Treatment of air leak in polytrauma patients with blunt chest injury

IntroductionPrecise diagnostics and an adequate therapeutic approach are mandatory in the treatment of air leak in polytrauma patients with blunt chest trauma. The aim of this study was to evaluate the incidence, characteristics, and management of air leak following this injury pattern.Patients and methodsData from 110 polytrauma patients was collected retrospectively. Fifty-four patients received initial treatment by chest tube placement for pneumothorax. These patients were classified into two groups, one with severe air leak and one with minor air leak. An evaluation of injury pattern, chest wall injuries in particular, duration of air leak, reason for drainage maintenance in place, hospital length of stay, ICU stay, ventilator duration, type of treatment, and the delay to surgical intervention was performed.ResultsWhereas 4 patients showed severe air leak and were subsequently scheduled for timely surgical intervention, the remaining 50 patients only showed minor air leak. Only 7 patients with minor air leak suffered from prolonged air leak (>5 days), which spontaneously resolved in all of them after a mean duration of 7.7 days (range 6–12 days). Absence of a prolonged air leak resulted in a shorter length of stay and a shorter duration of mechanical ventilation, although no statistical significance was observed.ConclusionsEarly spontaneous cessation of most minor air leaks as well as early surgical intervention for severe air leak lead to very satisfactory patient outcomes with a relatively short hospital stay in our patients. We therefore advocate early surgery for lacerations of the pulmonary parenchyma resulting in severe air leak, whereas minor air leaks can usually be treated conservatively.     

Risk factors for prolonged air leak and need for intervention following lung resection

 Open in a separate windowOBJECTIVESProlonged air leak (PAL; >5 days) following lung resection is associated with postoperative morbidity. We investigated factors associated with PAL and PAL requiring intervention.METHODSRetrospective review of all patients undergoing lobectomy, segmentectomy or wedge resection from 2016 to 2019 at our institution. Bronchoplastic reconstructions and lung-volume reduction surgeries were excluded. Incidence and risk factors for PAL and PAL requiring intervention were evaluated.RESULTSIn total, 2384 patients were included. PAL incidence was 5.4% (129/2384); 22.5% (29/129) required intervention. PAL patients were more commonly male (56.6% vs 39.7%), older (mean age 69 vs 65 years) and underwent lobectomy or thoracotomy (all P < 0.001). Patients with PAL had longer length of stay (9 vs 3 days), more discharge needs and increased odds of complication (all P < 0.050).Twenty-nine patients required intervention (9 chest tubes; 4 percutaneous drains; 16 operations). In 50% of operative interventions, an air leak source was identified; however, the median time from intervention to resolution was 13 days. Patients requiring intervention had increased steroid use, lower diffusion capacity for carbon monoxide and twice the length of stay versus PAL patients (all P < 0.050).On univariable analysis, forced expiratory volume in 1 s (FEV1) <40%, diffusion capacity for carbon monoxide <50%, steroid use and albumin <3 had increased odds of intervention (P < 0.050).CONCLUSIONSAge, gender and operative technique were related to PAL development. Patients with worse forced expiratory volume in 1 s or diffusion capacity for carbon monoxide, steroid use or poor nutrition were less likely to heal on their own, indicating a population that could benefit from earlier intervention.     

Chest tube management following pulmonary lobectomy: change of protocol results in fewer air leaks

Much controversy exists regarding the management of chest tubes following pulmonary lobectomy. The objective of this study was to analyse the effect of a new chest tube management protocol on clinical features, such as postoperative air leak, drain characteristics, 30-day postoperative complications and length of hospital stay. We retrospectively analysed 133 patients who underwent pulmonary lobectomy, from January 2005 to December 2008. A new chest tube protocol was introduced on 1 January 2007 and included placement of a single chest tube and early conversion to water seal. The chest tube was removed when air leak had resolved and (non-chylous) fluid drainage was <400 ml/day. The results of patients in the old (n=68) and the new protocol (n=65) were compared. In the new protocol group the median duration of air leak and duration of chest tube drainage declined significantly. Also the length of hospital stay decreased significantly to a median of eight days. The number of reinterventions and 30-day morbidity and mortality rates did not differ significantly. Our data suggest that placement of a single chest tube and early conversion to water seal decreases the duration of air leak and chest tube drainage and length of hospital stay.     

Estimating hospital costs attributable to prolonged air leak in pulmonary lobectomy.

OBJECTIVE: Prolonged air leak (PAL) after pulmonary surgery is a frequent occurrence and is reported to cause increased length of stay (LOS) and hospital costs although the costs directly attributable to PAL have never been published. The present study aims to compare the prevalence of pulmonary complications (atelectasis, pneumonia and pleural empyema) in patients with or without PAL and to quantify economic costs directly incurred by PAL in a series of pulmonary lobectomies. METHODS: A series of 238 patients scheduled for pulmonary lobectomy (January 2001-December 2003) have been reviewed. PAL was defined as air leakage which prevented hospital discharge for 5 postoperative days or over. Hospital costs (excluding operating room) for pulmonary lobectomies have been obtained and calculated as mean daily costs. Age, body mass index, diagnosis, Charlson co-morbidity index, ppoFEV1 and major post-operative cardio-pulmonary morbidity have been used to construct a Cox-regression model for hospital stay, considering deaths as censored cases. Individual risk function has been used as a new variable and expected LOS calculated for each case. This data has been used to estimate total excess hospital stay and costs incurred by cases with PAL. RESULTS: Prevalence of PAL was 23 cases (9, 7%). Mean daily hospital cost for lobectomy was 632.49. For the whole series, mean hospital stay was 5 days (10 days for patients with PAL). PAL cases had more postoperative pulmonary morbidity (risk-ratio: 2.78). Variables showing independent influence on stay were: diagnosis of non-malignant disease (P=0.001); FEV1ppo (P=0.032) and cardio-respiratory morbidity (P<0.001). Calculated total excess stay for PAL patients was 62 days. A total expense of 39,437.39 (38,724.96 hospital and 712.43 pharmacy charges) were estimated to result from postoperative air-leak. CONCLUSIONS: PAL patients are prone to developing major postoperative morbidity. PAL calculated costs are over 13,000 per year. This data is useful for designing technical cost-effective strategies to avoid post-lobectomy PAL.     

Pleural tent after upper lobectomy: a randomized study of efficacy and duration of effect

BACKGROUND: The object of this study was to assess the efficay and maximum duration of effect of the pleural tent in reducing the incidence of air leak after upper lobectomy. METHODS: Two hundred patients who underwent upper lobectomy were prospectively randomized into two groups: 100 patients who underwent an upper lobectomy and a pleural tent procedure (group 1; tented patients) and 100 patients who underwent only an upper lobectomy and not a pleural tent procedure (group 2; untented patients). The preoperative, operative, and postoperative characteristics of both groups were compared. Then multivariate analyses were used to identify factors predictive of prolonged air leaks and their duration. The reduction of incidences of air leak in the two groups was subsequently compared during successive postoperative periods. RESULTS: No differences were detected between the two groups in terms of preoperative and operative characteristics. A significant reduction occurred in group 1 patients for the mean duration of air leak in days (2.5 vs 7.2 days; p < 0001), the number of days a chest tube was required (7.0 vs 11.2 days; p < 0.0001), the length of postoperative hospital stay in days (8.2 vs 11.6 days; p < 0.0001), and the hospital stay cost per patient (4,110 dollars vs 5,805 dollars; p < 0.0001). Logistic regression analyses showed that not having undergone a pleural tent procedure was the most significant predictive factor of the occurrence and duration of prolonged air leaks. A greater reduction in the duration of air leaks was observed before postoperative day 4 in group 1, and logistic regression analysis showed that having undergone a pleural tent procedure was the most significant predictive factor of air leaks that persisted for less than 4 days. CONCLUSIONS: Pleural tenting after upper lobectomy was a safe procedure that reduced the duration of air leaks and the hospital stay costs. The benefit from that procedure was achieved before postoperative day 4.     

A comparative study of buttressed versus nonbuttressed staple line in pulmonary resections

BACKGROUND: Prolonged air leak is the major limiting factor in early hospital discharge following pulmonary resection. The purpose of this study was to determine whether the use of bovine pericardial strips as a buttress along the lung staple line would decrease air leaks and hospital stay after lobectomy and segmentectomy. METHODS: This was a multicenter trial consisting of 80 patients undergoing pulmonary resection, randomly assigned to the control group (40 patients) or treatment group (40 patients). The treatment group had reinforcement with bovine pericardium. RESULTS: No statistical differences were noted in the mean intensive care unit length of stay (p = 0.9), number of days with a chest tube (p = 0.6), or total length of stay (p = 0.24). Increased air leak duration was associated with assignment to the control group (r = 0.27, p = 0.02). The mean duration of air leak was 2 days and the mean time to chest tube removal was 5.9 days in patients with a buttressed staple line compared to 3 days and 6.3 days, respectively, for patients with nonbuttressed staple lines. CONCLUSIONS: Within the data of this study, no statistical differences were noted between buttressed and nonbuttressed patients. However, the trend toward shortened air leak time and tube removal time was apparent in the buttressed group. With greater number of patients studied, it is likely that the cost of bovine pericardium would be justified by shorter air leak duration and hospitalization.     

Chest Tube Management following Lung Resection in Pediatric Patients: A Retrospective Analysis

BackgroundPleural drainage following lung resection is almost universally practiced in pediatric surgery, but its necessity has been questioned in adult literature. We performed a cross-sectional study of pediatric patients undergoing lung resection to characterize chest tube (CT) practices and clarify their utility.MethodRetrospective chart review of patients <21 years of age undergoing pulmonary lobectomy or wedge resection at an academic children's hospital from 2013 to 2022. Variables regarding demographics and post-operative CT management were recorded.Results130 procedures meet inclusion criteria: 59 lobectomies (group 1), 19 diagnostic wedges (group 2), and 52 excisional wedges (group 3). 74.6% of group 1 patients had no air leak, and median CT duration was 2 days. In group 2, 89.5% had no air leak and median CT duration was 1 day. In Group 3, 80.8% had no air leak and median CT duration was 1 day. Overall, 43.1% patients had their CT removed on post-operative day 1 and 21.5% on post-operative day 2.ConclusionCT duration following lung resection in pediatric patients is typically brief, with most patients having no air leak and CT removal within 2 days of surgery. Obligatory CT drainage may not be necessary in select patients undergoing lung resection.Level of EvidenceLevel IV.Type of StudyRetrospective Study.     

Ambulatory treatment of persistent air leaks using a portable chest drainage system: Preliminary results

Introduction

Persistent air leaks (PAL) is the most frequent post-operative complication in Thoracic Surgery, leading to a longer hospital stay and an increase in patient morbidity. We present a prospective study conducted in the Dr. Josep Trueta University Hospital in Gerona, involving a portable chest drainage system (PCDS) connected to a pleural drainage which allowed air leaks to be treated ambulatorily. Our aim is to demonstrate that by using this system hospital stay is reduced without increasing post-operative morbidity, and improves the quality of life of the patient.

Material and methods

The Thoracic Surgery Department of Gerona Hospital collected the data on 33 patients with PAL in the post-surgical period and who were treated ambulatorily with a PCDS. Post-operative complications were recorded, along with the mean days of ambulatory treatment with the PCDS and the hospital days saved.

Results

The mean hospital stay of the 33 patients was 7.03 days. The mean number of days that the 33 patients were treated ambulatorily with the PCDS was 9.33 days. It was calculated that there was a saving of 308 hospital days.The ambulatory treatment of PAL did not increase post-operative morbidity.

Conclusions

The clinical results and the management of the PCDS support the treatment of this problem in patients who do not have any other causes to remain in hospital. The study shows a saving in a considerable number of hospital days stay, with no increase in patient morbidity. All the patients preferred this system to hospital admission.     

Work in progress report of a multicentre retrospective observational study to evaluate the association between the airflows and the intrapleural pressures digitally recorded after video-assisted lobectomy

 Open in a separate windowOBJECTIVESDigital chest drainage systems allow real-time and continuous monitoring and recording of air leak flow rate and intrapleural pressure (IPP) from the immediate postoperative period to the chest drainage removal. A multicentre retrospective observational analysis of consecutive patients undergoing pulmonary lobectomy for lung cancer was performed to evaluate the association between the airflow and IPP digitally recorded during the immediate postoperative period after video-assisted thoracic surgery (VATS) lobectomy for lung cancer. Here, we present a work in progress report. METHODSAll patients treated with VATS lobectomies for lung cancer were included. Multiple airflow measurements and minimum and maximum IPP through the chest tubes were digitally monitored and recorded using microelectronic mechanical sensor technology. The PALs were defined as an air leak lasting >5 days from the conclusion of the surgical procedure. The cessation of air leaks was defined as an airflow <10 ml/min during 6 consecutive hours.RESULTSThis analysis comprised 76 patients who underwent VATS lobectomy for lung cancer. Nineteen patients (25%) showed prolonged air leaks (PAL) (≥5 days). The operative time was higher in the PAL group (mean difference = 44 min) without a statistically significant difference. Before the 7th postoperative hours, there were no statistically significant differences in IPPs.CONCLUSIONSPatients with PAL showed less negative IPP in the first 24 postoperative hours. Therefore, the 7th—24th postoperative hours were critical in PAL prediction since the mechanism for PAL seems to develop after the 7th postoperative hour.     

Aortic Valve Replacement with Pericardial Valves in Patients with Small Aortic Roots. Clinical Results in a Consecutive Series of Patients Receiving 19 and 21 mm Prostheses

Objective - To determine how second generation pericardial valves perform in patients with small aortic roots. Design - Ninety patients who underwent isolated aortic valve replacement (AVR) with 19 or 21 mm Mitroflow® or Carpentier-Edwards (Perimount®) valves between 1989 and 1996 were studied. Mean age was 78 years. Concomitant coronary bypass surgery was performed in 41%. Results - Thirty-day mortality was 5.6%. Ninety-seven percent had acceptable transprosthetic mean pressure gradients (25 mmHg or less) 1 week after surgery. Follow-up was 100% complete and 76% of the patients were alive after a mean of 5 years. There was no structural valve failure or valve thrombosis. One patient required reoperation for perivalvular leak. Four patients had transient ischemic attacks and seven had strokes. These figures are, however, within the expected range for the age. Conclusion - Second generation pericardial valves perform well in elderly patients with small aortic roots. Postoperative hemodynamics are acceptable, valve durability of up to 8 years adequate, and the clinical results good, considering the age of the patients.     

Tube Cholecystostomy Before Cholecystectomy for the Treatment of Acute Cholecystitis

Methods:This study was a retrospective chart review of patients who underwent tube cholecystostomy from July 1, 2005, to July 1, 2012.Results:During the study period, 82 patients underwent 125 cholecystostomy tube placements. Four patients (5%) died during the year after tube placement. The mean hospital length of stay for survivors was 8.8 days (range, 1–59 days). Twenty-eight patients (34%) required at least 1 additional percutaneous procedure (range, 1–6) for gallbladder drainage. Twenty-nine patients (34%) ultimately underwent cholecystectomy. Surgery was performed a mean of 7 weeks after cholecystostomy tube placement. Laparoscopic cholecystectomy was attempted in 25 operative patients but required conversion to an open approach in 8 cases (32%). In another 4 cases, planned open cholecystectomy was performed. Major postoperative complications were limited to 2 patients with postoperative common bile duct obstruction requiring endoscopic retrograde cholangiopancreatography, 1 patient requiring a return to the operating room for hemoperitoneum, and 2 patients with bile leak from the cystic duct stump.Conclusions:In high-risk patients receiving cholecystostomy tubes for acute cholecystitis, only about one third will undergo surgical cholecystectomy. Laparoscopic cholecystectomy performed in this circumstance has a higher rate of conversion to open surgery and higher hepatobiliary morbidity rate.     

Congenital aortic and truncal valve reconstruction using the Ozaki technique: Short-term clinical results

ObjectivesAortic valve reconstruction (AVRec) with neocuspidization or the Ozaki procedure with complete cusp replacement for aortic valve disease has excellent mid-term results in adults. Limited results of AVRec in pediatric patients have been reported. We report our early outcomes of the Ozaki procedure for congenital aortic and truncal valve disease.MethodsA retrospective analysis was performed on all 57 patients with congenital aortic and truncal valve disease who had a 3-leaflet Ozaki procedure at a single institution from August 2015 to February 2019. Outcome measures included mortality, surgical or catheter-based reinterventions, and echocardiographic measurements.ResultsTwenty-four patients had aortic regurgitation (AR), 6 had aortic stenosis (AS), and 27 patients had AS/AR. Two patients had quadricuspid valves, 26 had tricuspid, 20 had bicuspid, and 9 had unicusp aortic valves. Four patients had truncus arteriosus. Thirty-four patients had previous aortic valve repairs and 5 had replacements. Preoperative echocardiography mean annular diameter was 20.90 ± 4.98 cm and peak gradient for patients with AS/AR was 53.62 ± 22.20 mm Hg. Autologous, Photofix, and CardioCel bovine pericardia were used in 20, 35, and 2 patients. Eight patients required aortic root enlargement and 20 had sinus enlargement. Fifty-one patients had concomitant procedures. Median intensive care unit and hospital length of stay were 1.87 and 6.38 days. There were no hospital mortalities or early conversions to valve replacement. At discharge, 98% of patients had mild or less regurgitation and peak aortic gradient was 16.9 ± 9.5 mm Hg. Two patients underwent aortic valve replacement. At median follow-up of 8.1 months, 96% and 91% of patients had less than moderate regurgitation and stenosis, respectively.ConclusionsThe AVRec procedure has acceptable short-term results and should be considered for valve reconstruction in pediatric patients with congenital aortic and truncal valve disease. Longer-term follow-up is necessary to determine the optimal patch material and late valve function and continued annular growth.     

Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement

BackgroundLaparoscopic sleeve gastrectomy (LSG) is an increasingly popular bariatric procedure. However, after LSG, leaks may occur that are difficult to treat and that can persist for months. Treatment is controversial and ranges from stent placement to total gastrectomy. We propose an alternative laparoscopic treatment. The aims of our study were to report on the incidence of chronic fistulas after LSG and the outcome of Roux-limb placement on these defects. The setting was a major teaching hospital in Belgium.MethodsFrom January 1, 2002, to December 31, 2011, we performed LSG as a primary weight loss operation (PLSG) in 728 patients and as a corrective operation (CLSG) in 84 patients. A retrospective chart and database review was conducted. When a chronic leak persisted beyond 4 months, we performed a laparoscopic Roux-limb placement on the defect.ResultsLeaks occurred in 26 patients (3.6%) after PLSG and in 6 (7.1%) after CLSG. A leak persisted beyond 4 months in 7 patients (26.9%) after PLSG and in 2 patients (33.3%) after CLSG. Two patients with a chronic fistula after PLSG were referred to our hospital. In 11 patients, a Roux limb was laparoscopically sutured to the defect. The mean time for a chronic fistula to heal after Roux-limb placement was 12.5±10.2 days, and the mean length of hospital stay was 19.6± 14.2.ConclusionProximal leaks after LSG are relatively rare. However, a significant number become chronic. Laparoscopic placement of a Roux-limb on the defect is a safe treatment with an eventual succes rate of 100%.     

Control of aerostasis in pulmonary metastasectomy by precision resection. Standard technique versus fibrin glue modification

The control of aerostasis after performing non-anatomical pulmonary resections constitutes a serious problem. The presence of an air leak in the postoperative period requires a prolonged thoracic drainage and consequently a longer hospital stay. The aim of our study was to evaluate the usefulness of fibrin glue and its effectiveness in the prevention of air leaks. At the Department of Thoracic Surgery of the National Cancer Institute of Milan, we conducted a case-control study in 90 patients submitted to metastasectomy for secondary lung cancer, removing multiple small nodules < or = 1.5 cm using the precision resection technique. We divided the patients into two groups, both of 45 subjects: group 1 treated with fibrin glue and group 2 submitted to cauterization of the pulmonary parenchyma. The patient characteristics were well matched for age, type of approach and operation, number of resections performed and type of pathology. The assessment parameters investigated were the duration of the air leak, expected complications, drainage time and length of hospital stay. In group 1 we performed fewer than 5 precision resections in 21 cases, from 5 to 10 in 16, and more than 10 in 8. In group 2 we executed fewer than precision resections in 21 cases, from 5 to 10 in 17, and more than 10 in 7. In group 1 the duration of the air leak was 2.93 +/- 1.91 days as against 6.95 +/- 7.01 days in group 2 (p = 0.000). In group 1 we had one complication (2%) (a long-term air leak lasting > 10 days), while in group 2 we had a long-term air leak in 11 cases (24%) (p = 0.000). Mean thoracic drainage time was 4.22 +/- 1.43 days in group 1, and 8.13 +/- 7.37 in group 2 (p = 0.000). The mean postoperative hospital stay was 6.22 +/- 1.43 days in group 1 compared to 10.13 +/- 7.37 days in group 2 (p = 0.000). In the group of patients treated with fibrin glue we obtained a significant reduction in drainage time, complications and postoperative hospital stay. The results of our experience show that the use of fibrin glue in non-anatomical resections with a high risk of developing air leakage is effective in reducing the expected complications, with a favourable impact also on the quality of life of patients with metasases.     

Initial chest tube management after pulmonary resection

Tube thoracostomy management with suction or water seal after anatomical pulmonary resection remains somewhat controversial. Initial chest tube management may influence the duration of pleural fluid drainage, duration of tube thoracostomy, and/or hospital length of stay following pulmonary resection. We hypothesized that initial chest tube management with water seal decreases time for chest tube removal and decreases time of hospital stay. A retrospective chart review was performed on 109 consecutive patients who underwent lobectomy or segmentectomy in Western Pennsylvania Hospital between December 1999 and December 2003. Comparison was made between chest tube management of water seal or suction in patients with and without air leak. Of the 109 patients, 78 (72%) had no air leak at the completion of surgery, and 31 (28%) had air leak. In the group without air leak (n = 78), water seal was used in 32 (41%) patients and suction in 46 (59%). In patients placed to water seal initially after surgery (n = 32), removal of chest tubes was on postoperative day (POD) 3.19 +/- 0.24 and hospital discharge was on POD 5.13 +/- 0.61. In patients placed to suction initially (n = 46), chest tubes were removed on POD 4.52 +/- 0.40. Hospital discharge was on POD 6.74 +/- 0.5. Both duration of chest tube (P < 0.007) and length of hospital stay (P < 0.04) were significantly lower in the water seal group. In the air leak group (n = 31), 7 (23%) patients were managed with water seal and 24 (77%) patients with suction. Both duration of chest tube (P = 0.001) and length of hospital stay (P < 0.05) were significantly lower in the water seal group. In patients without air leak, chest tubes should be managed with water seal following anatomical pulmonary resection, resulting in significantly shorter chest tube duration and hospital length of stay.     

Intraoperative identification and effective "blood patch" prevention of persistent air leak in lung resections

Persistent air leak (PAL) is the most common complication after lung resection, requiring additional treatments and hospital stay. Intraoperative prevention of PAL is usually left to the surgeon's subjective judgement, with inconsistent results. The aim of the study was to establish systematic, reproducible quantification of air leaks at thoracotomy in order to identify those which are potentially persistent, to be preventively treated by intraoperative "blood patch" pneumo-stasis. In a consecutive series of 570 lung resections, parenchymal suture air tightness was tested intraoperatively at end-inspiratory pressure intervals from 15 to 35 cm H2O. Air leaks at 15 cm H2O (n=40) were considered too critical, while air escape beyond 30 cm H2O (n=437) was deemed quickly self-sealing postoperatively; these conditions were managed by further surgery and standard chest tubes only, respectively. Air leaks between 16 and 30 cm H20 (n=93) were assumed to be the main source of postoperative PAL and were preventively treated with 50 cc of blood left in the cavity for 3 hours after closing the thoracotomy. Chest tubes were set up so as to avoid tension pneumothorax or occult bleeding. No early or late major complications were related to the intraoperative "blood patch" procedure. The cumulative incidence of PAL was 1.4%, most of which (6/8) belonging to the group leaking air in the 16-30 cm H2O pressure interval. In contrast, the PAL rate in the 437 patients reputed to be at low risk was 0.2%. The overall mean hospital stay was 7.2 days, the mean duration of chest tube duration 3.5 days, and the complication rate 15%. According to our retrospective data, air leaks occurring between 16 and 30 cm H2O of pressure in the intubated lung were identified as carrying the highest risk of becoming persistent postoperatively; intraoperative "blood patch" pneumo-stasis is a convenient and successful preventive method to minimize PAL occurrence in this group of patients.     

Is Acrylate Co-monomer (Glubran-2) Useful in the Prevention of Prolonged Air Leaks After Pulmonary Lobectomy?

Many synthetic materials are being used in order to reduce the frequency of prolonged air leak (PAL) in thoracic surgical practice. This study presents our experience with the topical application of acrylate co-monomer (Glubran-2) as a synthetic tissue adhesive in an attempt to decrease troublesome postoperative air leaks in patients undergoing resection for non-small cell lung carcinoma. Of the 112 patients who had undergone resection for lung carcinoma, 69 patients having lobectomy or bilobectomy were included in this study. The application group (group A) consisted of 33 patients where a synthetic tissue adhesive (Glubran-2) was used and compared with the control group (group C, n = 36) retrospectively. There was no difference between the groups regarding demographic details and operative variables. Both groups were compared in view to PAL, chest tube duration, in-hospital stay and hospital costs. There was no significant difference between group A (n = 11, 33 %) and group C (n = 6, 17 %) for the development of PAL (P = 0.11). Hospital stay was 16.1 ± 6.7 days in group A and 15.3 ± 5.8 days in group C (P = 0.66). The surgical cost was significantly higher in group A (€806 ± 127) than the group C (€624 ± 94) (P < 0.001). There was no significant difference between the groups regarding overall hospital costs (P = 0.41). In this study, the use of Glubran-2 following lung resection for non-small cell lung carcinoma did not decrease the incidence of PAL. Neither did it have a favorable effect concerning in-hospital stay nor did it decrease overall hospital costs while increasing surgical costs as expected.     

Endobronchial valve treatment of persistent alveolopleural fistulae in a patient with cystic fibrosis and empyema

Persistent air leak (PAL) is a common problem after secondary pneumothorax due to cystic fibrosis (CF). These leaks, caused by either bronchopleural or alveolopleural fistula, are associated with higher morbidity and mortality [1]. Air leaks are traditionally treated with chronic chest tube drainage, chemical pleurodesis, or autologous blood patching in non-surgical candidates [1]. However, these strategies can increase infectious risk or pleural scarring, which are associated with poorer lung transplant surgical outcomes. Endobronchial valve (EBV) placement, while FDA-approved for use in both some surgical PALs and bronchoscopic volume reduction therapy, is one alternative option, but it could theoretically increase the risk of infection, especially in CF patients. Here, we report the case of a CF patient under evaluation for lung transplant who received EBVs for PAL after bilateral secondary spontaneous pneumothoraces.     

Improving postoperative pain management in subpectoral tissue expander implant reconstruction of the breast using an elastomeric pump

IntroductionPostoperative pain after breast surgery is one of the major factors contributing to delay in mobilisation and prolonged hospital stay. A retrospective analysis was performed of patients undergoing skin sparing mastectomy and insertion of a subpectoral implant. The aim was to determine whether the use of an elastomeric local anaesthetic pump improved pain control and length of stay.MethodsTwenty-five consecutive patients undergoing the above procedure were sited with an elastomeric local anaesthetic infusion pump intraoperatively, in addition to standard regular and pro re nata analgesia. The control group comprised 25 patients undergoing the same procedure in the same year who received standard analgesia alone. Visual analogue scale scores were recorded for the duration of inpatient stay, as was any further analgesic requirement.ResultsThe median age was 51 years (range: 26–75 years) in the intervention group and 50 years (range: 28–70 years) in the control group. The mean visual analogue scale score was 0.28 (standard deviation [SD]: 0.61) at 24 hours for the intervention group and 1.84 (SD: 0.37) for the control group (p<0.0001). The mean length of stay was 1.8 days (SD: 0.71 days) for the intervention group and 2.28 days (SD: 0.94 days) for the control group (p=0.15). There were no complications involving catheter placement, leakage or toxicity relating to use of the local anaesthetic.ConclusionsThere was significantly reduced pain with the use of the local anaesthetic infusion pump. The elastomeric pump is a step towards enhanced patient recovery after breast surgery in the case of skin sparing mastectomy and subpectoral tissue expander reconstruction.     

Pneumoperitoneum after concomitant resection of the right middle and lower lobes (bilobectomy)

BACKGROUND: Removal of the right middle and lower lobes often leaves a pleural space problem that can cause prolonged air leaks. METHODS: A single surgeon prospectively randomized 16 patients who underwent bilobectomy. Eight patients had 1200 mL of air injected under the right hemidiaphragm after bilobectomy and 8 did not. The air was injected through a small transdiaphragmatic opening made in the right hemidiaphragm at the time of pulmonary resection. RESULTS: The age of the patients, preoperative pulmonary function, preoperative comorbidities, indications for surgery, and final pathology were not significantly different between the two groups. On postoperative day #1, a pneumothorax was present in 1 patient (13%) in the pneumoperitoneum group (P group) and in 4 patients (50%) in the nonpneumoperitoneum group (N-P group). On postoperative day 1, an air leak was present in 1 patient (13%) in the P group and 5 patients (63%) in the N-P group (p < 0.001). By the third postoperative day, no patient in the P group had an air leak; however, a leak was present in 4 patients (50%) in the N-P group (p < 0.001). Median hospital stay in the P group was 4 days (range, 3 to 6 days), compared with 6 days (range, 4 to 8 days) in the N-P group (p < 0.001). Three patients in the N-P group were sent home with a Heimlich valve. There was no operative mortality and no complications from the pneumoperitoneum. CONCLUSIONS: We conclude that pneumoperitoneum after bilobectomy is safe and easy to do. It decreases the incidence of air leaks and of pneumothoraces and shortens hospital stay without increasing morbidity. We recommend pneumoperitoneum after bilobectomy at the time of thoracotomy, especially if there are residual small air leaks that cannot be sealed before chest closure.