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Eur J Cardiothorac Surg 2005;27:334-336
© 2005 Elsevier Science NL

Predictors of prolonged air leak following pulmonary lobectomy

Alan J. Stolz*, Jan Schützner, Robert Lischke, Jan Simonek, Pavel Pafko

3rd Deptartment of Surgery, Charles University, University Hospital Motol, Kuvalu 84, Prague 15000, Czech Republic

Received 18 August 2004; received in revised form 4 November 2004; accepted 8 November 2004.

* Corresponding author. Tel.: +420 2 2443 8001; fax: +420 2 2443 8020. (E-mail: stolz{at}seznam.cz).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: To predict risk factors of a prolonged air leak following pulmonary lobectomy. Methods: From January 2003 to March 2004, 134 patients (95 male, mean age 66±7.7 years) underwent pulmonary lobectomy for lung tumor. Prolonged air leak (PAL) was defined as an air leak lasting 7 days or more of postoperative chest tube drainage. Chronic obstructive pulmonary disease (COPD) was defined as an FEV1 of <70% predicted and an FEV1/FVC ratio <70% based on the results of a preoperative pulmonary function test. Results: PAL occurred in 13 (9.7%) patients and it lasted 10.4±3.2 days. Eleven out of 13 patients with PAL were identified with this co-morbidity only. There was not reoperation for PAL. Differences in age, gender, exposure to neoadjuvant chemotherapy, body mass index (BMI) and type of lobectomy were not statistically significant. COPD remained the only variable predicted for PAL (P<0.05). Conclusions: Prolonged air leak is quite a common pulmonary complication after pulmonary lobectomy and can be treated conservatively. This complication significantly prolongs the length of hospitalization (P<0.01). We also conclude that COPD increases the risk of an air leak persisting for longer than 7 days.

Key Words: Pulmonary lobectomy • Prolonged air leak • Risk factors


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
One of the major limiting factor in early hospital discharge following pulmonary lobectomy is a prolonged air leak. With increasing concern for quality of medical care, length of hospital stay, and cost of health care delivery, it has become the responsibility of the surgeon to control all factors that lead to a prolonged hospitalization. Parenchymal air leak is quite a common and a potentially preventable complication following pulmonary resection. A prolonged air leak (PAL) can be defined as an air leak lasting more than 7 days. An incidence of PAL between 3 and 25% has been reported in heterogenous populations of patients with benign or malignant tumors undergoing pulmonary resections [1–4]. The purpose of this study was to determine the incidence of PAL and its clinical implications in patients undergoing pulmonary lobectomy and to identify those preoperative factors that may predispose to the development of PAL.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Our prospective study included 134 patients. They underwent pulmonary lobectomy in our institution between January 2003 and March 2004. Prolonged air leak (PAL) was defined as an air leak requiring 7 or more days of postoperative chest drainage. A chest tube required for drainage of fluid without air leak was not considered in this analysis. Patients were divided into two groups according to the presence (PAL group) or absence (non-PAL group) of air leak complication.

We considered the following preoperative variables: age, sex, body mass index (BMI), FEV1 (forced expiratory volume per second, percent of predicted), FVC (forced vital capacity, percent predicted), FEV1/FVC ratio. Airway obstruction (COPD) was defined as an FEV1<70% of predicted and an FEV1/FVC ratio of <70% [5].

Per and postoperative variables included the duration of chest drainage, type of surgery, status of pulmonary fissures, other pulmonary and cardiac complications, length of hospital stay.

Operability was determined according to existing guidelines for pneumonectomy and lobectomy [6]. All resections were performed with selective lung ventilation by a standard anterolateral thoracotomy approach. Lobectomy was done with manual suture of bronchus (PDS II, Ethicon), ligation of pulmonary veins, dissection and double ligation of pulmonary artery branches. Incomplete pulmonary fissure were divided using a linear stapler (75mm Linear Cutter, Ethicon). We use one chest tube for all types of resections. A complete perihilar and mediastinal node dissection was performed to evaluate an accurate pathologic staging in patients with lung cancer. All patients were extubated in the operating room. Postoperative pain was primarily controlled by means of epidural analgesia and in case of lack of effect by systemic opioids. Chest tube management was standardized. The chest tube was pulled out in the absence of pulmonary air leak and less than 150ml of fluid collected from pleural cavity per day. Patients had an active program of physiotherapy including deep-breathing exercises.

Data were computerized and analyzed using SPSS version 10.0 statistical packages. Predictors for prolonged air-leakage were analyzed by means of multivariate analysis. Categorical variables were compared using the {chi}2 test. Pearson correlation was used to asses relationships between continuous variables. Student's t-test was utilized to analyze continuous variables between the two groups. Statistical significance was defined as P<0.05 and highly significant as P<0.01.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Thirty-nine women and 95 men aged 26–80 years (mean, 59.1 years) were enrolled into this study. One hundred and seven lobectomies were done for NSCLC and six lobectomies for lung metastasis. Twenty-one lobectomies were done for benign tumors. There were 130 incomplete fissures and we used linear 75mm staplers to totally free the fissures. We did not use reinforcement for parenchymal suture. The postoperative course was uneventful in 91 patients. We observed 53 complications and 1 death in the remaining 43 patients. PAL was diagnosed in 13 (9.7%) patients. The length of PAL was 10.4±3.2 days (range, 7–17 days). All 13 patients were treated conservatively with chest tube drainage. Three patients (23%) had an air leak lasting longer than 14 days. PAL was the only identified morbidity in 11 patients. No empyema, bronchopleural fistula, pneumonia, atelectasis or respiratory failure was associated with PAL. Two patients (15%) in the PAL group had a minor cardiac complication and there was no significant difference to the non-PAL group (19%).

The results of {chi}2 analysis between patients with and without PAL are summarized in Table 1. The differences in age, gender, exposure to neoadjuvant chemotherapy and BMI did not reached statistical significance. We compared upper, middle and lower lobectomies to determine which one is at higher risk for PAL. We did not find significant differences in the type of lobectomy. The only variable predicted of PAL remained COPD (P=0.047). PAL significantly prolonged the length of hospital stay (13.7 vs. 7.9 days, P<0.01).


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  		Table 1. Comparison of characteristics between non-PAL and PAL groups following lobectomy
 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
The objective of this study was to identify predictors of PAL after pulmonary lobectomy. The majority of reports in the past 10 years have defined a persistent PAL as a complication when persisting for more than 7 days. For the purpose of this study, a PAL is defined as a leak that lasts for more than 7 days after pulmonary lobectomy. Incidences of this complication have been reported in 1–15% of patients after pulmonary resections. Rice and Kirby reported that 30–197 patients (15.2%) had a PAL for more than 7 days [8]. Venuta et al. reported a PAL in 4% of patients undergoing lobectomy [9]. Keagy et al. reported 4.3% incidence of PAL in a review of 369 lobectomies [10]. It has been reported that upper lobectomy was a greater risk factor for developing postoperative PAL compared to smaller resections [11]. Presumably because they often result in a large apical air space with poor visceral-parietal apposition, and thus frequently predispose these patients to prolonged pulmonary air leaks. Several authors have found that the pleural tent was a safe and quick procedure that reduces the incidence of PAL, shortens the hospitalization and decreases the cost of hospitalization [2]. In our department, we do not apply this procedure after upper lobectomy. Comparing all pulmonary resections, we did not find significant differences between the different types of lobectomy and PAL. Patients with COPD are at a greater risk for PAL, because of the expression of an increased airway resistance and pathological parenchymal changes [4,5,11].

The prevention of air leak control is the responsibility of the surgeon in charge and depends on his knowledge and experience. The main prevention of PAL remains intraoperative recognition and management. Prevention of PAL is in a precise surgical dissection and attention to pneumostatic principles. We prefer to use stapler rather than manual dissection to complete the fissures. This can be the crucial moment for prevention of the PAL, as mechanical closure of pulmonary parenchyma is more precise and pneumostatic. Several surgical techniques were recommended to decrease a risk of PAL (i.e. polydioxane ribbon, bovine pericardial strips, and expanded polytetrafloutoethelen sleeves) [7]. Several studies reported the utilization of bovine pericardium in air leak control and the decrease and duration of air leak and length of stay [9,10,12]. Miller et al. found in a prospective study about bovine pericardial strips use as a buttress along the lung staple line no statistical differences between buttressed and non-buttressed patients. The trend toward shortened air leak time and tube removal time was apparent in the buttressed group [13]. We do not apply these reinforcing techniques in our patients routinely as we have low cost-effectiveness of the bovine pericardial strips use.

However, despite all attempts of the surgeon to maximize control of air leaks, some will persist postoperatively. In this case, the surgeon should be aware of a number of factors. We have quite a conservative protocol in the management of prolonged air leak. These include patience, consideration of suction or no suction, the need for additional chest tubes, Heimlich valve, and the possible need for reoperation. We perform bronchoscopy to exclude bronchopleural fistula.

It is our conclusion that within the parameters of this study, COPD was identified as the only risk factor for the complication a prolonged air leak. PAL can be treated conservatively, but significantly prolongs the length of hospitalization.


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

  1. Stephan F, Boucheseiche S, Hollande J, Flahault A, Cheffi A, Bazelly B, Bonnet F. Pulmonary complication following lung resection. Chest 2000;118:1263-1270.[Abstract/Free Full Text]
  2. Brunelli A, Montebverde M, Borrin A, Salati M, Marasco R, Fianchini A. Predictors of prolonged air leak after pulmonary lobectomy. Ann Thorac Surg 2004;77:1205-1210.[Abstract/Free Full Text]
  3. Isowa N, Hasegawa S, Bando T, Wada H. Preoperative risk factors for prolonged air leak following lobectomy or segmentectomy for primary lung cancer. Eur J Cardiothorac Surg 2002;73:1727-1731.
  4. Abholda A, Liu D, Brooks A, Burt M. Prolonged air leak following radical upper lobectomy. Chest 1998;113:1507-1510.[Abstract/Free Full Text]
  5. Sekine Y, Kesler KA, Behnia M, Brooks-Bruin J, Sekine E, Brown J. COPD may increase the incidence of refractory supraventicular arrhytmias following pulmonary resection for non-small cell lung cancer. Chest 2001;120:1763-1790.[Free Full Text]
  6. Bolliger CT, Perruchoud AP. Functional evaluation of the lung resection candidate. Eur Respir J 1998;11:198-212.[Abstract/Free Full Text]
  7. Vaughn C, Wolner E, Dahan M, Grunenwald D, Vaughn C, Klepetko W, Filaire M, Vaughn P, Baratz RA. Prevention of air leaks after pulmonary wedge resection. Ann Thorac Surg 1997;63:864-866.[Abstract/Free Full Text]
  8. Rice TW, Kirby TJ. Prolonged air leak. Chest Surg Clin N Am 1992;2:803-811.
  9. Venuta F, Rendina EA, DeGiacomo TE. Techniques to reduce air leaks after pulmonary lobectomy. Eur J Cardiothorac Surg 1998;13:361-364.
  10. Keagy BA, Lores ME, Starek PK, Murray GF, Lucas CL. Elective pulmonary lobectomy. Factors associated with morbidity and operative mortality. Am Thorac Surg 1985;40:349-352.[Abstract]
  11. Cerfolio RJ, Bass CS, Pask AH, Katholi CR. Predictors and treatment of persistent air leaks. Ann Thorac Surg 2002;73:1727-1731.[Abstract/Free Full Text]
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  13. Miller JI, Landreneau RJ, Wright CE, Santucci TS, Sammons BH. A comparative study of buttressed versus nonbuttressed staple line in pulmonary resections. Ann Thorac Surg 2001;71:319-323.[Abstract/Free Full Text]



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This Article
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