Management of air leaks post-surgical lung resection

In vivo comparative assessments on pleural adhesive effects of three commercially available sealants

Objective

Surgical sealant, which is used for the reinforcement of suture lines, has been widely used in lung-resection surgeries with the aim of reducing postoperative morbidity; however, it may exacerbate surgical-site adhesion, creating the risks of restrictive thoracic movement and a difficult entrance for redo operation. We aimed to assess the pleural adhesive effects of 3 frequently used surgical sealants, (1) fibrin glue (fibrin), (2) a composite of polyethylene glycol and human serum albumin (PEG/HSA), and (3) bioabsorbable polyglycolic acid felt (PGA), in an in vivo setting.

Methods

Eighty-one rats were randomly assigned to 3 experimental groups-fibrin, PEG/HSA, and PGA. After intrapleural application of the sealants, the extent and severity of adhesion and inflammation were quantitatively compared among the 3 groups at 2, 4, and 8 weeks.

Results

The scores for both the extent and severity of adhesion were significantly greater in the PGA group than the other 2 groups throughout postoperative period (P < .001 for all). Although both scores in the PES/HSA and fibrin groups were 0 at 2 weeks, the fibrin group showed significantly greater scores than the PES/HSA group thereafter (P < .001 for all). Trends in inflammation scores were similar of those of adhesion scores, favoring the PES/HSA group followed by the fibrin group (P < .001 for all).

Conclusions

Among 3 commonly used sealants, PEA/HSA showed least degree of adhesion/inflammation compared with fibrin and PGA, whereas PGA demonstrated greatest degrees of adhesion/inflammation throughout a postoperative course of 8 weeks in an in vivo model.

Application of three-dimensional printed models with near-infrared fluorescence technology in video-assisted thoracoscopic surgery segmentectomy: a single-center propensity-score matching analysis

Background

The combination of three-dimensional printing (3DP) technology and near-infrared fluorescence (NIF) technology using indocyanine green (ICG) has demonstrated significant potential in enhancing surgical margin and safety, as well as simplifying segmental resection. However, there is limited literature available on the integrated use of these techniques. The current study assessed the effectiveness and value of integrating 3DP-NIF technologies in the perioperative outcomes of thoracoscopic segmental lung resection.

Methods

This single-center, retrospective study recruited 165 patients with pulmonary nodules who underwent thoracoscopic segmentectomy. Eligible patients were categorized into two groups: the 3DP-NIF group (71 patients) treated with a combination of 3DP-NIF technology, and the three-dimensional computed tomography bronchography and angiography with modified inflation-deflation (3D-CTBA-ID) group (94 patients). Following rigorous propensity-score matching (PSM) analysis (1:1 ratio), perioperative outcomes between these two approaches were compared.

Results

Sixty-six patients were successfully matched in each group. In the 3D-CTBA-ID group, inadequate visualization of segmental planes was noted in 14 cases, compared to only five cases in the 3DP-NIF group (P=0.03). In addition, the 3DP-NIF group demonstrated a shorter time for clear intersegmental boundary line (IBL) presentation {9 [8, 10] vs. 1,860 [1,380, 1,920] s} (P<0.001), and shorter operative time (134.09±34.9 vs. 163.47±49.4 min) (P<0.001), postoperative drainage time (P<0.001), and postoperative hospital stay (P=0.002) compared to the 3D-CTBA-ID group. Furthermore, the incidence of postoperative air leak was higher in the 3D-CTBA-ID group than in the 3DP-NIF group (33.3% vs. 7.6%, P<0.001).

Conclusions

The combination of 3DP-NIF technologies served as a reliable technical safeguard, ensuring the safe and efficient execution of thoracoscopic pulmonary segmentectomy.

Presentation and management of delayed bronchopleural fistula after pulmonary lobectomy: a case report

BACKGROUND

Lung cancer is the second most diagnosed cancer and the leading cause of cancer deaths worldwide. Surgical lung resection is the best treatment modality in the early stages of lung cancer as well as in some locally advanced cases. Postoperative air leak is one of the most common complications after pulmonary resection with incidence ranging between 20 and 33%. The majority of air leaks seal, within 5 days after surgery, on their own by conservative management. However, at least 5% of patients still have prolonged air coming out from the residual lung at discharge. This report describes the management of a thin lady with right lung cancer who underwent a right lower lobectomy and then suffered from a delayed air leak 7 weeks after surgery and required extensive thoracic and general surgery collaboration.

CASE PRESENTATION

A 72-year-old heavy smoker female patient diagnosed with stage I lung cancer underwent right robotic-assisted thoracoscopic surgery converted to thoracotomy because of a fused fissure, right lower lobectomy, and mediastinal lymphadenectomy presented with delayed air leak 49 days after surgery. VATS decortication and mechanical pleurodesis were done 2 weeks after unsuccessful conservative treatment. Still, the lung failed to expand four weeks later so the patient was sent to surgery; she is underweight (BMI of 18) with not many options for a big flap to fill the chest cavity empty space. Accordingly; the decision was to use multiple pedicle flaps; omentum, intercostal muscle, and serratus anterior muscle to cover the bronchopleural fistulas and fill the pleural space in addition to mechanical and chemical pleurodesis. Full expansion of the lung was obtained. The patient was discharged on Post-Operative day 5 without remnant pneumothorax.

CONCLUSIONS

Air leaks After lobectomy usually presents directly postoperatively; various management options are available ranging from conservative and minimally invasive to major operative treatment. We presented what we believe was unusual delayed bronchopleural fistula post-lobectomy in a thin lady which demonstrates clearly how a delayed air leak was detected and how collaborative efforts were crucial for delivering high-quality, safe, and patient-centered care till treated and complete recovery.

What are the risk factors for postoperative home oxygen therapy in patients with lung cancer?

Background

Home oxygen therapy (HOT) is used to treat chronic respiratory diseases and is sometimes required in patients with lung cancer after radical surgery. We aimed to identify the risk factors for postoperative home-based oxygen therapy in patients with lung cancer.

Methods

Patients who underwent surgery for primary lung cancer at Chiba University Hospital between January 2019 and March 2021 were included. Patients who did not undergo complete resection, died in hospital after surgery, or used oxygen therapy preoperatively were excluded. Eligible patients were divided into HOT and non-HOT groups. They were retrospectively analyzed for risk factors for postoperative HOT using medical records in a multivariate analysis.

Results

A total of 410 patients were included in this study, 24 (5.9%) of whom required HOT after surgery. The HOT group comprised significantly more men, heavy smokers, and patients with pulmonary comorbidities, low percent forced expiratory volume, percent forced vital capacity, predicted postoperative forced expiratory volume in 1 s, and postoperative pulmonary complications on univariate analysis. In a multivariate analysis, independent risk factors for postoperative HOT were pulmonary comorbidities [odds ratio (OR): 5.94; 95% confidence interval (CI): 1.64-21.5; P=0.002) and postoperative pulmonary complications (OR: 5.39; 95% CI: 2.14-13.5; P<0.001). The postoperative HOT application rate was calculated according to a formula developed for this purpose.

Conclusions

Comorbid pulmonary diseases and postoperative pulmonary complications were significantly associated with postoperative HOT in patients with lung cancer.

Effectiveness of pleurodesis for postoperative air leaks after lung resection

BACKGROUND

Pleurodesis is often performed for air leaks; however, the ideal materials and timing of the procedure remain controversial. We investigated the efficacy of pleurodesis using different materials and timing.

METHODS

We retrospectively reviewed 913 consecutive patients who underwent segmentectomy or lobectomy for non-small cell lung cancer between 2014 and 2021. Pleurodesis efficacy was assessed on the day of chest tube removal.

RESULTS

Eighty-six patients (9%) underwent pleurodesis for postoperative air leaks. Pleurodesis was performed on a median of postoperative day (POD) 5. Talc was the most frequently used material (n = 52, 60%), followed by autologous blood patches (n = 20, 23%), OK-432 (n = 12, 14%), and others (n = 2, 2%). No difference existed in the number of days from initial pleurodesis to chest tube removal among the three groups (talc, 3 days; autologous blood patch, 3 days; OK-432, 2 days; P = 0.55). No difference in patient background, except for sex, was observed between patients who underwent pleurodesis within 4 PODs and those who underwent pleurodesis on POD 5 or later. Drainage time was significantly shorter in patients who underwent pleurodesis within 4 PODs (median, 7 vs. 9 days; P = 0.004).

CONCLUSIONS

The efficacies of autologous blood patch, talc, and OK-432 would be considered comparable and early postoperative pleurodesis could shorten drainage time. Prospective studies are required.

Effectiveness of fibrin sealant after pulmonary resection: a propensity score matching analysis

Introduction

Alveolar air leak is a common and troublesome complication after pulmonary resection because it can lead to longer hospital stay and chest tube drainage time.

Aim

As fibrin sealants are useful in the management of alveolar air leaks, we evaluated their benefit in patients undergoing pulmonary resection.

Material and methods

This retrospective study included patients who underwent pulmonary resection in our hospital between 2016 and 2021. We grouped patients on the basis of whether fibrin sealant was used during surgery and compared outcomes between those with (fibrin sealant group) and without (control group) sealant use after propensity score matching (1 : 1).

Results

During the study period, 375 patients underwent pulmonary resection; of these, fibrin sealant was applied at the staple line in 107 patients (fibrin sealant group), whereas sealant was not used in 268 patients (control group). After propensity score matching (1 : 1), there were 95 patients in both groups. There were no differences between the two groups in duration of chest tube drainage (3 days vs. 3 days; p = 0.753) or length of hospital stay (5 days vs. 4 days; p = 0.499). However, the sealant group showed higher cost of hospitalization (USD 4,360 vs. 3,614; p < 0.001). Multivariate analysis for identifying risk factors of persistent air leak revealed that male sex and chronic obstructive pulmonary disease were associated.

Conclusions

Our results indicate that application of fibrin sealant was not effective in reducing length of hospital stay, duration of chest drains or air leakage.

Robotic approach for pediatric pulmonary resection: preliminary investigation and comparative study with thoracoscopic approach

BACKGROUND

Minimal invasive pulmonary resection in children is challenging, irrespective of whether it is conducted using a robot or a thoracoscope. This study presents the preliminary results of pediatric robotic pulmonary resection (RPR) and comparison outcomes with conventional thoracoscopic pulmonary resection (TPR).

METHODS

This is a retrospective study conducted in patients underwent RPR (RPR group; n=30) and TPR (TPR group; n=44). The clinical data, including operative time, post-operative body temperature, surgical complications, surgeon's workload (by NASA-TLX), postoperative hospital stay, and scar score (using the SCAR scale), of both the RPR and TPR groups were collected and compared.

RESULTS

Both groups had similar age and weight. The youngest patient belonged to the RPR group and was 6 months old and weighed 8 kg. One case in the RPR group and two in the TPR group were converted to thoracotomy. RPR had a longer total operative time (148.3±36.8 min), but a shorter pure operative time (103.9±28.5 min) than those of the TPR group [118.3±22.5 (P<0.001) and 111.4±18.3 min (P=0.045), respectively]. Compared to the TPR group, fewer patients in the RPR group reported fever postoperatively (2/29 vs. 11/42, P=0.039). The workload of the surgeons was also lower in the RPR group (55.2±4.7 vs. 62.9±6.0, P<0.01). No significant difference was observed in perioperative complications, drainage length, postoperative hospital stays, and scar score of the two groups.

CONCLUSIONS

The safety and effectiveness of the robotic approach are similar to those of the thoracoscopic surgery for pediatric pulmonary resection in children heavier than 8 kg. In addition, the robotic approach shows improved operative dissection efficiency and accuracy for patients and reduced workload for surgeons. Hence, it is beneficial to both surgeons and patients.

Construction and validation of a nomogram for predicting prolonged air leak after minimally invasive pulmonary resection

Background

Prolonged air leak (PAL) remains one of the most frequent postoperative complications after pulmonary resection. This study aimed to develop a predictive nomogram to estimate the risk of PAL for individual patients after minimally invasive pulmonary resection.

Methods

Patients who underwent minimally invasive pulmonary resection for either benign or malignant lung tumors between January 2020 and December 2021 were included. All eligible patients were randomly assigned to the training cohort or validation cohort at a 3:1 ratio. Univariate and multivariate logistic regression were performed to identify independent risk factors. All independent risk factors were incorporated to establish a predictive model and nomogram, and a web-based dynamic nomogram was then built based on the logistic regression model. Nomogram discrimination was assessed using the receiver operating characteristic (ROC) curve. The calibration power was evaluated using the Hosmer-Lemeshow test and calibration curves. The nomogram was also evaluated for clinical utility by the decision curve analysis (DCA).

Results

A total of 2213 patients were finally enrolled in this study, among whom, 341 cases (15.4%) were confirmed to have PAL. The following eight independent risk factors were identified through logistic regression: age, body mass index (BMI), smoking history, percentage of the predicted value for forced expiratory volume in 1 second (FEV1% predicted), surgical procedure, surgical range, operation side, operation duration. The area under the ROC curve (AUC) was 0.7315 [95% confidence interval (CI): 0.6979–0.7651] for the training cohort and 0.7325 (95% CI: 0.6743–0.7906) for the validation cohort. The P values of the Hosmer-Lemeshow test were 0.388 and 0.577 for the training and validation cohorts, respectively, with well-fitted calibration curves. The DCA demonstrated that the nomogram was clinically useful. An operation interface on a web page (https://lirongyangql.shinyapps.io/PAL_DynNom/) was built to improve the clinical utility of the nomogram.

Conclusion

The nomogram achieved good predictive performance for PAL after minimally invasive pulmonary resection. Patients at high risk of PAL could be identified using this nomogram, and thus some preventive measures could be adopted in advance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02716-w.

Bronchoscopic Intra-Pleural Instillation of Fibrin Glue and Autologous Blood to Manage Persistent Air Leaks after Lung Resection

Background: Persistent air leak is a common complication after lung resection causing prolonged length of stay and increased healthcare costs. Surgical intervention can be an option, but other more conservative approaches should be considered first. Here, we describe the use of flexible bronchoscopy to apply fibrin glue and autologous blood sequentially to the damaged lung. We named the technique “flexible thoracoscopy”. Methods: Medical records from patients with persistent air leaks after lung resection were collected retrospectively. Depending on the type of aerostasis that was performed, two groups were created: flexible thoracoscopy and surgery (thoracotomy). Flexible thoracoscopy was introduced at our institution in 2013. We entered the pleural space with a bronchoscope following the same surgical pathway that was used for tube thoracostomy. Perioperative characteristics and outcomes were analyzed using R software (ver. 3.4.4). Results: From 1997 to 2021, a total of 23 patients required an intervention for persistent air leaks. Aerostasis was performed via flexible thoracoscopy in seventeen patients (69%) and via thoracotomy in six patients (31%). The median age was 70 years (22–82). Twenty patients were males (87%). There was no difference in age, sex distribution, BMI, comorbidities and FEV1%. An ASA score of 3 was more represented in the flexible thoracoscopy group; however, no evidence of a difference was found when compared to the thoracotomy group (p = 0.124). Length of in-hospital stay and chest tube duration was also similar between groups (p = 1 and p = 0.68, respectively). Conclusions: Aerostasis achieved either by flexible thoracoscopy or by thoracotomy showed similar results. We believe that flexible thoracoscopy could be a valid alternative to facilitate minimally invasive treatments for persistent air leaks. Further studies are needed to confirm these results.

[The role of the intensive care unit after thoracic surgery]

Lung (bronchial) cancer is the leading cause of cancer-related death in Western countries today. Thoracic surgery represents a major therapeutic strategy and the various advances made in recent years have made it possible to develop less and less invasive techniques. That said, the postoperative period may be lengthy, post-surgical approaches need to be more precisely codified, and it matters that the different interventions involved be supported by sound scientific evidence. To date, however, there exists no evidence that preventive postoperative admission to intensive care is beneficial for patients having undergone lung resection surgery without immediate complications. A stratification of the risk of complications taking into consideration the patient's general state of health (e.g., nutritional status, degree of autonomy, etc.), comorbidities and type of surgery could be a useful predictive tool regarding the need for postoperative intensive care. However, serious post-operative complications remain relatively frequent and post-operative management of these intensive care patients is liable to become complex and long-lasting. In the aftermath of the validation of "enhanced recovery after surgery" (ERAS) in thoracic surgery, new protocols are needed to optimize management of patients having undergone pulmonary resection. This article focuses on the main postoperative complications and more broadly on intensive care patient management following thoracic surgery.

Impact of postoperative pleurodesis on pulmonary function after lung segmentectomy

Objective

Pleurodesis is among several treatment strategies for postoperative alveolo-pleural fistula (APF) after lung resection. Accordingly, the present study aimed to determine the influence of pleurodesis on postoperative pulmonary function.

Methods

Patients who underwent anatomical segmentectomy between January 2009 and March 2020 and pulmonary function tests 6 and 12 months after initial surgery were included in this study. Differences in pulmonary function decline between patients who did and did not undergo pleurodesis were compared.

Results

Among the 319 patients included, 39 (12.2%) underwent pleurodesis. Among patients who did not receive pleurodesis, there were no difference in decline of vital capacity at 6 months (−13.7% ± 1.1% vs −11.2% ± 0.7%; P = .063) and 12 months (−10.7% ± 1.3% vs −9.5% ± 0.7%; P = .391) after surgery between patients who had APF on postoperative day 2 and those who did not. Patients who received pleurodesis had a significantly larger decline in vital capacity at 6 months (−19.4% ± 2.4% vs −13.7% ± 1.1%; P = .015) and 12 months (−16.2% ± 1.6% vs −10.7% ± 1.3%; P = .010) after surgery compared with those who had APF on postoperative day 2 and did not receive pleurodesis. There were no significant differences in decline of forced expiratory volume in 1 second.

Conclusions

Pleurodesis negatively influenced postoperative vital capacity after lung segmentectomy. Although the clinical influence of this is unknown, careful consideration is needed before performing pleurodesis given its potential influence on postoperative pulmonary function.

Prevention of pulmonary air leaks using a biodegradable tissue-adhesive fiber sheet based on Alaska pollock gelatin modified with decanyl groups

Tissue adhesives have been widely used in surgery to treat pulmonary air leaks. However, conventional adhesives have poor interfacial strength under wet conditions. To overcome this clinical problem, we modified Alaska pollock-derived gelatin to include decanyl (C10) groups (C10-ApGltn) and used electrospinning to create a tissue-adhesive fiber sheet (AdFS). C10-AdFS showed higher burst strength when adhering to porcine pleura compared with a sheet of original ApGltn (Org-ApGltn). Hematoxylin-eosin-stained sections after burst experiments reveal that a dense C10-AdFS layer remained on the surface of the porcine pleura. The effect of the degree of C10 modification of ApGltn on the burst strength was evaluated. ApGltn with a C10 modification ratio of 13 mol% amino groups (13C10-AdFS) exhibited the highest burst strength. Furthermore, from ex vivo experiments with extracted rat lung, 13C10-AdFS exhibited a higher burst strength (41 cm H₂O) than Org-AdFS. The decanyl groups in 13C10-AdFS interacted with the hydrophobic proteins and the lipid bilayers of the cells, resulting in the high interfacial strength between 13C10-AdFS and the pleura. Moreover, 13C10-AdFS samples implanted subcutaneously in the backs of rats were completely degraded within 21 days without any severe inflammation. These results show that 13C10-AdFS is a promising adhesive material for the treatment of pulmonary air leaks.

A Prospective Study Investigating Blood Patch Pleurodesis for Postoperative Air Leaks After Pulmonary Resection

BACKGROUND

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.

MATERIALS AND METHODS

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.

RESULTS

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).

CONCLUSIONS

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.