Eur J Cardiothorac Surg 2007;31:203-208. doi:10.1016/j.ejcts.2006.11.030
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
The approach of fused fissures with fissureless technique decreases the incidence of persistent air leak after lobectomy
Abel Gómez-Caroa,*,
Maria Jose Roca Calvoa,
Juan Torres Lanzasa,
Ryan Chaua,
Pedro Cascalesb,
Pascual Parrillab
a General Thoracic Surgery Department, Hospital Universitario Virgen de Arrixaca, Autovia Murcia-Cartagena s/n, Murcia, Spain
b General Surgery Department, Hospital Universitario Virgen de Arrixaca, Autovia Murcia-Cartagena s/n, Murcia, Spain
Received 3 July 2006;
received in revised form 9 November 2006;
accepted 22 November 2006.
* Corresponding author. Address: General Thoracic Surgery Department, Hospital Clínic i Provincia de Barcelona, C\Villarroel 170, CP 08036 Barcelona, Spain. Tel.: +34 932 279959; fax: +34 932 279813. (Email: abelitov{at}yahoo.es).
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Abstract
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Objective: To evaluate two different approaches used to perform fused fissures in lobectomies in terms of persistent air leak (PAL) and their impact on length of hospital stay. Methods: One hundred and nineteen patients underwent lobectomy or bilobectomy in our unit. We focused on patients with fused fissures (63 patients), all of whom were selected intraoperatively based on predefined criteria. These patients with incomplete fissures were randomly assigned to two groups: Group A patients who underwent a ‘traditional technique’ to approach fused fissures and Group B patients who underwent a ‘fissureless technique’. The latter technique avoids dissecting the lung parenchyma over the pulmonary artery, reducing the chances of air leak. Patients in both groups had shown no significant difference in preoperative variables (p
> 0.05). Results: The incidence of PAL was significantly higher among patients with incomplete or fused fissures (0 case vs 8 cases (Groups A and B), p
< 0.005). Furthermore, the incidence of PAL was significantly higher in the Group A (traditional technique) (7 vs 1) (p
< 0.05, OR = 3.1, CI 0.22–0.51). The probability for air leak cessation was significantly higher in patients of Group B (fissureless technique) (log rank p
< 0.0001). The length of hospital stay was higher in Group A (5.76 ± 3.1) compared with Group B (4.9 ± 1.7) (p
< 0.05). No other variables were identified as risk factors for PAL in this series. Conclusions: The fissureless technique appears to be a superior approach for fused fissures in terms of both preventing persistent air leak and reducing the length of hospitalisation. This technique can be performed safely at no additional cost and without adverse consequences.
Key Words: Lobectomy • Lung • Lung cancer • Surgery • Complications • Suture
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1. Introduction
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The incidence of persistent air leak (PAL) after pulmonary surgery is between 8 and 12% in different studies [1–3]. This common postoperative complication following pulmonary surgery leads to extended hospital stay, increased hospitalisation as well as pharmacy cost [2]. Almost all patients undergoing pulmonary surgery have air leak during the first few hours postoperatively, but less than 10% of these patients have a persistent air leak 1 week after surgery. There is no standard definition of PAL in the literature. Classically, PAL is defined as ‘persisting air leak 7 days after pulmonary surgery’ [4]. A better definition, however, may be ‘air leak following pulmonary surgery that persists beyond the normal hospital stay’ [2,5].
Conventional lobectomy is performed by ligation of branches of the pulmonary artery, the pulmonary vein and the bronchus to the corresponding lobe. Traditionally, exposure of the pulmonary artery at the fissure is done by dividing the lung parenchyma overlying the artery. This is commonly performed by electrocautery, blunt or sharp dissection [6]. Despite closure with staples afterwards, air and fluid leak often result with prolonged chest tube drainage and hospitalisation.
Novel techniques such as fissureless surgery avoid dissecting the lung parenchyma over the pulmonary artery. Instead, division of the lung parenchyma takes place after the separation of the lobar bronchus, using staples directly to reduce the chance of air leak. [1,7,8].
The aim of this randomized study is to evaluate these two different techniques via impact on immediate outcome, especially relating to air leak and the length of hospital stay.
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2. Patients and methods
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Between January 2004 and September 2005, 143 patients were scheduled for surgical treatment of non-small cell lung cancer (NSCLC) in our department. Pneumonectomies, wedge resections and non-resectable thoracotomies were excluded in this study. One hundred and nineteen patients were enrolled in total. Clinical and surgical variables were collected prospectively, including intraoperative findings and surgical techniques used in each case. The patients were surgically treated by three consultant thoracic surgeons. The standard approach was posterolateral thoracotomy through the fifth intercostal space, with sparing of serratus anterior muscle. Lobectomy or bilobectomy and mediastinal node dissections were performed in all cases. We performed all the neo-fissures with mechanical staplers (Ethicon GIA staplers®) and no parenchymal sealant was used. Pleural tent or other similar procedures to prevent PAL were not used in these patients.
Patients in this cohort were first divided into having complete or incomplete fissures intraoperatively. Incomplete fissures were defined in cases where, after reasonable blunt dissection (without much damage to the parenchyma in the fissure), we were unable to identify the pulmonary artery, and 50% or more of the fissure was fused. These patients with incomplete fissures were randomly assigned to two groups. Randomization was conducted preoperatively by computer (on-line web www.randomizer.org (1997–2005 by Geoffrey C. Urbaniak and S. Plous). Thus, we assigned the patients with fused fissures into one of these groups:
Group A patients underwent a ‘traditional technique’ and Group B patients underwent a ‘fissureless technique’. Patients in both groups had no significant difference in clinical, oncological, and preoperative variables (Table 1
) (p
> 0.05).
Group A (n
= 32) patients underwent pulmonary resection (lobectomy or bilobectomy) with traditional management of fissures using electrocautery or blunt dissection of the parenchyma over the pulmonary artery. Once the pulmonary artery was identified and ligated, mechanical staplers were used to divide the fused fissures and the lobar bronchus was divided last.
Group B (n
= 31) patients underwent a ‘fissureless technique’ carefully described by Nomori et al. [7] and Cerfolio and coworkers [1,8]. This technique can be used in both lobectomies and bilobectomies. When we performed upper lobectomies we divided the superior pulmonary veins with staplers. Next we dissected and ligated the upper lobe branches of the pulmonary artery from above followed by dissection and division of the upper lobe bronchus. This step allows good exposure to the posterior ascending artery on the right side and the posterior artery or the lingular arteries on the left side. These were ligated and thereafter fused fissures were divided with staplers. At this point it is crucial to preserve the lower arteries whose supply might be jeopardized by dividing the fissures with staplers. In right lower lobectomies, the pulmonary vein was divided first, followed by the right lower lobe bronchus using a posterior approach with a stapler. This approach provides good exposure to the pulmonary artery. Conversely, in left lower lobectomies, the pulmonary artery must be divided first, the superior segmental artery of the lobe exposed and ligated, finally followed by division of the posterior side of the fused fissure with staplers. Again this gives a clear exposure to the pulmonary artery, this time in relation to the basal segment of the left lower lobe and the lingula arterial branches. After ligating the basal artery, the remaining anterior side of the fused fissure is divided. Finally, the lobar bronchus is divided, thus completing the lobectomy. This is the only type of lobectomy where the bronchus is divided at the end [7]. This technique is not suitable to all the lobectomies for non-small cell lung cancer. In fact, it is particularly inappropriate in patients with lobar of sublobar lymph nodes disease (N1 disease). In these cases, the dissection of the bronchus or the pulmonary artery may jeopardize morbidity and oncological failure, being necessary a previous control of the pulmonary artery above in the main pulmonary artery, especially in upper lobectomies preserving the lower arterial supply.
The aim of this technique is to avoid dissection over the fissures, decreasing the risk of lung parenchyma injury and therefore the chances of PAL. This technique is a modification (by dividing the lobar bronchus first and suturing the fissures in the end, except in the case of left lower lobectomy) of the fissureless technique described by Temes et al. [6]. Intraoperative air leak was dealt with manual or mechanical sutures if this was possible.
We consider PAL for this study as ‘air leak more than 5 days after surgery’ because this is the mean length of stay in our department [9].
All chest drains used were classical Argyle © 28 Fr tubes (Sherwood Services AG, TYCO Healthcare, Ireland). Some patients received only a single drain and others received two drains according to a separate randomized study being performed in our department at the time [9]. The drains were connected to a thoracic drain unit (SENTINEL SEAL, Sherwood Services AG, TYCO Healthcare, Ireland) using a Y connector for patients receiving two drains. All drains were connected in theatre and kept on low suction (15–20 mmHg) until removed. After 5 days, if a persistent air leak was detected, suction would be removed and the algorithm of Cerfolio et al. followed [10,11]. Daily drainage volumes and air leak were reviewed by a consultant thoracic surgeon. Air leak was measured daily and classified as: (1) no air leak, (2) leak only in forced expiration (on coughing), or (3) leak in normal expiration.
Epidural thoracic catheters were inserted in all patients in theatre preoperatively. During the first 48 h, patients received epidural infusion (Bupivicaine 0.125 mg and fentanyl 2 µg/ml/h) and intravenous non-steroidal anti-inflammatory drugs.
After extubation in theatre, patients enrolled in this study spent the first 12–24 h in ICU where chest drainage and air leak were reviewed hourly. Chest X-rays were performed at 3 and 24 h after the procedure. The importance of physiotherapy had been emphasized to the patients preoperatively and these exercises were commenced on ICU.
Each patient was examined clinically every morning and evening, and the decision to remove the drains was made based on the lack of air leak on coughing, a drainage of less than 150 ml in the previous 24 h, and the absence of a haemothorax or pneumothorax (less than 10%) on chest radiographs.
Length of hospital stay, time to drain removal, number of chest X-rays films taken, the amount of fluid drained and complications including the requirement for repeated chest drain insertion, subcutaneous emphysema requiring intervention, residual space or residual pleural effusions were collected prospectively until the 30th postoperative day.
Statistical analyses were carried out with the computer program package SPSS v.13 (SPSS Inc., Chicago, IL). Qualitative variables were compared with the 
2 statistical test or Fisher's exact test where appropriate, with a significance taken at level p
< 0.05. The excess of risk was estimated using the Mantel–Haenszel test. The probability of air leak cessation was analysed with Kaplan–Meier test, and log-rank test was used to compare the two different surgical techniques. Graphpad prism v4 was used for the construction of all illustrations.
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3. Results
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The complications of the total cohort of patients (n
= 119) are listed in Table 2
, and are further subdivided into postoperative complications for patients in Groups A and B. With the exception of PAL, the incidence of postoperative complications was similar in all groups (Groups A and B and the total cohort (p
= NS)).
The incidence of PAL was significantly higher among patients (in Groups A and B) with incomplete or fused fissures compared to the non-fused or complete fissures (0 case vs 8 cases, p
< 0.005). Moreover, the incidence of PAL was significantly higher among the patients of Group A (traditional technique) (p
< 0.05). By comparison, there was only 1 case of PAL in Group B (lobectomy using the modified fissureless technique) versus 7 cases in Group A (p
< 0.05, OR = 3.1, CI 0.22–0.51). No other variables (COPD, age, sex FEV1%, FEV1ppo%, type or side of surgery, oncological stage) (Table 3
) were identified as risk factors for PAL in this series. Only two patients who had PAL had COPD in addition to their primary diagnosis and only two of these had a very reduced spirometry (FEV1 < 1.5 l, FEV1% < 70, FEV1 < 40%ppo).
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Table 3. Comparison between patients underwent non-persistent air leak (non-PAL) and persistent air leak (PAL) after lobectomy or bilobectomy
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We have focused on air leak after surgery in detail in this study. Fig. 1
shows the duration of air leak. The probability for cessation of air leak was significantly higher in patients who underwent the fissureless technique (Group B) (log-rank, p
< 0.0001). In this series we documented and classified the air leak during the postoperative course daily until the 6th day and the results are shown in Table 4
. Air leak was significantly more severe (score of 3) on the first and second postoperative days in patients in Group A (p
< 0.05). Furthermore, the lack of air leak on the 1st postoperative day was significantly less in Group B (p
< 0.05).
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Fig. 1. Likelihood of air leak cessation in both groups: A (traditional technique) and B (fissureless technique) in fused fissures patients.
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The length of hospital stay and the mean number of days chest drains remained in situ were similar in both Group A (5.76 ± 3.1, mean ± SD) and Group B (5.1 ± 1.7, mean ± SD) (p
> 0.05) (Table 5
). There was no significant difference between the two groups in terms of stapler loads, length of stay, types of resection, upper versus lower lobectomies, pleural adhesions, amount of drainage or any other characteristics studied.
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Table 5. Comparison of Groups A and B in terms of hospital stay, days of chest drains, amount of drainage, surgeons, upper or lower lobectomies and loads of staples
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4. Comment
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It is well known that PAL is one of the most frequently detected complications following pulmonary surgery and a common cause of extended hospital stay. Almost all patients after pulmonary surgery have some degree of air leak during the first few hours. Most of these are self-limiting and do not require any further intervention [12]. However, the incidence of this complication can be in the region of 5–15% depending on the definition of PAL quoted [3,5].
To our knowledge, there is no agreed definition of PAL in the literature. In our experience it is clinically more useful to define PAL with reference to the mean length of hospital stay [2,5]. In our study, we defined PAL as air leak for 5 days or more, based on the mean length of hospital stay after surgery in our department [13].
Other studies have shown a number of predictors for air leak including low FEV1 and COPD, low ratio FEV1/FVC, male gender, lobectomy or bilobectomy instead of wedge resection [11,14,15], upper lobectomy and the finding of pleural adhesions [3,16]. Air leak has also been linked to other factors such as systematic mediastinal dissection and elderly patients [17]. In recent studies, quantitative computer tomography (CT) seems to offer both an objective and sensitive method to assess and predict PAL after pulmonary resection. There seems to be stronger correlation between PAL detection and CT rather than spirometry. CT may aid in identifying high-risk candidates for PAL and consequently encourage the use of preventive procedures (pulmonary sealants, special surgical techniques) in such patients [18].
FEV1 less than 1500cc and FEV1ppo less than 40% have been associated with a higher incidence of PAL in others studies [3,13,19]. We did not identify these as risk factors in our study. We acknowledge that this may be in part due to the small number of patients (13) with very low FEV1 in our cohort. Thus, it is difficult to draw conclusions regarding PAL among patients with significant airflow obstruction. Nonetheless, the authors believe that the use of the fissureless technique is very appropriate for such patients [8]. Furthermore, patients who suffer from pulmonary diseases such as COPD, pulmonary fibrosis, and bronchiectasis may be more susceptible to chest infections. Such infections may cause to pleural adhesions, which have been identified as a risk factor for PAL by Brunelli et al., possibly via the technical difficulties they create during surgery [3,12]. Patients undergoing upper lobectomy seem to be particularly at risk of PAL, because of the residual pleural space frequently associated with this type of surgery [3,4].
Prevention of PAL should start in theatre with meticulous and careful surgical technique [4]. The main risk factor of PAL continues to be incomplete or fused fissures. In our study, all patients who suffered from PAL had had incomplete fissures. Thus, we believe that a correct approach to address this problem decreases the risk of this complication.
We could not find an accurate pathological definition of ‘fused fissures’ in the literature. Hence, we have adopted a practical definition according to the intraoperative findings and the shape of dissections needed to release the pulmonary artery in the fissure. We defined incomplete fissures when, after a reasonable blunt dissection (without damage to the parenchyma in the fissure), we were unable to identify the pulmonary artery and 50% or more of the fissure was fused. The incidence of fused interlobar fissures vary between 50 and 80% according to different authors [13,20,21].
In our series, a large number of patients suffered from air leak 48 h after surgery. The incidence of PAL in the total series (119 patients) was 6.7% (8 patients). We did not detect PAL in patients who were considered to have complete fissures based on our criteria. All PAL in this series were found among those with incomplete fissures and mainly in Group A (7 vs 1). The incidence of severe air leak (during expiration without Valsalva manoeuvres) was less in patients who underwent a fissureless technique for the management of incomplete fissures. Moreover, the absence of air leak on the first postoperative day was significantly higher among patients in Group B (fissureless technique).
To date, there has been no study in the literature comparing these two techniques in terms of outcome of PAL and length of hospital stay. In this trial, we have tried to address this question. Despite our study being randomized, we were aware of the limitation of these small number of cases to draw very solid conclusions. Conversely, this, in our opinion, is an original study designed to compare two different techniques to approach fused fissures during lobectomy and bilobectomy. We conclude that the fissureless technique is superior in terms of prevention of persistent air leak. In our series this technique can be performed safely without additional costs or adverse consequences.
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Acknowledgments
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The authors are indebted to Dr Mackay from the Freeman Hospital (Newcastle Upon Tyne, UK) for his contribution in the translation and arrangement of this manuscript.
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Abstract
1. Introduction
