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Gilboa E, Eshkol-Yogev I, Giladi S, Zilberman M. Cellulose fibres enhance the function of hemostatic composite medical sealants. J Biomater Appl 2024; 39:83-95. [PMID: 38768480 DOI: 10.1177/08853282241254845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Tissue adhesives and sealants offer promising alternatives to traditional wound closure methods, but the existing trade-off between biocompatibility and strength is still a challenge. The current study explores the potential of a gelatin-alginate-based hydrogel, cross-linked with a carbodiimide, and loaded with two functional fillers, the hemostatic agent kaolin and cellulose fibres, to improve the hydrogel's mechanical strength and hemostatic properties for use as a sealant. The effect of the formulation parameters on the mechanical and physical properties was studied, as well as the biocompatibility and microstructure. The incorporation of the two functional fillers resulted in a dual micro-composite structure, with uniform dispersion of both fillers within the hydrogel, and excellent adhesion between the fillers and the hydrogel matrix. This enabled to strongly increase the sealing ability and the tensile strength and modulus of the hydrogel. The fibres' contribution to the enhanced mechanical properties is more dominant than that of kaolin. A combined synergistic effect of both fillers resulted in enhanced sealing ability (247%), tensile strength (400%), and Young's modulus (437%), compared to the unloaded hydrogel formulation. While the incorporation of kaolin almost did not affect the physical properties of the hydrogel, the incorporation of the fibres strongly increased the viscosity and decreased the gelation time and swelling degree. The cytotoxicity tests indicated that all studied formulations exhibited high cell viability. Hence, the studied new dual micro-composite hydrogels may be suitable for medical sealing applications, especially when it is needed to get a high sealing effect within a short time. The desired hemostatic effect is obtained due to kaolin incorporation without affecting the physical properties of the sealant. Understanding the effects of the formulation parameters on the hydrogel's properties enables the fitting of optimal formulations for various medical sealing applications.
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Affiliation(s)
- Efrat Gilboa
- Department of Materials Science and Engineering, Tel-Aviv University, Tel-Aviv, Israel
| | - Inbar Eshkol-Yogev
- Department of Biomedical Engineering, Tel-Aviv University, Tel-Aviv, Israel
| | - Shir Giladi
- Department of Materials Science and Engineering, Tel-Aviv University, Tel-Aviv, Israel
| | - Meital Zilberman
- Department of Materials Science and Engineering, Tel-Aviv University, Tel-Aviv, Israel
- Department of Biomedical Engineering, Tel-Aviv University, Tel-Aviv, Israel
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2
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Ruenwilai P. Bronchoscopic management in persistent air leak: a narrative review. J Thorac Dis 2024; 16:4030-4042. [PMID: 38983160 PMCID: PMC11228722 DOI: 10.21037/jtd-24-46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/30/2024] [Indexed: 07/11/2024]
Abstract
Background and Objective Persistent air leak (PAL) represents a challenging medical condition characterized by prolonged air leak from the lung parenchyma into the pleural cavity, often associated with alveolar-pleural fistula or bronchopleural fistula (BPF). The objective of this narrative review is to explore the causes, clinical implications, and the evolving landscape of bronchoscopic treatment options for PAL. Methods The literature search for this review was conducted using databases such as PubMed/MEDLINE, and Scopus databases. Articles published from inception until 28th August, 2023, focusing on studies that discussed the causes, diagnosis, and management strategies for PAL were included. Keywords included bronchoscopic management, bronchopleural fistula, endobronchial valve, sealant, blood patch pleurodesis, spigot, air leak, PAL, management, comparative study. Key Content and Findings PAL commonly arises from secondary spontaneous pneumothorax, necrotizing pneumonia, barotrauma induced by mechanical ventilation, chest trauma, or postoperative complications. Understanding the underlying etiology is crucial for tailoring effective management strategies. While conventional intercostal drainage resolves the majority of pneumothorax cases, PAL is diagnosed when the air leak persists beyond 5 to 7 days. Prolonged PAL can lead to worsening pneumothorax, respiratory distress, and increased morbidity. Early identification and intervention are essential to prevent complications. Conservative approaches involve close monitoring and supplemental oxygen therapy. These strategies aim to promote natural healing and resolution of the air leak without invasive interventions. Bronchoscopic techniques, such as endobronchial valves (EBVs), sealants, and autologous blood patch (ABP), have emerged as promising alternatives for refractory PAL. These interventions offer a targeted and minimally invasive approach to seal the fistulous connection, promoting faster recovery and reducing the need for surgical interventions. Conclusions PAL is a clinical challenge, and their management requires a tailored approach based on the underlying cause and severity. Bronchoscopic interventions have shown efficacy in cases of refractory PAL. Early recognition, multidisciplinary collaboration, and a personalized treatment plan are essential for optimizing outcomes in patients with PAL.
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Affiliation(s)
- Parinya Ruenwilai
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Cannone G, Campisi A, Comacchio GM, Lorenzoni G, Terzi S, Pangoni A, Lomangino I, Catelli C, Rea F, Dell'Amore A. Is chest tube capnography effective in differentiating between true and false air leaks after minimally invasive thoracic surgery? Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02025-x. [PMID: 38598079 DOI: 10.1007/s11748-024-02025-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/14/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Air leak (AL) is the most frequent adverse event after thoracic surgery. When AL occurs, the concentration of the principal gas in the pleural space should be similar to that of air exhaled. Accordingly, we tried to develop a new method to identify AL by analyzing pCO2 levels in the air flow from the chest drainage using capnography. METHODS This is a prospective observational study of 104 patients who underwent VATS surgery between January 2020 and July 2021. Digital drainage systems were used to detect AL. RESULTS Eighty-two patients (79%) had lung resection. Among them, 19 had post-operative day 1 air leaks (median 67 ml/min). AL patients had higher intrapleural CO2 levels (median 24 mmHg) (p < 0.001). Median chest drainage duration was 2 days (range 1.0-3.0). Univariable logistic regression showed a linear and significant association between intrapleural CO2 levels and AL risk (OR 1.26, 95% CI 1.17-1.36, p < 0.001, C index: 0.94). The Univariable Gamma model demonstrated that an elevation in CO2 levels was linked to AL on POD1 (with an adjusted mean effect of 7.006, 95% CI 1.59-12.41, p = 0.011) and extended duration of drainage placement (p < 0.001). CONCLUSIONS Intrapleural CO2 could be an effective tool to assess AL. The linear association between variables allows us to hypothesize the role of CO2 in the identification of AL. Further studies should be performed to identify a CO2 cutoff that will standardize the management of chest drainage.
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Affiliation(s)
- Giorgio Cannone
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Padua, Italy.
- Unit of Thoracic Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy.
| | - Alessio Campisi
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- Thoracic Surgery Department, University and Hospital Trust - Ospedale Borgo Trento, Verona, Italy
| | - Giovanni Maria Comacchio
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Padua, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua, Italy
| | - Stefano Terzi
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Padua, Italy
| | - Alessandro Pangoni
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Padua, Italy
| | - Ivan Lomangino
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Padua, Italy
| | - Chiara Catelli
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Padua, Italy
| | - Federico Rea
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Padua, Italy
| | - Andrea Dell'Amore
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Padua, Italy
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Li X, Yang H, Cai Y, Ye X, Chen Q, Ji Y, Wang J, Fu Y, Hu B, Miao J. Chest tube removal at different gas flows in prolonged air leak: a randomized non-inferiority trial. Eur J Cardiothorac Surg 2024; 65:ezae097. [PMID: 38479816 PMCID: PMC10963076 DOI: 10.1093/ejcts/ezae097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/20/2024] [Accepted: 03/12/2024] [Indexed: 03/27/2024] Open
Abstract
OBJECTIVES To evaluate the safety and feasibility of removing drainage tubes at larger size of air leak in patients with prolonged air leak after pulmonary surgery. METHODS Ninety-five patients who underwent pulmonary surgery with prolonged air leak in our centre were enrolled in this randomized controlled, single-centre, non-inferiority study. The drainage tube was clamped with a stable size of air leak observed over the last 6 h, which was quantified by gas flow rate using the digital drainage system. The control group (n = 48) and the study group (n = 46) had their drainage tube clamped at 0-20 ml/min and 60-80 ml/min, respectively. We continuously monitored clinical symptoms, conducted imaging and laboratory examinations, and decided whether to reopen the drainage tube. RESULTS The reopening rate in the study group was not lower than that in the control group (2.08% vs 6.52%, P > 0.05). The absolute difference in reopening rate was 4.44% (95% confidence interval -0.038 to 0.126), with an upper limit of 12.6% below the non-inferiority margin (15%). There were significant differences in the length of stay [16.5 (13-24.75) vs 13.5 (12-19.25), P = 0.017] and the duration of drainage [12 (9.25-18.50) vs 10 (8-12.25), P = 0.007] between the control and study groups. No notable differences were observed in chest X-ray results 14 days after discharge or in the readmission rate. CONCLUSIONS For patients with prolonged air leak, removing drainage tubes at larger size of air leak demonstrated similar safety compared to smaller size of air leak, and can shorten both length of stay and drainage duration. CLINICAL TRIAL REGISTRATION NUMBER Name of registry: Gas flow threshold for safe removal of chest drainage in patients with alveolar-pleural fistula prolonged air leak after pulmonary surgery. Registration number: ChiCTR2200067120. URL: https://www.chictr.org.cn/.
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Affiliation(s)
- Xinyang Li
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hang Yang
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yongsheng Cai
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin Ye
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qirui Chen
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ying Ji
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jing Wang
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yili Fu
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bin Hu
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jinbai Miao
- Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Iida T, Shimada Y, Sato M. Management and mindset for air leak and intraoperative bleeding in thoracic surgery. J Thorac Dis 2023; 15:4137-4140. [PMID: 37691662 PMCID: PMC10482642 DOI: 10.21037/jtd-23-972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 07/13/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Takahiro Iida
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yoshihisa Shimada
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
- Department of Thoracic Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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Duron G, Backer E, Feller-Kopman D. Evaluation and management of persistent air leak. Expert Rev Respir Med 2023; 17:865-872. [PMID: 37855445 DOI: 10.1080/17476348.2023.2272701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/16/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Persistent air leaks (PAL) represent a challenging clinical problem for which there is not a clear consensus to guide optimal management. PAL is associated with significant morbidity, mortality, and increased length of hospital stay. There are a variety of surgical and non-surgical management options available. AREAS COVERED This narrative review describes the current evidence for PAL management including surgical approach, autologous blood patch pleurodesis, chemical pleurodesis, endobronchial valves, and one-way valves. Additionally, emerging topics such as drainage-dependent air leak and intensive care unit management are described. EXPERT OPINION There has been considerable progress in understanding the pathophysiology of PAL and growing evidence to support the various non-surgical treatment modalities. Increased recognition of drainage-dependent persistent air leaks offers the opportunity to decrease the number of patients requiring additional invasive treatment. Randomized control trials are needed to guide optimal management.
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Affiliation(s)
- Garret Duron
- Department of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elliot Backer
- Dartmouth-Hitchcock Medical Center, Department of Pulmonary and Critical Care Medicine, 1 Medical Center Drive, Lebanon, NH, Lebanon
| | - David Feller-Kopman
- Dartmouth-Hitchcock Medical Center, Department of Pulmonary and Critical Care Medicine, 1 Medical Center Drive, Lebanon, NH, Lebanon
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Aprile V, Bacchin D, Calabrò F, Korasidis S, Mastromarino MG, Ambrogi MC, Lucchi M. Intraoperative prevention and conservative management of postoperative prolonged air leak after lung resection: a systematic review. J Thorac Dis 2023; 15:878-892. [PMID: 36910073 PMCID: PMC9992588 DOI: 10.21037/jtd-22-736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 02/06/2023] [Indexed: 02/28/2023]
Abstract
Background Prolonged air leak (PAL) due to an alveolar-pleural fistula (APF) is the most common complication after lung surgery. PAL is associated with an increased risk of morbidity and mortality, a longer chest tube duration, hence a prolonged hospitalization. Management of PAL may be challenging, and the thoracic surgeon should be aware of the possible therapeutic strategies. Methods A systematic literature review was performed in PubMed, Cochrane Library, EMBASE, Ovid and Google Scholar. Title, abstract and full-text screening was performed, followed by structured data extraction, methodological quality assessment and Cochrane risk of bias assessment. Inclusion criteria were: case-control studies/randomized controlled trials (RCTs) comparing the new tested method with the standard of care to manage PAL after lung surgery; PAL due to APF; at least 10 patients; English-written papers. Results A total of 942 initial papers from literature search, resulted in 43 papers after the selection. This systematic review found that the use of intraoperative measures as surgical sealants or pleural tenting, as well as a proper management of the chest drain and the use of blood patch or sclerosant agents seem to reduce postoperative air leaks incidence and/or duration and length of chest drain stay and hospitalization. Conclusions Different measures have been described in literature to manage or prevent postoperative PAL. Most of them seem to be safe and efficient if compared to the "wait and see" strategy, even if large comparative studies that standardize the intra- and post-operative management of APF after lung resection are lacking and, actually, hard to conceptualize. However, there is a large consensus on the value of a preoperative PAL-risk stratification and on the necessity of tailoring PAL management or prevention's strategy and its timing on each patient's features.
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Affiliation(s)
- Vittorio Aprile
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Diana Bacchin
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Fabrizia Calabrò
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Stylianos Korasidis
- Thoracic Surgery Unit, Cardiac-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | | | - Marcello Carlo Ambrogi
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Marco Lucchi
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy.,Thoracic Surgery Unit, Cardiac-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
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8
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Hong JI, Lee JH, Kim HK. Early Pleurodesis for Postoperative Air Leak with Autologous Blood and 50% Glucose Solution. J Chest Surg 2023; 56:16-22. [PMID: 36530129 PMCID: PMC9845852 DOI: 10.5090/jcs.22.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/21/2022] [Accepted: 11/06/2022] [Indexed: 12/23/2022] Open
Abstract
Background Postoperative air leaks after pulmonary resection prolong the duration of chest drainage and the length of hospital stay. One of the many treatment options is bedside pleurodesis using various agents. This study evaluated the feasibility of an early intervention to stop postoperative air leaks with either autologous blood or a 50% glucose solution. Methods We retrospectively reviewed 323 patients who underwent bedside pleurodesis between January 2017 and March 2022. Sixty-four patients received autologous blood patch pleurodesis, and 36 were treated with a 50% glucose solution after pulmonary resection. The primary endpoints were the total postoperative tube indwelling time, post-pleurodesis tube indwelling time, and hospital stay. A propensity score-matched analysis was performed. Results In the autologous blood patch pleurodesis and 50% glucose solution groups, the mean initiation timing of postoperative pleurodesis were 2.06±1.62 and 3.28±1.56 days, the mean duration of the tube indwelling time after surgery was 6.58±3.02 and 6.42±4.92 days, and the mean duration of the tube indwelling time after pleurodesis, it was 4.53±3.10 and 3.11±4.80 days, respectively. In addition, the total length of hospital stay was 9.11±5.42 and 7.83±4.75 days in the autologous blood patch pleurodesis and 50% glucose solution groups, respectively. Conclusion Early postoperative air leak cessation with autologous blood patch pleurodesis or 50% glucose solution pleurodesis is a feasible procedure with acceptable outcomes that effectively shortens the hospital stay.
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Affiliation(s)
- Jeong In Hong
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea,Corresponding author Hyun Koo Kim Tel 82-2-2626-3106 Fax 82-2-866-6377 E-mailORCIDhttps://orcid.org/0000-0001-7604-4729 See Commentary page 23
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Advantages of applying digital chest drainage system for postoperative management of patients following pulmonary resection: a systematic review and meta-analysis of 12 randomized controlled trials. Gan To Kagaku Ryoho 2023; 71:1-11. [PMID: 36175611 DOI: 10.1007/s11748-022-01875-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This meta-analysis aimed to evaluate the value of the chest digital drainage system for the postoperative management of patients who have undergone pulmonary resection. METHODS We searched the PubMed, EMBASE, the Cochrane Library, and Web of Science databases for included randomized controlled trials (RCTs) on the application of digital drainage systems versus the analog drainage system for patients with lung disease after pulmonary resection. Dichotomous variables were evaluated using risk ratios (RRs) and 95% confidence intervals (CIs), and mean and standardized mean differences (MDs and SMDs, respectively) with 95% CIs were used to calculate continuous variables. Statistical analyses were performed using Stata and RevMan software. RESULTS In total, 12 RCTs involving 2000 patients were analyzed. Significant differences in duration of chest tube placement (SMD = -0.49; 95% CI = -0.78 to -0.20), length of hospital stay (MD =-0.79 days; 95% CI = -1.24 to -0.34), and number of chest tube clamping tests (RR = 0.74; 95% CI = 0.36-1.49) were observed between the two groups, which did not significant differ in the occurrence of prolonged air leak or cardiopulmonary complication rate. CONCLUSIONS The digital chest drainage system is mainly advantageous in the duration of chest tube placement, length of hospital stay, and number of chest tube clamping tests. Future research should evaluate the requirements and economic impact of using digital system in routine clinical practice.
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Li C, Duan W, Zhu Y, Li G, Gao M, Weng Z, Zhu Y, Bu Y. Cohesion Design-Led Tough Sealants with Controllably Dissolvable Properties. ACS APPLIED MATERIALS & INTERFACES 2022; 14:34415-34426. [PMID: 35857427 DOI: 10.1021/acsami.2c08328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Leakage is a common complication of surgeries and injuries, causing pain and increasing the economic burden on patients. Although there are commercially available sealants for leakage prevention, few of them are entirely satisfactory due to disease transmission, high cost, and poor biocompatibility. In addition, none of them can be controllably removed for further healthcare. In this paper, by using cohesion design, a sealant based on amino-modified gelatin (AG) and bi-polyethylene glycol N-hydroxysuccinimide active ester (Bi-PEG-SS) was fabricated. To increase the bursting pressure, the cohesion strength was enhanced by increasing the cross-linking density of the sealant. To endow the sealant with controllably dissolvable properties, the smart succinic ester units were introduced into the cohesion network. Both the in vitro and in vivo experiments showed that this sealant processed high bursting pressure with efficient hemorrhage control. Moreover, no side effects were observed after 7 days of in vivo sealing, including little inflammation and fibrogenesis. These results, together with the easy availability of the raw materials, revealed that this sealant might be a promising alternative for leakage sealing.
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Affiliation(s)
- Chaowei Li
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350108, China
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
| | - Wanglin Duan
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
| | - Ye Zhu
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
| | - Guanying Li
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an 710061, China
| | - Min Gao
- Institute of Molecular and Translational Medicine, Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University, Xi'an 710061, China
| | - Zuquan Weng
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Yuan Zhu
- Department of Gynecology, The Affiliated Maternal and Child Healthcare Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
- Department of Gynecology, Jiangxi Provincial Maternal and Child Health Hospital, Nanchang, Jiangxi 330006, China
| | - Yazhong Bu
- Institute of Medical Engineering, Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Xi'an Jiaotong University, Xi'an 710061, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an 710061, China
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Bronchoscopic Intra-Pleural Instillation of Fibrin Glue and Autologous Blood to Manage Persistent Air Leaks after Lung Resection. J Clin Med 2022; 11:jcm11071934. [PMID: 35407542 PMCID: PMC8999597 DOI: 10.3390/jcm11071934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Duan W, Bian X, Bu Y. Applications of Bioadhesives: A Mini Review. Front Bioeng Biotechnol 2021; 9:716035. [PMID: 34540814 PMCID: PMC8446440 DOI: 10.3389/fbioe.2021.716035] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/22/2021] [Indexed: 11/13/2022] Open
Abstract
Bioadhesives have demonstrated their superiority in clinical applications as tissue adhesives, hemostats, and tissue sealants. Because of the intrinsic stickiness, the applications have been expanded to various areas, such as functional wound dressing, factor delivery vehicles, and even medical device fixation. While many literature works discussed the mechanism of bioadhesives, few of them specifically summarized the applications of bioadhesives. To fill in the blanks, this review covers recent research articles and focuses precisely on the applications of bioadhesives which can be generally classified as follows: 1) wound closure, 2) sealing leakage, and 3) immobilization, including those already in the clinic and those showing great potential in the clinic. It is expected that this article will provide a whole picture on bioadhesives' applications and lead to innovations in the application of bioadhesives in new fields.
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Affiliation(s)
- Wanglin Duan
- Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Institute of Medical Engineering, Xi’an Jiaotong University, Xi’an, China
| | - Xiangbing Bian
- The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yazhong Bu
- Department of Biophysics, School of Basic Medical Sciences, Health Science Center, Institute of Medical Engineering, Xi’an Jiaotong University, Xi’an, China
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13
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Mitsui S, Tauchi S, Uchida T, Ohnishi H, Shimokawa T, Tobe S. Low suction on digital drainage devices promptly improves post-operative air leaks following lung resection operations: a retrospective study. J Cardiothorac Surg 2021; 16:105. [PMID: 33882977 PMCID: PMC8059315 DOI: 10.1186/s13019-021-01485-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We investigated the most effective suction pressure for preventing or promptly improving postoperative air leaks on digital drainage devices after lung resection. METHODS We retrospectively analyzed the postoperative data of 242 patients who were monitored with a digital drainage system after pulmonary resection in our institution between December 2017 and June 2020. We divided the patients into three groups according to the suction pressure used: A (low-pressure suction group: - 5 cm H2O), B (intermediate-pressure group: - 10 cm H2O), and C (high-pressure suction group: - 20 cm H2O). We evaluated the duration of air leaks, timing of chest tube replacement, the amount of postoperative air leak, volume of fluid drained before chest tube removal, and the total number of air leaks during drainage. RESULTS In total, 217 patients were included in this study. The duration of air leaks gradually decreased with significant difference between the groups, the highest decrease in A, the lowest decrease in C (P = 0.019). Timing of chest tube replacement, on the other hand, did not significantly differ between the three groups (P = 0.126). The number of postoperative air leaks just after surgery did not significantly differ between the three groups (P = 0.175), but the number of air leaks on postoperative day 1 were fewest in group A, then B, and greatest in group C (P = 0.033). The maximum amount of air leaks during drainage was lowest in A, then B, and highest in C (P = 0.036). Volume of fluid drained before chest tube removal did not significantly differ between the three groups (P = 0.986). CONCLUSION Low-pressure suction after pulmonary resection seems to avoid or promptly improve postoperative air leaks in digital drainage devices after lung resection. TRIAL REGISTRATION This is a single-institution, retrospective analysis-based study of data from an electronic database. Study protocol was approved by the Akashi Medical Center Institutional Research Ethics Board (approval number: 2020-9).
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Affiliation(s)
- Suguru Mitsui
- Department of Thoracic Surgery, Akashi Medical Center, 743-33 Okubocho Yagi, Akashi, Hyogo, 674-0063, Japan
| | - Shunsuke Tauchi
- Department of Thoracic Surgery, Akashi Medical Center, 743-33 Okubocho Yagi, Akashi, Hyogo, 674-0063, Japan.
| | - Takahiro Uchida
- Department of Thoracic Surgery, Akashi Medical Center, 743-33 Okubocho Yagi, Akashi, Hyogo, 674-0063, Japan
| | - Hisashi Ohnishi
- Department of Respiratory Medicine, Akashi Medical Center, Akashi, Japan
| | - Toshio Shimokawa
- Clinical Study Center, School of Medicine, Wakayama Medical University Hospital, Wakayama, Japan
| | - Satoshi Tobe
- Department of Thoracic Surgery, Akashi Medical Center, 743-33 Okubocho Yagi, Akashi, Hyogo, 674-0063, Japan
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14
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De León LE, Rochefort MM, Bravo-Iñiguez CE, Fox SW, Tarascio JN, Cardin K, DuMontier C, Frain LN, Jaklitsch MT. Opportunities for quality improvement in the morbidity pattern of older adults undergoing pulmonary lobectomy for cancer. J Geriatr Oncol 2021; 12:416-421. [PMID: 32980269 PMCID: PMC8011279 DOI: 10.1016/j.jgo.2020.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/01/2020] [Accepted: 09/16/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is limited information on the frequency of complications among older adults after oncological thoracic surgery in the modern era. We hypothesized that morbidity and mortality in older adults with lung cancer undergoing lobectomy is low and different than that of younger patients undergoing thoracic surgery. METHODS All patients undergoing lobectomy at a large volume academic center between May 2016 and May 2019 were included. Patients were prospectively monitored to grade postoperative morbidity by organ system, based on the Clavien-Dindo classification. Patients were divided into two groups: Group 1 included patients 65-91 years of age, and Group 2 included those <65 years. RESULTS Of 680 lobectomies in 673 patients, 414(61%) were older than 65 years of age (group 1). Median age at surgery was 68 years (20-91). Median hospital stay was 4 days (1-38) and longer in older adults. Older adults experienced higher rates of grade II and IV complications, mostly driven by an increased incidence of delirium, atrial fibrillation, prolonged air leak, respiratory failure and urinary retention. In this modern cohort, there was only 1 stroke (0.1%), and delirium was reduced to 7%. Patients undergoing minimally invasive (MI) surgery had a lower rate of Grade IV life-threatening complications. Older adults were more likely to be discharged to a rehabilitation facility, however this difference also disappeared with MI surgical procedures. CONCLUSIONS Current morbidity of older adults undergoing lobectomy for cancer is low and is different than that of younger patients. Thoracotomy may be associated with postoperative complications in these patients. Our findings suggest the need to consider MI approaches and broad-based, geriatric-focused perioperative management of older adults undergoing lobectomy.
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Affiliation(s)
- Luis E De León
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Matthew M Rochefort
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carlos E Bravo-Iñiguez
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sam W Fox
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey N Tarascio
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin Cardin
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Clark DuMontier
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura N Frain
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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15
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Sikander N, Ahmad T, Mazcuri M, Ali N, Thapaliya P, Nasreen S, Abid A. Role of Anti-Tuberculous Treatment in the Outcome of Decortication for Chronic Tuberculous Empyema. Cureus 2021; 13:e12583. [PMID: 33575146 PMCID: PMC7870130 DOI: 10.7759/cureus.12583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction: Chronic tuberculous empyema (CTE) is a common complication of tuberculosis that requires some form of surgical intervention along with anti-tuberculosis therapy (ATT). The aim of this study was to determine the optimum duration of pre-operative ATT in CTE prior to the decortication and its outcomes. Material and Methods: This comparative prospective study was conducted from August 2019 to August 2020 in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan. A total of 70 patients were included in the study. They were grouped into two arms: patients operated at or within six weeks of ATT commencement (Group A) and patients operated after six weeks of ATT (Group B). Both groups had 35 participants each. Patients were evaluated based on a self-administered questionnaire. A p-value of less than 0.05 was considered significant. Result: In this study, there were 55 (78.6%) males and 15 (21.4%) females with a mean age of 33.5 ± 11.2 years. Diagnosis of CTE was most commonly made through sputum acid-fast bacilli (AFB) smear (n=35, 50%) which most commonly involved right upper (n=20, 28.6%) and lower lung lobes (n=20, 28.6%). Complications such as air leaks, need for ventilator support, need for intensive care unit (ICU) stay, residual collection, and pneumothorax all were significantly higher in Group A (31 patients out of 35) compared to Group B (18 patients out of 35). In Group B, 21 (60%) participants had full post-operative expansion of lungs, compared to eight (22.8%) in Group A (p=0.002). In total five participants had failure to expand lungs; all of them belonged to Group A (p=0.02). Conclusion: The optimum timing of surgery and preoperative ATT is crucial for achieving better outcomes and requires good collaboration between the treating pulmonologist and thoracic surgeon. Our study highlights the importance of pre-operative ATT for at least more than six weeks before undertaking decortication for better outcomes and minimizing morbidity.
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Affiliation(s)
- Nazish Sikander
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Tanveer Ahmad
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Misauq Mazcuri
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Nadir Ali
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | | | - Shagufta Nasreen
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Ambreen Abid
- Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
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16
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Liu Z, Mao J, Su M, Mu C, Chen T, Zhao J, Jiang J. New treatment of bronchopleural fistula following surgical resection of the dorsal segment of the left lower lobe: A case report. Thorac Cancer 2020; 12:382-386. [PMID: 33305506 PMCID: PMC7862795 DOI: 10.1111/1759-7714.13734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 11/27/2022] Open
Abstract
Anatomical segment-based or subsegmental resection for early lung cancer surgery has been used in selected cases, although postoperative complications of bronchopleural fistula sometimes occur. Persistent air leaks can cause complications such as empyema and aspiration pneumonia, resulting in prolonged patient hospitalization. The traditional treatment for postoperative bronchopleural fistula is reoperation, but the advent of bronchoscopic interventional therapy usually prevents patients from needing a second operation. This article details a case of thoracoscopic segmentectomy of the left lower lung dorsal segment resulting in residual subsegmental pleural fistula, and because the use of pleural adhesives made the patient's fistula inappropriate for surgical repair, we finally used bronchoscopic injury of the airway mucosa combined with an absorbable gelatin sponge and an autologous blood closure method for successful treatment.
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Affiliation(s)
- Ziyi Liu
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jinyu Mao
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Meiqin Su
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chuanyong Mu
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Tao Chen
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jun Zhao
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Junhong Jiang
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
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17
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Joshi V, Dimarakis I. Objective analysis of postoperative air leaks can aid in decision-making, but does the use of digital drains really impact patient outcomes? J Thorac Dis 2020; 12:3927-3929. [PMID: 32944301 PMCID: PMC7475533 DOI: 10.21037/jtd.2020.04.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Vijay Joshi
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, UK
| | - Ioannis Dimarakis
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, UK.,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
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18
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Xing T, Li X, Liu J, Huang Y, Wu S, Guo M, Liang H, He J. Early removal of chest tubes leads to better short-term outcome after video-assisted thoracoscopic surgery lung resection. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:101. [PMID: 32175394 DOI: 10.21037/atm.2019.12.111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Currently, some studies have shown that early removal of a chest tube after video-assisted thoracoscopic surgery (VATS) lobectomy is safe and can shorten the length of hospital stay. The purpose of our study was to retrospectively analyze the association between early chest tube removal and hospital stay in patients who have undergone lobectomy. Methods This retrospective analysis included patients undergoing different types of lung resections including lobectomy and wedge resection. Consecutive patients who underwent VATS lobectomy or wedge resection (March 2018 to April 2019) for lung tumor were analyzed. Patients were divided into two groups according to the drainage time: those in whom the chest tube was removed within 48 hours and the traditional management group. Results All 931 patients were included. After propensity score matching (PSM). There are no statistically significant differences between the two groups. Compared with the traditional management group, the hospital stay in the early removal group was significantly shorter (5.05±2.27 vs. 7.17±3.03; P<0.001). Regarding complications, compared with the traditional management group, the rates of both lung infection and no complication in the early removal group were less (0.2% vs. 2.3%, 93.0% vs. 91.1%; P=0.005), and the necessity of re-operation was also less (0% vs. 1.2%; P<0.001). Regarding both pleural effusion and thoracentesis, a slight increase in the patient number was observed in the early removal group compared with the traditional management group (4.7% vs. 4.0%, 1.2% vs. 0.9%; P=0.005). Conclusions Compared with the traditional management group, early removal of the chest tube after VATS lobectomy and wedge resection is safe and feasible, and could decrease morbidity and postoperative complications, importantly, resulting in a shorter hospital stay.
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Affiliation(s)
- Tuo Xing
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
| | - Xukai Li
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
| | - Jun Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
| | - Ying Huang
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
| | - Shilong Wu
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
| | - Minzhang Guo
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
| | - Hengrui Liang
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
| | - Jianxing He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou 510120, China.,National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
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19
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Jacobsen K, Talbert S, Boyer JH. The benefits of digital drainage system versus traditional drainage system after robotic-assisted pulmonary lobectomy. J Thorac Dis 2019; 11:5328-5335. [PMID: 32030250 PMCID: PMC6988061 DOI: 10.21037/jtd.2019.11.69] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/12/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Postoperative air leaks are the most common complication after a pulmonary resection. There is no data in the literature comparing the traditional and digital chest drainage system after a robotic-assisted pulmonary lobectomy. METHODS This was a retrospective, correlational study. Medical records from 182 eligible robotic-assisted lobectomy patients were evaluated to determine the association between digital and traditional chest tube drainage systems (CTDS) with postoperative chest tube days, hospital LOS, chest tube reinsertion during hospitalization, and 30-day readmission for pneumothorax. Multiple regression was used to determine the association between CTDS while controlling for confounding variables. RESULTS No differences were noted between groups for age, gender, BMI, smoking, adhesions or neoadjuvant therapy. Patients with digital drainage systems had significantly shorter chest tube duration than those with traditional drainage systems (2.07 vs. 2.73 days, P=0.003). After controlling for age and BMI, CTDS was not found to be a significant predictor of CT duration. Digital drainage system were also associated with significantly shorter hospital LOS (4.02 vs. 5.06 days, P=0.01) After controlling for age, BMI, and presence of post-op a-fib, use of a digital CTDS was significantly associated with 1 day shorter hospital LOS. Chest tube reinsertion occurred four times more frequently with traditional drainage systems, but the difference did not achieve the level of statistical significance (P=0.059). The frequency of readmission due to pneumothorax was very low (1 patient per group), which prevented comparative statistical analysis. CONCLUSIONS In the digital drainage system there are shorter chest tube days and hospital length of stay after a robotic-assisted lobectomy. The decision to remove chest tubes in the traditional drainage system is burdened with uncertainty. The digital drainage system reduces intraobserver variability allowing for improved decision making in chest tube removal. Both CT duration and hospital LOS were shorter using unadjusted analyses. Type of CTDS was not significantly associated with CT duration after controlling for age and BMI. However, after controlling for age, BMI, and post-op atrial fibrillation, use of the digital CTDS was associated with a 1 day reduction in hospital LOS.
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Affiliation(s)
| | - Steven Talbert
- UCF College of Nursing, University of Central Florida, Orlando, FL, USA
| | - Joseph H. Boyer
- Division of Cardiothoracic Surgery, Director, AdventHealth Cardiovascular Institute Robotics and Minimally Invasive Cardiothoracic Surgery, Orlando, FL, USA
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20
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Abu-Hijleh M, Styrvoky K, Anand V, Woll F, Yarmus L, Machuzak MS, Nader DA, Mullett TW, Hogarth DK, Toth JW, Acash G, Casal RF, Hazelrigg S, Wood DE. Intrabronchial Valves for Air Leaks After Lobectomy, Segmentectomy, and Lung Volume Reduction Surgery. Lung 2019; 197:627-633. [PMID: 31463549 DOI: 10.1007/s00408-019-00268-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/21/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Air leaks are common after lobectomy, segmentectomy, and lung volume reduction surgery (LVRS). This can increase post-operative morbidity, cost, and hospital length of stay. The management of post-pulmonary resection air leaks remains challenging. Minimally invasive effective interventions are necessary. The Spiration Valve System (SVS, Olympus/Spiration Inc., Redmond, WA, US) is approved by the FDA under humanitarian use exemption for management of prolonged air leaks. METHODS This is a prospective multicenter registry of 39 patients with air leaks after lobectomy, segmentectomy, and LVRS managed with an intention to use bronchoscopic SVS to resolve air leaks. RESULTS Bronchoscopic SVS placement was feasible in 82.1% of patients (32/39 patients) and 90 valves were placed with a median of 2 valves per patient (mean of 2.7 ± 1.5 valves, range of 1 to 7 valves). Positive response to SVS placement was documented in 76.9% of all patients (30/39 patients) and in 93.8% of patients when SVS placement was feasible (30/32 patients). Air leaks ultimately resolved when SVS placement was feasible in 87.5% of patients (28/32 patients), after a median of 2.5 days (mean ± SD of 8.9 ± 12.4 days). Considering all patients with an intention to treat analysis, bronchoscopic SVS procedure likely contributed to resolution of air leaks in 71.8% of patients (28/39 patients). The post-procedure median hospital stay was 4 days (mean 6.0 ± 6.1 days). CONCLUSIONS This prospective registry adds to the growing body of literature supporting feasible and effective management of air leaks utilizing one-way valves.
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Affiliation(s)
- Muhanned Abu-Hijleh
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, POB Building II, Dallas, TX, 75390, USA.
| | - Kim Styrvoky
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vikram Anand
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fernando Woll
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Section of Interventional Pulmonology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael S Machuzak
- Department of Pulmonary, Allergy, Critical Care Medicine and Transplant Center, Interventional Pulmonology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Nader
- Department of Medicine, Pulmonary and Critical Care Medicine, Interventional Pulmonology, Cancer Treatment Centers of America, Tulsa, OK, USA
| | - Timothy W Mullett
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - D Kyle Hogarth
- Section of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Jennifer W Toth
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ghazwan Acash
- Department of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Lahey Hospital and Medical Center, Tufts University School of Medicine, Burlington, MA, USA
| | - Roberto F Casal
- Department of Pulmonary Medicine, Interventional Pulmonology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Stephen Hazelrigg
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Douglas E Wood
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
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21
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Bronstein ME, Koo DC, Weigel TL. Management of air leaks post-surgical lung resection. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:361. [PMID: 31516907 DOI: 10.21037/atm.2019.04.30] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Airleaks are one of the most common complications associated with elective lung resection. There have been many techniques and modern advancements in thoracic surgery, however airleaks persist. This review article will discuss several interventions ranging from conservative noninvasive to surgical management of the persistent airleak. These techniques include stopping of suction on the plueravac, fibrin patches, pleurodesis, use of endobronchial valves (EBVs), return to OR for operative intervention, and lastly to send patients home with mini pleuravacs.
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Affiliation(s)
| | | | - Tracey L Weigel
- Division of Thoracic Surgery, Westchester Medical Center, Valhalla, NY, USA
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22
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Bhora F, Ghosh SK, Kassis E, Yoo A, Ramisetti S, Johnston SS, Rehmani S, Kalsekar I. Association of tumor location with economic outcomes and air leak complications in thoracic lobectomies: results from a national hospital billing dataset. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:373-383. [PMID: 31239734 PMCID: PMC6559234 DOI: 10.2147/ceor.s190644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 03/26/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose: To assess whether tumor location during thoracic lobectomies affects economic outcomes or air leak complications. Patients and methods: Retrospective, observational study using Premier Healthcare Database. The study included patients aged ≥18 years who underwent elective inpatient thoracic lobectomy for lung cancer between 2012 and 2014 (first qualifying=index admission). Three mutually exclusive tumor location groups were formed: upper lobe, middle lobe, and lower lobe. Primary outcomes were index admission’s length of stay (LOS), total hospital costs, and operating room time; in-hospital air leak complications (composite of air leak/pneumothorax) served as an exploratory outcome. Multivariable models were used to examine the association between tumor location and the study outcomes, accounting for covariates and hospital-level clustering. Results: 8,750 thoracic lobectomies were identified: upper lobe (n=5,284), middle lobe (n=512), and lower lobe (n=2,954). Compared with the upper lobe, the middle and lower lobe groups had statistically significant (p<0.05): shorter adjusted LOS (7.0 days upper vs 5.8 days middle, 6.6 days lower), lower adjusted mean total hospital costs ($26,177 upper vs $23,109 middle, $24,557 lower), and lower adjusted odds of air leak complications (odds ratio middle vs upper=0.81, 95% CI=0.74–0.89; odds ratio lower vs upper=0.60, 95% CI=0.46–0.78). Findings were similar but varied in statistical significance when stratified by open and video-assisted thoracoscopic surgery approach. Conclusion: Among patients undergoing elective thoracic lobectomy for lung cancer in real-world clinical practice, upper lobe tumors were significantly associated with increased in-hospital resource use and air leak complications as compared with lower or middle lobe tumors.
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Affiliation(s)
- Faiz Bhora
- Health Quest Health System, Poughkeepsie, NY 12601, USA
| | - Sudip K Ghosh
- Global Health Economics and Market Access, Ethicon, Inc., Cincinnati, OH, USA
| | | | - Andrew Yoo
- Medical Devices - Epidemiology, Johnson and Johnson, New Brunswick, NJ, USA
| | - Sushama Ramisetti
- Medical Devices - Epidemiology, Johnson and Johnson, New Brunswick, NJ, USA
| | - Stephen S Johnston
- Medical Devices - Epidemiology, Johnson and Johnson, New Brunswick, NJ, USA
| | - Sadiq Rehmani
- Department of Thoracic Surgery, Mount Sinai St. Luke's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Iftekhar Kalsekar
- Medical Devices - Epidemiology, Johnson and Johnson, New Brunswick, NJ, USA
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Gologorsky RC, Alabaster AL, Ashiku SK, Patel AR, Velotta JB. Progel Use is Not Associated with Decreased Incidence of Postoperative Air Leak after Nonanatomic Lung Surgery. Perm J 2019; 23:18-059. [PMID: 30939277 DOI: 10.7812/tpp/18-059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Progel Pleural Air Leak Sealant (CR Bard, Warwick, RI) is a US Food and Drug Administration-approved hydrogel designed for application to surgical staple lines to prevent air leak after lung surgery. This product has demonstrated efficacy in reducing intraoperative air leaks compared with standard air leak closure methods. However, the impact on chest tube duration and length of hospital stay has not been reported. OBJECTIVE To evaluate the effect on rates of postoperative air leak, chest tube duration, and hospital stay in surgical patients with and without use of Progel. DESIGN Retrospective study of 176 patients aged 18 to 80 years who underwent video-assisted thoracoscopic wedge resections between 2014 and 2016. Eighty-four (48%) cases using Progel were included, as well as a representative sample of non-Progel cases (n = 92; 52%). MAIN OUTCOME MEASURE Presence of postoperative lung air leak. RESULTS No difference existed between the Progel and non-Progel groups in the rate of postoperative air leak (20/84, 23.81% Progel; 16/92, 17.39% non-Progel; p = 0.33). The length of time patients had a chest tube was similar (23.5 vs 23 hours, p = 0.721), as was percentage of patients with a less than 2-day hospitalization (77.17% non-Progel vs 82.14% Progel, p = 0.414). CONCLUSION Our results suggest that Progel, used routinely in patients undergoing nonanatomic lung resection, does not have a significant impact on postoperative air leak, chest tube duration, or length of hospital stay. Further studies are warranted to evaluate the utility of Progel in reducing postoperative complications after thoracoscopic wedge resection in those treated for air leak or in the reduction of postoperative air leak in high-risk patients.
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Affiliation(s)
- Rebecca C Gologorsky
- University of California, San Francisco-East Bay Department of Surgery, Oakland, CA
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Wang H, Hu W, Ma L, Zhang Y. Digital chest drainage system versus traditional chest drainage system after pulmonary resection: a systematic review and meta-analysis. J Cardiothorac Surg 2019; 14:13. [PMID: 30658680 PMCID: PMC6339372 DOI: 10.1186/s13019-019-0842-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 01/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several randomized controlled trials (RCTs) and observational studies have compared the efficacy of digital chest drainage system versus traditional chest drainage system. However, the results were inconsistent. METHODS We searched the Web of Science and Pubmed for observational studies and RCTs that compared the effect of digital chest drainage system with traditional chest drainage system after pulmonary resection. Eight studies (5 randomized control trails and 3 observational studies) comprising 1487 patients met the eligibility criteria. RESULTS Compared with the traditional chest drainage system, digital chest drainage system reduced the risk of prolonged air leak (PAL) (RR = 0.54, 95%CI 0.40-0.73, p < 0.0001), and shortened the duration of chest drainage (SMD = - 0.35, 95%CI -0.60 - -0.09, p = 0.008) and length of hospital stay (SMD = - 0.35, 95%CI -0.61 - -0.09, p = 0.007) in patients after pulmonary resection. CONCLUSIONS Digital chest drainage system is expected to benefit patients to attain faster recovery and higher life quality as well as to reduce the risk of postoperative complications. Further RCTs with larger sample size are still needed to more clearly elucidate the advantages of digital chest drainage system.
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Affiliation(s)
- Hong Wang
- Department of Surgery, Zhejiang University Hospital, Zhejiang University, Hangzhou, China
| | - Wenbin Hu
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Liang Ma
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Yiran Zhang
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China.
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Bertolaccini L, Bonfanti B, Kawamukai K, Forti Parri SN, Lacava N, Solli P. Bronchoscopic management of prolonged air leak. J Thorac Dis 2018; 10:S3352-S3355. [PMID: 30450241 DOI: 10.21037/jtd.2018.04.167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Broncho-pleural fistula (BPF) is an atypical communication between the tracheobronchial tree and the alveolar/pleural space, with prolonged air leak (PAL). BPF is frequent and related to significant morbidity, prolonged length of hospital stay, and mortality. Nevertheless, in about 10%, more than 5 days of an air leak is considered a PAL, accounted for significant morbidity. Endobronchial valve is a novel device for the PAL management with minimal morbidity if related to surgical repairs. While it is suggested that surgical treatment should be undertaken when possible, endobronchial valves should be recommended as a therapeutic choice in high-risk patients. Placement techniques remain operator and patient friendly and allow the procedure to be performed with relative ease. Prospectively conducted, randomised, controlled clinical trials are needed where valve treatment is compared with other bronchoscopic techniques, surgical procedures, or both.
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Affiliation(s)
- Luca Bertolaccini
- Department of Thoracic Surgery, Maggiore Teaching Hospital, Bologna, Italy
| | - Barbara Bonfanti
- Department of Thoracic Surgery, Maggiore Teaching Hospital, Bologna, Italy
| | - Kenji Kawamukai
- Department of Thoracic Surgery, Maggiore Teaching Hospital, Bologna, Italy
| | | | - Nicola Lacava
- Department of Thoracic Surgery, Maggiore Teaching Hospital, Bologna, Italy
| | - Piergiorgio Solli
- Department of Thoracic Surgery, Maggiore Teaching Hospital, Bologna, Italy
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26
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Fiorelli A, D'Andrilli A, Cascone R, Occhiati L, Anile M, Diso D, Cassiano F, Poggi C, Ibrahim M, Cusumano G, Terminella A, Failla G, La Sala A, Bezzi M, Innocenti M, Torricelli E, Venuta F, Rendina EA, Vicidomini G, Santini M, Andreetti C. Unidirectional endobronchial valves for management of persistent air-leaks: results of a multicenter study. J Thorac Dis 2018; 10:6158-6167. [PMID: 30622787 DOI: 10.21037/jtd.2018.10.61] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To evaluate the efficacy of Endo-Bronchial Valves in the management of persistent air-leaks (PALs) and the procedural cost. Methods It was a retrospective multicenter study including consecutive patients with PALs for alveolar pleural fistula (APF) undergoing valve treatment. We assessed the efficacy and the cost of the procedure. Results Seventy-four patients with persistent air leaks due to various etiologies were included in the analysis. In all cases the air leaks were severe and refractory to standard treatments. Sixty-seven (91%) patients underwent valve treatment obtaining a complete resolution of air-leaks in 59 (88%) patients; a reduction of air-leaks in 6 (9%); and no benefits in 2 (3%). The comparison of data before and after valve treatment showed a significant reduction of air-leak duration (16.2±8.8 versus 5.0±1.7 days; P<0.0001); chest tube removal (16.2±8.8 versus 7.3±2.7 days; P<0.0001); and length of hospital stay (LOS) (16.2±8.8 versus 9.7±2.8 days; P=0.004). Seven patients not undergoing valve treatment underwent pneumo-peritoneum with pleurodesis (n=6) or only pleurodesis (n=1). In only 1 (14%) patient, the chest drainage was removed 23 days later while the remaining 6 (86%) were discharged with a domiciliary chest drainage removed after 157±41 days. No significant difference was found in health cost before and after endobronchial valve (EBV) implant (P=0.3). Conclusions Valve treatment for persistent air leaks is an effective procedure. The reduction of hospitalization costs related to early resolution of air-leaks could overcome the procedural cost.
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Affiliation(s)
- Alfonso Fiorelli
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio D'Andrilli
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Roberto Cascone
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Luisa Occhiati
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Anile
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Daniele Diso
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Francesco Cassiano
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Camilla Poggi
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Mohsen Ibrahim
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Giacomo Cusumano
- Thoracic Surgery Unit, Policlinico Vittorio Emanuele Hospital, Catania, Italy
| | - Alberto Terminella
- Thoracic Surgery Unit, Policlinico Vittorio Emanuele Hospital, Catania, Italy
| | - Giuseppe Failla
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | - Alba La Sala
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | - Michela Bezzi
- Interventional Pneumology Unit, Policlinico Firenze, Florence, Italy
| | | | - Elena Torricelli
- Interventional Pneumology Unit, Policlinico Firenze, Florence, Italy
| | - Federico Venuta
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Erino Angelo Rendina
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Giovanni Vicidomini
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Claudio Andreetti
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
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27
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Abstract
This review of the development of a specialist nursing service within a thoracic surgery centre looks at the implementation of a specialist nursing role. An analysis of the needs of the service allowed identification of areas where specialist nursing input could have a positive impact on the patient pathway: (I) a nurse-led clinic for review of patients who require early review after discharge, in particular those discharged home with chest drains, was developed; (II) improvements to the patient pathway such as day of surgery admission were introduced along with a reduction in the number of patients who require admission to intensive care after surgery; (III) the specialist nurse leads on the introduction of new technology such as electronic chest drains. The specialist nurse works in the follow-up clinic, seeing patients autonomously, with a particular emphasis on patients under long-term follow-up after thoracic surgery. A telephone clinic has been introduced for patients on long-term CT follow-up. These are well received by patients; (IV) specialist nurses also work on in-patient wards, providing specialist input to the patient pathway, and can also take on work traditionally undertaken by junior medical staff. To be successful the specialist nursing role needs to be supported by the multidisciplinary team (MDT). These roles are developed to meet the needs of each unit and can have a very positive impact on the patient pathway.
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Shintani Y, Funaki S, Ose N, Kawamura T, Kanzaki R, Minami M, Okumura M. Air leak pattern shown by digital chest drainage system predict prolonged air leakage after pulmonary resection for patients with lung cancer. J Thorac Dis 2018; 10:3714-3721. [PMID: 30069369 DOI: 10.21037/jtd.2018.05.150] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background A common cause of complications after a pulmonary resection procedure is prolonged air leakage. Recently introduced digital drainage systems provide accurate recording of air leak data for later review. We investigated the clinical usefulness of the continuous stream of data recorded by such a device. Methods We analyzed data obtained from 299 patients with pulmonary malignancy who underwent a pulmonary resection procedure for lung cancer patients with use of a digital chest drainage system. Postoperative air leak patterns were divided into 4 groups and their correlation with prolonged air leakage after pulmonary resection was evaluated. Results The incidence of prolonged air leak was 10% (30/299). The postoperative air leak patterns noted in the present patients were divided into none (n=217, 73%), intermittent (n=21, 7%), decrease (n=40, 13%), and variable (n=21, 7%). The incidence of prolonged air leak in each group was 0.5% (1/217) in the none group, 24% (5/21) in the intermittent group, 20% (8/40) in the decrease group, and 76% (16/21) in the variable group. The amount of air leakage immediately after surgery was highest in the variable group. Patients in the intermittent and variable groups had longer durations of air leakage and chest tube placement. The frequency of postoperative interventional treatment was significantly higher in the variable group as compared to the others. Chest tube reinsertion for pneumothorax and increased subcutaneous emphysema after the initial chest tube removal was only seen in the intermittent group. Conclusions Advantages of digital drainage system use are continuous monitoring and recording capabilities, which show the detailed air leak pattern after pulmonary resection. That pattern can be used to predict the durations of air leakage and chest tube drainage, as well as for producing an air leak management algorithm.
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Affiliation(s)
- Yasushi Shintani
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan
| | - Soichiro Funaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan
| | - Naoko Ose
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan
| | - Tomohiro Kawamura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan
| | - Ryu Kanzaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan
| | - Masato Minami
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan
| | - Meinoshin Okumura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan
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29
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Casha AR, Bertolaccini L, Camilleri L, Manche A, Gauci M, Melikyan G, Gatt R, Dudek K, Solli P, Grima JN. Pathophysiological mechanism of post-lobectomy air leaks. J Thorac Dis 2018; 10:3689-3700. [PMID: 30069367 DOI: 10.21037/jtd.2018.05.116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Air leak post-lobectomy continues to remain a significant clinical problem, with upper lobectomy associated with higher air leak rates. This paper investigated the pathophysiological role of pleural stress in the development of post-lobectomy air leak. Methods Preoperative characteristics and postoperative data from 367 consecutive video assisted thoracic surgery (VATS) lobectomy resections from one centre were collected prospectively between January 2014 and March 2017. Computer modelling of a lung model using finite element analysis (FEA) was used to calculate pleural stress in differing areas of the lung. Results Air leak following upper lobectomy was significantly higher than after middle or lower lobectomy (6.3% versus 2.5%, P=0.044), resulting in a significant six-day increase in mean hospital stay, P=0.004. The computer simulation model of the lung showed that an apical bullet shape was subject to eightyfold higher stress than the base of the lung model. Conclusions After upper lobectomy, the bullet shape of the apex of the exposed lower lobe was associated with high pleural stress, and a reduction in mechanical support by the chest wall to the visceral pleura due to initial post-op lack of chest wall confluence. It is suggested that such higher stress in the lower lobe apex explains the higher parenchymal air leak post-upper lobectomy. The pleural stress model also accounts for the higher incidence of right-sided prolonged air leak post-resection.
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Affiliation(s)
- Aaron R Casha
- Department of Cardiothoracic Surgery, Mater Dei Hospital, Malta.,Faculty of Medicine, Medical School, University of Malta, Malta
| | - Luca Bertolaccini
- Department of Thoracic Surgery, Maggiore Teaching Hospital, Bologna, Italy
| | - Liberato Camilleri
- Department of Statistics and Operational Research, Faculty of Science, University of Malta, Malta
| | | | - Marilyn Gauci
- Department of Anaesthesia, Mater Dei Hospital, Malta
| | - Gor Melikyan
- Department of Cardiothoracic Surgery, Mater Dei Hospital, Malta
| | - Ruben Gatt
- Metamaterials Unit, Faculty of Science, University of Malta, Malta
| | - Krzysztof Dudek
- Metamaterials Unit, Faculty of Science, University of Malta, Malta
| | - Piergiorgio Solli
- Department of Thoracic Surgery, Maggiore Teaching Hospital, Bologna, Italy
| | - Joseph N Grima
- Metamaterials Unit, Faculty of Science, University of Malta, Malta
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30
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Baringer K, Talbert S. Chest drainage systems and management of air leaks after a pulmonary resection. J Thorac Dis 2017; 9:5399-5403. [PMID: 29312751 DOI: 10.21037/jtd.2017.11.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Air leaks after a pulmonary resection continue to be the most common postoperative complication. The presence of an air leak occurs in approximately 30-50% of patients immediately after surgery. Prolonged air leaks (PALs) predict an increased hospital length of stay, additional chest tube days and increased pain. The two types of systems used after surgery are digital and traditional chest drainage devices. Eighteen articles from four databases were evaluated for this analysis in chest drainage systems and managing air leaks after thoracic surgery. The digital and traditional drainage devices were evaluated. PALs were examined with interobserver variability of air leak assessment and differences in the two systems were addressed. The research gaps in the digital system are examining what flow thresholds should be used to safely remove a chest tube after surgery and for what length of time. In future research, the next step is standardizing chest tube management to decrease individual surgeon preference. Treatment of air leaks implementing scientific data instead of personal preference and opinion by a surgeon can lead to earlier chest tube removal, decreased morbidity and a shorter hospital stay.
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Affiliation(s)
- Kristina Baringer
- Division of Cardiothoracic Surgery, Florida Hospital, University of Central Florida, Orlando, FL, USA
| | - Steve Talbert
- UCF College of Nursing, University of Central Florida, Orlando, FL, USA
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Intraoperative ventilatory leak predicts prolonged air leak after lung resection: A retrospective observational study. PLoS One 2017; 12:e0187598. [PMID: 29121081 PMCID: PMC5679576 DOI: 10.1371/journal.pone.0187598] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 10/23/2017] [Indexed: 11/19/2022] Open
Abstract
Prolonged air leak (PAL), defined as air leak more than 5 days after lung resection, has been associated with various adverse outcomes. However, studies on intraoperative risk factors for PAL are not sufficient. We investigated whether the intraoperative ventilatory leak (VL) can predict PAL. A retrospective study of 1060 patients with chest tubes after lung resection was conducted. Tidal volume data were retrieved from the electronic anesthesia records. Ventilatory leak (%) was calculated as [(inspiratory tidal volume-expiratory tidal volume)/ inspiratory tidal volume × 100] and was measured after restart of two-lung ventilation. Cox proportional hazards regression analysis was performed using VL as a predictor, and PAL as the dependent outcome. The odds ratio of the VL was then adjusted by adding possible risk factors including patient characteristics, pulmonary function and surgical factors. The incidence of PAL was 18.7%. VL >9.5% was a significant predictor of PAL in univariable analysis. VL remained significant as a predictor of PAL (1.59, 95% CI, 1.37-1.85, P <0.001) after adjusting for 7 additional risk factors including male gender, age >60 years, body mass index <21.5 kg/m2, forced expiratory volume in 1 sec <80%, thoracotomy, major lung resection, and one-lung ventilation time >2.1 hours. C-statistic of the prediction model was 0.80 (95% CI, 0.77-0.82). In conclusion, VL was a quantitative measure of intraoperative air leakage and an independent predictor of postoperative PAL. Monitoring VL during lung resection may be uselful in recommending additional surgical repair or use of adjuncts and thus, help reduce postoperative PAL.
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32
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Lazarus DR, Casal RF. Persistent air leaks: a review with an emphasis on bronchoscopic management. J Thorac Dis 2017; 9:4660-4670. [PMID: 29268535 DOI: 10.21037/jtd.2017.10.122] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Persistent air leak (PAL) is a cause of significant morbidity in patients who have undergone lung surgery and those with significant parenchymal lung disease suffering from a pneumothorax. Its management can be complex and challenging. Although conservative treatment with chest drain and observation is usually effective, other invasive techniques are needed when conservative treatment fails. Surgical management and medical pleurodesis have long been the usual treatments for PAL. More recently numerous bronchoscopic procedures have been introduced to treat PAL in those patients who are poor candidates for surgery or who decline surgery. These techniques include bronchoscopic use of sealants, sclerosants, and various types of implanted devices. Recently, removable one-way valves have been developed that are able to be placed bronchoscopically in the affected airways, ameliorating air-leaks in patients who are not candidates for surgery. Future comparative trials are needed to refine our understanding of the indications, effectiveness, and complications of bronchoscopic techniques for treating PAL. The following article will review the basic principles of management of PAL particularly focusing on bronchoscopic techniques.
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Affiliation(s)
- Donald R Lazarus
- Department of Pulmonary, Critical Care, and Sleep Section, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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Abstract
PURPOSE OF REVIEW The method for identification of alveolopleural fistulae (APF) by visual inspection of air bubbles in the chest drainage system has several limitations and suffers from poor accuracy. Here we discuss the use of a novel technique of pleural gas analysis in the identification and management of APF. RECENT FINDINGS We found that pleural gas analysis has higher sensitivity and specificity than visual inspection in identifying APF. Additionally, we demonstrated that intrapleural gas milieu impacts lung healing and reduction of intrapleural carbon dioxide can promote resolution of APF. SUMMARY Pleural gas analysis is a novel technique to identify and manage APF. Integration of gas analysis in chest drainage systems would provide a more objective method for managing chest tubes and providing a favorable pleural gas environment for lung healing.
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34
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Carvalho MV, Marchi E, Fruchi AJ, Dias BV, Pinto CL, dos Santos GR, Acencio MM. Local and systemic effects of fibrin and cyanoacrylate adhesives on lung lesions in rabbits. Clinics (Sao Paulo) 2017; 72:624-628. [PMID: 29160425 PMCID: PMC5666443 DOI: 10.6061/clinics/2017(10)06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/18/2017] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Tissue adhesives can be used to prevent pulmonary air leaks, which frequently occur after lung interventions. The objective of this study is to evaluate local and systemic effects of fibrin and cyanoacrylate tissue adhesives on lung lesions in rabbits. METHODS Eighteen rabbits were submitted to videothoracoscopy + lung incision alone (control) or videothoracoscopy + lung incision + local application of fibrin or cyanoacrylate adhesive. Blood samples were collected and assessed for leukocyte, neutrophil and lymphocyte counts and interleukin-8 levels preoperatively and at 48 hours and 28 days post-operatively. After 28 days, the animals were euthanized for gross examination of the lung surface, and lung fragments were excised for histopathological analysis. RESULTS Fibrin and cyanoacrylate produced similar adhesion scores of the lung to the parietal pleura. Microscopic analysis revealed uniform low-cellular tissue infiltration in the fibrin group and an intense tissue reaction characterized by dense inflammatory infiltration of granulocytes, giant cells and necrosis in the cyanoacrylate group. No changes were detected in the leukocyte, neutrophil or lymphocyte count at any time-point, while the interleukin-8 levels were increased in the fibrin and cyanoacrylate groups after 48 hours compared with the pre-operative control levels (p<0.01). CONCLUSION Both adhesive agents promoted normal tissue healing, with a more pronounced local inflammatory reaction observed for cyanoacrylate. Among the serum markers of inflammation, only the interleukin-8 levels changed post-operatively, increasing after 48 hours and decreasing after 28 days to levels similar to those of the control group in both the fibrin and cyanoacrylate groups.
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Affiliation(s)
- Marcus V.H. Carvalho
- Departamento de Cirurgia Toracica, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
- *Corresponding author. E-mail:
| | - Evaldo Marchi
- Departamento de Cirurgia Toracica, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
- Laboratorio de Pleura, Divisao Pulmonar, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Andre J. Fruchi
- Departamento de Cirurgia Toracica, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
| | - Bruno V.B. Dias
- Departamento de Cirurgia Toracica, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
| | - Clovis L. Pinto
- Departamento de Patologia, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
| | | | - Milena M.P. Acencio
- Laboratorio de Pleura, Divisao Pulmonar, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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35
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Yoo A, Ghosh SK, Danker W, Kassis E, Kalsekar I. Burden of air leak complications in thoracic surgery estimated using a national hospital billing database. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:373-383. [PMID: 28721079 PMCID: PMC5498775 DOI: 10.2147/ceor.s133830] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background One of the most common outcomes of lung resections are parenchymal air leaks. These air leaks are most often self-limited and spontaneously resolve several days after surgery. Historically, only prolonged air leaks have been considered to have a significant effect on patient outcomes. This study aims to evaluate the impact of any air leak complications (aALCs) on resource utilization and mortality. Methods The Premier Perspective® database was used to identify all elective primary lobectomy, segmentectomy, and wedge resections performed from 2012 to 2014; aALC was defined as a composite of air leak and pneumothorax. Generalized estimating equation models were used to estimate the impact of aALCs on length of stay (LOS), operating room time (ORT), hospital costs, and mortality during index hospitalization. Results A total of 21,150 patients undergoing lung resection surgery were included in the analysis: lobectomy (n=10,946), segmentectomy (n=1,788), and wedge resection (n=8,416). The overall incidence of aALCs was 24.26% (95% CI [23.68, 24.83]). Identified risk factors included resection type, surgical approach, male gender, and presence of COPD. Patients with aALCs had a significantly higher economic burden (adjusted mean [standard error of mean, SE]: LOS=7.24 [SE=0.12] days; ORT=214.9 [SE=6.4] min; and hospital costs=$26,070 [SE=$1404]) compared to those without aALCs (adjusted mean [SE]: LOS=4.75 [SE=0.07] days; ORT=201.7 [SE=3.9] min; and hospital costs=$19,558 [SE=$399]). aALC was also associated with increased overall index hospitalization mortality (odds ratio=1.90, 95% CI [1.42, 2.55]). Conclusion This analysis showed that aALCs are not only frequent but also associated with significantly higher resource utilization and mortality.
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Affiliation(s)
- Andrew Yoo
- Medical Devices - Epidemiology, Johnson and Johnson, New Brunswick
| | - Sudip K Ghosh
- Global Health Economics and Market Access, Ethicon Inc., Somerville, NJ
| | - Walter Danker
- Global Health Economics and Market Access, Ethicon Inc., Somerville, NJ
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Optimal age for elective surgery of asymptomatic congenital pulmonary airway malformation: a meta-analysis. Pediatr Surg Int 2017; 33:665-675. [PMID: 28293700 DOI: 10.1007/s00383-017-4079-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2017] [Indexed: 10/24/2022]
Abstract
Controversy exists on the optimal age for elective resection of asymptomatic congenital pulmonary airway malformation. Current recommendations vary widely, highlighting the overall lack of consensus. A systematic search of Embase, MEDLINE, CINAL, and CENTRAL was conducted in January 2016. Identified citations were screening independently in duplicate and consensus was required for inclusion. Results were pooled using inverse variance fixed effects meta-analysis. Meta-analysis results indicate no statistically significant differences for complications within the 3-month and 6-month age comparison groups [odds ratio (OR) 4.20, 95% confidence interval (CI) 0.78-22.77, I 2 = 0%; OR 2.39, 95% CI 0.63-9.11, I 2 = 0%, respectively]. Older patients were significantly favoured for 3-month and 6-month age comparison groups for length of hospital stay [mean difference (MD) 4.13, 95% CI 2.31-5.96, I 2 = 0%; MD 3.38, 95% CI 0.44-6.31, I 2 = 0%, respectively]. Borderline statistical significance was observed for chest tube duration in patients ≥6 months of age (MD 1.06, 95% CI 0.02-2.09, I 2 = 0%). No mortalities were recorded. Surgical treatment appears to be safe at all ages, with no mortalities and similar rates of complications between age groups. The included evidence was not sufficient to make a conclusive recommendation on optimal age for elective resection.
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Muruganandan S, Kumar S, Lee YCG. Blood Patch for Pneumothorax: a Literature Review. CURRENT PULMONOLOGY REPORTS 2017. [DOI: 10.1007/s13665-017-0163-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Okada S, Shimada J, Kato D, Tsunezuka H, Inoue M. Prolonged air leak following lobectomy can be predicted in lung cancer patients. Surg Today 2017; 47:973-979. [PMID: 28091813 DOI: 10.1007/s00595-016-1467-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/05/2016] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose of this study was to identify the factors associated with prolonged air leak (PAL) following pulmonary lobectomy for lung cancer. METHODS The data of 146 patients who underwent pulmonary lobectomy for lung cancer between August 2010 and July 2015 were retrospectively reviewed. Air leaks were assessed daily by a visual evaluation and were categorized as follows: forced expiratory only (Grade 1), expiratory only (Grade 2), or continuous (Grade 3). Logistic regression analyses were performed to identify the predictors of PAL (>5 days). RESULTS PAL occurred in 23 patients (16%). An air leak at rest (Grade ≥ 2) was detected on postoperative day (POD) 1 in 48% of the patients with PAL and 7% of the patients without PAL. A univariate analysis demonstrated that PAL was significantly associated with male sex, a smoking history of ≥ 40 pack years, a serum albumin level of ≤4.0 mg/dL, and an air leak on POD1 (Grade ≥ 2). A multivariate analysis demonstrated that a serum albumin level of ≤4.0 mg/dL (p = 0.027) and an air leak on POD1 (p = 0.006) were independent predictors of PAL. PAL occurred in 75% of the patients with these two risk factors. CONCLUSIONS The preoperative serum albumin level and the presence of a visually evaluated air leak on POD1 may be useful indicators for the perioperative management of air leaks.
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Affiliation(s)
- Satoru Okada
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Junichi Shimada
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Daishiro Kato
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hiroaki Tsunezuka
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Masayoshi Inoue
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
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Glover JR, Velez-Cubian FO, Zhang WW, Toosi K, Tanvetyanon T, Ng EP, Moodie CC, Garrett JR, Fontaine JP, Toloza EM. Effect of gender on perioperative outcomes after robotic-assisted pulmonary lobectomy. J Thorac Dis 2016; 8:3614-3624. [PMID: 28149556 DOI: 10.21037/jtd.2016.12.11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Female gender has been associated with worse outcomes after cardiovascular surgery and critical illness. We investigated the effect of gender on perioperative outcomes following robotic-assisted pulmonary lobectomy. METHODS We retrospectively analyzed 282 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon over 53 months. Perioperative outcomes and clinically significant intraoperative and postoperative complications, including respiratory and cardiovascular events, were noted. Chi-Square (χ2), Fisher's exact test, Analysis of Variance (ANOVA), Student's t-test, and Kruskal-Wallis or Mood's median test were used to compare variables, with significance at P≤0.05. RESULTS There were 128 men (mean age, 68.8 yr) and 154 women (mean age, 65.9 yr; P=0.02). Women had higher preoperative forced expiratory volume in 1 second as percent of predicted (FEV1%; P=0.001). There were more former smokers in the male cohort (P=0.03) and more nonsmokers in the female cohort (P<0.001). Women had smaller tumors (3.0±0.1 vs. 3.5±0.2 cm, P=0.04), lower estimated blood loss (EBL) (150±34 vs. 250±44 mL, P<0.001), and shorter operative time (168±6 vs. 196±7 min, P=0.01). Rates of intraoperative complications (7.1% vs. 8.6%, P=0.65) and of conversion to open lobectomy (7.8% vs. 8.6%; P=0.81) were similar between genders. Postoperative complications were fewer in women (27.9% vs. 44.5%; P=0.004), the most common of which, in both women and men, were prolonged air leak for ≥7 days (13.0% vs. 22.7%, P=0.03), atrial fibrillation (7.1% vs. 14.8%, P=0.04), and pneumonia (7.8% vs. 10.2%, P=0.49). Hospital length of stay (LOS) (4±0.3 vs. 5±0.5 days) was also shorter for women (P=0.02). Despite the higher postoperative complication rate in men, in-hospital mortality did not differ between genders (P=0.23). Multivariable analyses did not identify female gender as an independent predictor of post-operative complications. CONCLUSIONS Female gender was associated with rates of intraoperative complications and of conversion to open lobectomy as low as those for men, but with better perioperative outcomes, lower risk of intraoperative bleeding, and fewer postoperative complications. Thus, robotic-assisted pulmonary lobectomy is feasible and safe for women.
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Affiliation(s)
- Jessica R Glover
- Morsani College of Medicine, University of South Florida Health, Tampa, FL, USA
| | - Frank O Velez-Cubian
- Department of Surgery, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Wei Wei Zhang
- Department of Surgery, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Kavian Toosi
- Morsani College of Medicine, University of South Florida Health, Tampa, FL, USA
| | - Tawee Tanvetyanon
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Emily P Ng
- Morsani College of Medicine, University of South Florida Health, Tampa, FL, USA
| | - Carla C Moodie
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Joseph R Garrett
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jacques P Fontaine
- Department of Surgery, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA;; Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL, USA;; Department of Oncologic Sciences, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Eric M Toloza
- Department of Surgery, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA;; Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL, USA;; Department of Oncologic Sciences, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
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Attaar A, Winger DG, Luketich JD, Schuchert MJ, Sarkaria IS, Christie NA, Nason KS. A clinical prediction model for prolonged air leak after pulmonary resection. J Thorac Cardiovasc Surg 2016; 153:690-699.e2. [PMID: 27912898 DOI: 10.1016/j.jtcvs.2016.10.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/15/2016] [Accepted: 10/05/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Prolonged air leak increases costs and worsens outcomes after pulmonary resection. We aimed to develop a clinical prediction tool for prolonged air leak using pretreatment and intraoperative variables. METHODS Patients who underwent pulmonary resection for lung cancer/nodules (from January 2009 to June 2014) were stratified by prolonged parenchymal air leak (>5 days). Using backward stepwise logistic regression with bootstrap resampling for internal validation, candidate variables were identified and a nomogram risk calculator was developed. RESULTS A total of 2317 patients underwent pulmonary resection for lung cancer/nodules. Prolonged air leak (8.6%, n = 200) was associated with significantly longer hospital stay (median 10 vs 4 days; P < .001). Final model variables associated with increased risk included low percent forced expiratory volume in 1 second, smoking history, bilobectomy, higher annual surgeon caseload, previous chest surgery, Zubrod score >2, and interaction terms for right-sided thoracotomy and wedge resection by thoracotomy. Wedge resection, higher body mass index, and unmeasured percent forced expiratory volume in 1 second were protective. Derived nomogram discriminatory accuracy was 76% (95% confidence interval [CI], 0.72-0.79) and facilitated patient stratification into low-, intermediate- and high-risk groups with monotonic increase in observed prolonged air leaks (2.0%, 8.9%, and 19.2%, respectively; P < .001). Patients at intermediate and high risk were 4.80 times (95% CI, 2.86-8.07) and 11.86 times (95% CI, 7.21-19.52) more likely to have prolonged air leak compared with patients at low risk. CONCLUSIONS Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability. Risk stratification can support surgical decision making, and help initiate proactive, patient-specific surgical management.
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Affiliation(s)
- Adam Attaar
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pa
| | - James D Luketich
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Matthew J Schuchert
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Inderpal S Sarkaria
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Neil A Christie
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Katie S Nason
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
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Wood DE, Lauer LM, Layton A, Tong KB. Prolonged length of stay associated with air leak following pulmonary resection has a negative impact on hospital margin. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:187-95. [PMID: 27274293 PMCID: PMC4876678 DOI: 10.2147/ceor.s95603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Protracted hospitalizations due to air leaks following lung resections are a significant source of morbidity and prolonged hospital length of stay (LOS), with potentially significant impact on hospital margins. This study aimed to evaluate the relationship between air leaks, LOS, and financial outcomes among discharges following lung resections. Materials and methods The Medicare Provider Analysis and Review file for fiscal year 2012 was utilized to identify inpatient hospital discharges that recorded International Classification of Diseases (ICD-9) procedure codes for lobectomy, segmentectomy, and lung volume reduction surgery (n=21,717). Discharges coded with postoperative air leaks (ICD-9-CM codes 512.2 and 512.84) were defined as the air leak diagnosis group (n=2,947), then subcategorized by LOS: 1) <7 days; 2) 7–10 days; and 3) ≥11 days. Median hospital charges, costs, payments, and payment-to-cost ratios were compared between non-air leak and air leak groups, and across LOS subcategories. Results For identified patients, hospital charges, costs, and payments were significantly greater among patients with air leak diagnoses compared to patients without (P<0.001). Hospital charges and costs increased substantially with prolonged LOS, but were not matched by a proportionate increase in hospital payments. Patients with LOS <7, 7–10, and ≥11 days had median hospital charges of US $57,129, $73,572, and $115,623, and costs of $17,594, $21,711, and $33,786, respectively. Hospital payment increases were substantially lower at $16,494, $16,307, and $19,337, respectively. The payment-to-cost ratio significantly lowered with each LOS increase (P<0.001). Higher inpatient hospital mortality was observed among the LOS ≥11 days subgroup compared with the LOS <11 days subgroup (P<0.001). Conclusion Patients who develop prolonged air leaks after lobectomy, segmentectomy, or lung volume reduction surgery have the best clinical and financial outcomes. Hospitals experience markedly lower payment-to-cost ratios as LOS increases. Interventions minimizing air leak or allowing outpatient management will improve financial performance and hospital margins for lung surgery.
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Affiliation(s)
- Douglas E Wood
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, USA
| | | | | | - Kuo B Tong
- Quorum Consulting, Inc., San Francisco, CA, USA
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Ravaglia C, Bonifazi M, Wells AU, Tomassetti S, Gurioli C, Piciucchi S, Dubini A, Tantalocco P, Sanna S, Negri E, Tramacere I, Ventura VA, Cavazza A, Rossi A, Chilosi M, La Vecchia C, Gasparini S, Poletti V. Safety and Diagnostic Yield of Transbronchial Lung Cryobiopsy in Diffuse Parenchymal Lung Diseases: A Comparative Study versus Video-Assisted Thoracoscopic Lung Biopsy and a Systematic Review of the Literature. Respiration 2016; 91:215-27. [PMID: 26926876 DOI: 10.1159/000444089] [Citation(s) in RCA: 244] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/13/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A diagnosis of interstitial lung diseases (ILDs) may include surgical lung biopsy (SLB), which is associated with significant morbidity and mortality and also appreciable costs. Transbronchial lung cryobiopsy (TBLC) is adopting an important role. OBJECTIVES The aim of this study was to compare the diagnostic yield (DY) and safety of TBLC and SLB in a large cohort of patients and to perform a systematic review of the literature as well as a meta-analysis. METHODS We performed a retrospective analysis of 447 cases with ILD undergoing TBLC and/or SLB and a systematic review of the literature (MEDLINE and Embase for all original articles on the DY and safety of TBLC in ILDs up to July 2015). RESULTS A total of 150 patients underwent SLB and 297 underwent TBLC. The median time of hospitalization was 6.1 days (SLB) and 2.6 days (TBLC; p < 0.0001). Mortality due to adverse events was observed for 2.7% (SLB) and 0.3% (TBLC) of the patients. Pneumothorax was the most common complication after TBLC (20.2%). No severe bleeding was observed. TBLC was diagnostic for 246 patients (82.8%), SLB for 148 patients (98.7%, p = 0.013). A meta-analysis of 15 investigations including 781 patients revealed an overall DY of 0.81 (0.75-0.87); the overall pooled probability of developing a pneumothorax, as retrieved from 15 studies including 994 patients, was 0.06 (95% CI 0.02-0.11). CONCLUSION Cryobiopsy is safe and has lower complication and mortality rates compared to SLB. TBLC might, therefore, be considered the first diagnostic approach for obtaining tissue in ILDs, reserving the surgical approach for cases in which TBLC is not diagnostic.
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Affiliation(s)
- Claudia Ravaglia
- Pulmonology Unit, Department of Thoracic Diseases, G.B. Morgagni - L. Pierantoni Hospital, Forlx00EC;, Italy
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Bharat A, Graf N, Cassidy E, Smith S, Gillespie C, Meyerson S, Sporn PHS, Sznajder JI, DeCamp MM. Pleural Gas Analysis for Detection of Alveolopleural Fistulae. Ann Thorac Surg 2015; 99:2179-82. [PMID: 26046869 DOI: 10.1016/j.athoracsur.2014.12.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 12/11/2014] [Accepted: 12/23/2014] [Indexed: 10/23/2022]
Abstract
PURPOSE Visual inspection (VI) of bubbles in the chest drainage unit does not differentiate a true leak of alveolopleural fistula (APF) from a false leak. We hypothesized that detection of elevated levels of carbon dioxide, increase in oxygen content, or both, in pleural gas upon the administration of supplemental oxygen would accurately identify APF. DESCRIPTION Prospective study comparing pleural gas analysis (GA) with VI to detect APF after surgical lobectomy (n = 50). EVALUATION APF was found in 22 (44%) patients at the time of analysis. VI revealed air bubbles in 31 (62%) patients, indicating the presence of APF, of whom 12 (38.7%) were false leaks. VI failed to identify APF in 3 (6%) patients that resulted in post-tube removal pneumothorax. By contrast, GA accurately demonstrated APF in 21 patients, with only one false negative and no false positives. GA demonstrated better sensitivity (95.5% vs 86.4%), specificity (100% vs 57.1%), positive predictive value (100% vs 61.3%), and negative predictive value (96.6% vs 84.2%) compared to VI. CONCLUSIONS Pleural gas analysis is an effective technique to detect APF and can facilitate timely and safe chest tube removal.
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Affiliation(s)
- Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, Illinois.
| | - Nicole Graf
- Division of Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Emily Cassidy
- Division of Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sean Smith
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Colin Gillespie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Shari Meyerson
- Division of Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Peter H S Sporn
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University, Chicago, Illinois; Jesse Brown Veterans Medical Center, Chicago, Illinois
| | - Jacob I Sznajder
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Malcolm M DeCamp
- Division of Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
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Decreased CXCL12 is associated with impaired alveolar epithelial cell migration and poor lung healing after lung resection. Surgery 2015. [PMID: 26212341 DOI: 10.1016/j.surg.2015.04.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Prolonged air leak (PAL) is an important cause of morbidity and mortality after lung resection, but its pathogenesis has not been elucidated. Migration of alveolar type II epithelial cells is essential for lung wound repair. Here we determined the role of C-X-C motif chemokine 12 (CXCL12) on alveolar epithelial cell migration and lung wound healing. METHODS CXCL12 in the pleural fluid of patients was analyzed using enzyme-linked immunosorbent assay. Human A549 and murine MLE12 alveolar epithelial cell lines were used for wound closure, cell migration, and proliferation assays. Western blot was used to analyze Rac1 and cofilin. RESULTS Pleural CXCL12 was decreased in patients with PAL (1,389 ± 192 vs 3,270 ± 247 pg/mL; P < .0001). CXCL12 enhanced scratch wound closure in both A549 (77.9 ± 0.7% vs 71.5 ± 0.4%; P = .0016) and MLE12 (92.9 ± 4.9% vs 66.0 ± 4.8%; P = .017). CXCL12 enhanced migration by 57% in A549 (P = .0008) and by 86% in MLE12 (P < .0001). AMD3100, a selective CXCR4 antagonist, prevented the effects of CXCL12. CXCL12 increased Rac1 and cofilin activation but did not change bromodeoxyuridine incorporation or cell counts. CONCLUSION Reduced pleural CXCL12 is associated with PAL. CXCL12 promotes alveolar epithelial cell migration by binding to its receptor CXCR4 and may have a role in lung healing. CXCL12-mediated alveolar epithelial cell migration is associated with Rac1 and cofilin activation.
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Van Schil PE, Hendriks JM, Lauwers P. Focus on treatment complications and optimal management surgery. Transl Lung Cancer Res 2015; 3:181-6. [PMID: 25806298 DOI: 10.3978/j.issn.2218-6751.2014.06.07] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 06/19/2014] [Indexed: 11/14/2022]
Abstract
Thoracic surgery comprises major procedures which may be challenging, not only from a technical point of view but also regarding anesthetic and postoperative management. Complications are common occurrences which are also related to the comorbidity of the patients. After major lung resections pulmonary and pleural complications are often encountered. In this overview more surgically related complications are discussed, focusing on postpneumonectomy pulmonary edema, thromboembolic disease including pulmonary embolism, prolonged air leak, lobar torsion, persistent pleural space, empyema and bronchopleural fistula. Prevention, timely recognition, and early adequate treatment are key points as complications initially considered to be minor, may suddenly turn into life-threatening events. To this end multidisciplinary cooperation is necessary. Preoperative smoking cessation, adequate pain control, attention to nutritional status, incentive spirometry and early mobilization are important factors to reduce the incidence of postoperative complications.
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Affiliation(s)
- Paul E Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Belgium
| | - Jeroen M Hendriks
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Belgium
| | - Patrick Lauwers
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Belgium
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