“Stripping” to Prevent Prolonged Air Leak; Is There a Future in the Past?[*]

Abstract

Background: A number of technical precautions and many synthetic or biological materials have been suggested to reduce the frequency of prolonged air leak (PAL) following lung resection. Preserving the three-dimensional properties of the remaining lung parenchyma may prevent this complication to some extent. This study presents our experience with an old technique called “stripping” for the division of incomplete fissures to preserve the original shape of the remaining lung with the hope that this will minimize PAL-related problems. Methods: 262 consecutive patients with incomplete fissures underwent lobectomy or bilobectomy. Stripping was employed for the division of incomplete fissures in Group S (Study arm; n = 148) and a cut-and-sew technique or staplers were used in Group C (Control arm; n = 114). To evaluate a possible learning curve effect with this technique, Group S was further divided into two subgroups, designated the initial experience (Group S_IE) and the late experience group (Group S_LE) and consisting of the first 1/3 (n = 50) and remaining 2/3 (n = 98) of patients, respectively. The frequency of PAL and other related morbidities were investigated. Results: Morbidity and mortality rates were comparable between Group S and C (10 % vs. 8.7 % and 2 % vs. 2.6 %; p = 0.83 and p = 0.96), as was the frequency of PAL, which occurred in 12 (8.1 %) and 13 (11.4 %) patients (p = 0.40), respectively. When each of the subgroups was compared with Group C, PAL occurred in 9 (18 %) patients in Group S_IE (p = n. s.) but only in 3 (3 %) patients in Group S_LE (p = 0.03). There was also more postoperative persistent air space in Group C, without this difference reaching statistical significance. Conclusion: This study suggests that preservation of the original shape of the remaining lung might decrease the incidence of PAL in patients with relatively healthy lung tissue. An actual favorable effect of stripping over other techniques emerges only when the technique is precisely applied, which is only possible with experience.

Key words

surgery - complications - surgical equipment (instruments - sutures - etc.) - outcomes (includes mortality - morbidity) - pathophysiology - postoperative care

1 Presented at the 17^th European Conference on General Thoracic Surgery, 31 May–3 June 2009, Krakow, Poland.

References

• 1 Rice T W, Kirby T J. Prolonged air leak.  Chest Surg Clin N Am. 1992;  2 803-811
• 2 Gómez-Caro A, Jose M, Calvo R et al. The approach of fused fissures with fissureless technique decreases the incidence of persistent air leak after lobectomy.  Eur J Cardiothorac Surg. 2007;  31 203-208
• 3 Brunelli A, Xiume F, Al Refai M, Salati M, Marasco R, Sabbatini A. Air leaks after lobectomy increase the risk of empyema but not of cardiopulmonary complications. A case-matched analysis.  Chest. 2006;  130 1150-1156
• 4 Tambiah J, Rawlins R, Robb D, Treasure T. Can tissue adhesives and glues significantly reduce the incidence and length of postoperative air leaks in patients having lung resections?.  Interact Cardiovasc Thorac Surg. 2007;  6 (4) 529-533
• 5 Churchill E D, Belsey R. Segmental pneumonectomy in bronchiectasis. The lingual segment of the left upper lobe.  Ann Surg. 1939;  109 (4) 481-499
• 6 Wain J C, Kaiser L, Johnstone D W et al. Trial of a novel synthetic sealant in preventing air leaks after lung resection.  Ann Thorac Surg. 2001;  71 (5) 1623-1628
• 7 Shields T W. Pulmonary resections.. In: Shields T W, ed. General Thoracic Surgery.. Philadelphia: Lea & Febriger; 1972: 331-350
• 8 Schipper P H, Meyers B F. Surgery for bullous disease.. In: Pearson F G, Patterson G A, Cooper J D, Deslauriers J, Rice T W, Luketich J D, Lerut A EMR, eds. Pearson's Thoracic and Oesophageal Surgery.. Philadelphia: Churchill Livingstone; 2008: 631-652
• 9 Brunelli A, Monteverde M, Borri A, Salati M, Marasco R D, Fianchini A. Predictors of prolonged air leak after pulmonary lobectomy.  Ann Thorac Surg. 2004;  77 (4) 1205-1210
• 10 Baldi S, Ruffini E, Harari S et al. Does lobectomy for lung cancer in patients with chronic obstructive pulmonary disease affect lung function? A multicenter national study.  J Thorac Cardiovasc Surg. 2005;  130 1616-1622

1 Presented at the 17^th European Conference on General Thoracic Surgery, 31 May–3 June 2009, Krakow, Poland.