drainage and hospital stay, amount of total pleural drainage, the presence of prolonged air leaks (5 days), and presence of residual air space.

Numerical variables were expressed as the mean±standard error of the mean and analysed by unpaired Student's t-test. Fischer's exact test was used for categorical variables.

2.2. Patients’ profile
Preoperative parameters of the patients are summarized in Table 1. In tented group, 16 patients were operated for non-small cell carcinoma, two patients for multi-drug resistant tuberculosis, and one patient for infected air cyst and, one patient for traumatic bronchial stricture. Right upper lobectomy was performed in nine patients, right upper and middle lobectomy in four patients and left upper lobectomy in seven patients. In non-tented group, 17 patients were operated for non-small cell carcinoma and one each patient for aspergilloma, multi-drug resistant tuberculosis, and sequel of tuberculosis cavity. Right upper lobectomy was performed in ten patients, left upper lobectomy in nine patients and right upper and middle lobectomy in one patient. The reason for upper and middle lobectomy in both groups was the presence of invasion of carcinoma in minor fissure.

Pleura was dissected from endothoracic fascia beginning from side of thoracotomy incision towards to apex of the lung and continued both anterior and posterior sides until mediastinal surface was encountered. Only 2 cm of upper mediastinal pleura was dissected to drop the apical pleura completely. Pleura was hold by ring forceps and managed gently in avoid to tear it. Small tears less than 2 cm were sutured by 3/0 chromic catgut. Three cases in whom parietal pleura was largely torn during dissection were not included in the study, one with aspergilloma, one with multi-drug-resistant tuberculosis and other with tumour causing atelectasis. While thorax were being closed, lateral side of the tent was attached to chest wall by three or four pericostal sutures. The mean duration of tenting procedure changed between 5–10 min. Two chest tubes were placed routinely. All patients received prophylactic antibiotic therapy with one of third generation cephalosporins, beginning half an hour before induction of anaesthesia and it continued until the chest tubes were removed. Chest tubes were connected to underwater seal with 10–20 cm H₂O negative suction. Thoracic epidural catheter was placed preoperatively by anaesthesiologist and 2-days epidural bupivacaine analgesia together with a parenteral non-steroidal anti-inflammatory drug was applied to all patients.

Air leaks and amounts of pleural drainage were recorded and chest X-rays were taken daily. The chest tubes were removed when air leak was stopped and daily drainage reduced to less then 50 ml per day. Postoperative morbidities were recorded and managed accordingly. Preoperative parameters of age, sex, laterality, FVC and FEV₁ as Litre and percentage, and post-operative parameters such as durations of chest tube and hospital stay, and amount of total pleural drainage in tented and non-tented groups were compared statistically.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
There was no statistically significant difference between the patients’ characteristics in two groups (Table 1). When the postoperative variables of two groups were compared, duration of chest tube drainage was found to be shorter in tented group than non-tented one (4.30±0.16 days versus 7.40±0.68 days, P<0.0001). Patients in tented group had shorter hospital stay when compared to non-tented group (7.6±0.47 days versus 9.35±0.61 days, P=0.024). Although amount of total drainage was less in tented group (667.5±57.72 ml versus 802.5±83.38 ml), the difference was not statistically significant (P=0.191).

Chest tubes of 13 (65%) of 20 patients in tented group were removed within 4 days whereas chest tubes could be removed in only two (10%) of 20 patients in non-tented group within same duration (P=0.0008).

Postoperative complications occurred in two patients in tented group: superficial infection in skin incision in one and oesophago–pleural fistula resulting with pleural empyema in another. Both were not related to tenting procedure and managed conservatively. Apical extrapleural space was observed on plain radiography in three patients. No complication was seen in follow-up of these patients.

Prolonged air leak together with apical air space was seen in three non-tented patients. Such space problems may have been related to an incorrect placement of the anterior chest tube at the time of the operation. In order to diminish the space and stop the air leak, another chest tube was inserted through second intercostal space in mid-axillary line and connected to underwater seal and negative suction. Air leak and air space gradually disappeared within 3 days in one patient whereas air leaks stopped and air space got smaller but not disappeared in two patients. Their chest tubes were removed in fifth and seventh days respectively and no complication was seen in their follow-up.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Prolonged air leak and residual air space are not uncommon problems following upper lobectomies of the lung. The rate of this problem readily decreases by the experience of the surgeon. However, presence of some technical disabilities such as an inadequate expansion capability of the remaining lobe(s) to fill the hemithorax can never be eradicated so that the rate of postoperative air space problem and prolonged air leak never falls to a situation that can be called as a ‘rarity’.

This prospective study shows that apical pleural tenting following upper lobectomy or bilobectomy of the lung decreases the rate of prolonged air leak and related air space problems, shortens the durations of chest tube drainage and hospital stay. We must emphasise that tented group which had better postoperative parameters included four upper bilobectomies (which could be expected to have more common air space problem) in contrast to one upper bilobectomy in non-tented group. Although not statistically significant, pleural tenting was found to lessen the amount of total pleural drainage as well. This later result reveals that apical pleural lysis is not associated with an increased bleeding as commonly thought. The procedure is simple, it adds less than 10 min to the total operation time and is associated with no side effects at all. It can be difficult to create a pleural tent in inflammatory upper lobe disease. Three cases with inflammatory disease were not included in the study because of large tears in pleura.

Air space problems, which are the risk factors for prolonged air leak and infection after pulmonary resections have always been an important concern of general thoracic surgery. A consequence of high number of pulmonary resections for inflammatory lung diseases at the past, the residual air space problems was more commonly encountered when compared to today's general thoracic surgical practice, which is more commonly interested with resection for pulmonary neoplasia. Thoracoplasty, myoplasty, pneumoperitoneum were the methods used for space reducing purposes. Another method, the pleural tenting, first described by Miscall and Hansen, has begun to be used for almost same purposes [5,6]. Rainer later described extrapleural apicolysis, which was a similar procedure [10]. He dropped endothoracic fascia together with parietal pleura but this procedure was associated with a considerable haemorrhage. No report about this method has appeared in literature till to 1993 when it was used after lung volume reduction surgery to prevent air leaks from stapler lines. Robinson and his co-workers in 1998 and Brunelli and co-workers in 2000 used this method after upper lobectomy and reported that pleural tenting after upper lobectomy decreased chest tube time and total hospitalisation days [8,9].

The rationale behind the pleural tent is to sustain the symphysis of two pleural surfaces as reported by Rice et al. [11]. This symphysis causes not only a diminution in intrapleural space but also maintenance of sealing of small air leaks from lung surface. Early termination of air leaks leads early removal of chest tubes, resulting the decreased probability of postoperative complications, most importantly the infection, and increased patient comfort with early discharge from the hospital.

In conclusion, some factors such as age of the patient, emphysematous lung, incomplete fissures requiring extensive use of staplers, air leaks from the lung surface observed at the end of the procedure are associated with the increased postoperative air space problems and longer hospital stay following upper lobectomy or bilobectomy of the lung. Pleural tenting which is a safe and simple procedure with no additional morbidity should be kept in mind as a tool to prevent these problems in these patients.

	Footnotes

 
Presented at the 8th European Conference on General Thoracic Surgery of the European Society of Thoracic Surgeons, London, UK, November, 1–4, 2000.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

1. Bell J.W. Management of post-resection space in tuberculosis: II. Following lobectomy. J Thorac Surg 1956;31:442.
2. Wareham E.E., Barber H., McGoey J.S. The persistent pleural space following partial pulmonary resection. J Thorac Surg 1956;31:593.
3. Managing the postoperative pleural space. Southern Thoracic Surgical Association 46th Meeting, 1999.
4. Barker W.L. Natural history of residual air spaces after pulmonary resection. Chest Surg Clin North Am 1996;6:585-613.[Medline]
5. Miscall L., Duffy R.W., Nolan R.B., Klopstock R. The pleural tent as a simultaneous tailoring procedure in combination with pulmonary resection. Am Rev Tuberc 1956;73:831-852.[Medline]
6. Hansen J.L. Parietal pleurolysis (the pleural tent) as a simultaneous space — reducing procedure in combination with pulmonary resection. Acta Chir Scand 1957;112:485-488.[Medline]
7. Cooper J.D., Petterson G.A., Sundaresan R.S., Trulock E.P., Yusen R.D., Pohl M.S., Lefrak S.S. Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg 1996;112:1319-1330.[Abstract/Free Full Text]
8. Robinson L.A., Pretsko D. Pleural tenting during upper lobectomy decreases chest tube time and total hospitalisation days. J Thorac Cardiovasc Surg 1998;115:319-327.[Abstract/Free Full Text]
9. Brunelli A., Al Rafai M., Muti M., Sabbatini A., Fianchini A. Pleural tent after upper lobectomy: a prospective randomised study. Ann Thorac Surg 2000;69:1722-1724.[Abstract/Free Full Text]
10. Rainer W.G., Newby J.P. Prevention of residual space problems after pulmonary resection. Am J Surg 1967;114:744-747.[Medline]
11. Rice T.W., Kirby T.J. Prolonged air leak. Chest Surg Clin North Am 1992;2:803-811.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Erdal Okur Altan Kir Semih Halezeroglu Ali Atasalihi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Okur, E. Articles by Atasalihi, A. Search for Related Content PubMed PubMed Citation Articles by Okur, E. Articles by Atasalihi, A. Related Collections Lung - other