Ann Thorac Surg 1999;67:575-577
© 1999 The Society of Thoracic Surgeons
How To Do It
Ablation of persistent air leaks after thoracic procedures with fibrin sealant
Patricia A. Thistlethwaite, MD, PhDa,
James D. Luketich, MDb,
Peter F. Ferson, MDb,
Robert J. Keenan, MDb,
Stuart W. Jamieson, MBa
a Division of Cardiothoracic Surgery, University of California, San Diego, San Diego, California, USA
b Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Accepted for publication July 26, 1998.
Address reprint requests to Dr Thistlethwaite, Division of Cardiothoracic Surgery, 200 W Arbor Dr, University of California, San Diego, San Diego, CA 92103-8892
 |
Abstract
|
|---|
Prolonged air leak after thoracic procedures was successfully treated in 11 of 12 patients under local anesthesia using video thoracoscopic instillation of fibrin sealant over the site of the leak. No related complications occurred. This method should be considered an effective option for the treatment of persistent pulmonary air leaks.
|
Introduction
|
|---|
Prolonged air leak after thoracic operations is a complication associated with increased morbidity and hospitalization stay. In most cases, air leaks from the pulmonary parenchyma close with thoracostomy tube suction. Certain patients, however, are prone to air leaks of longer duration and volume, including those with severe emphysema or fibrosis, incomplete fissure, or numerous adhesions requiring lysis at the time of operation [1–3]. Advances such as pericardial or Teflon (L. R. Bard, Tempe, AZ) felt buttressing of suture lines and laser ablation have contributed to the decreased incidence of prolonged air leak but not eradicated this complication [4].
We have developed a new technique of direct fibrin sealant injection under local anesthesia to obliterate air leaks. This procedure was done with thoracoscopic visualization of the air leak site. Using this method in 12 patients with persistent air leaks, we achieved complete lung expansion and ablation of the leak within 24 hours of the procedure in all but 1 patient, with no morbidity.
|
Technique
|
|---|
From April 1996 to January 1997, 12 patients at our institutions developed persistent air leaks (> 10 days) after thoracic operations and procedures. In all patients, conventional methods of obliterating the leak were tried, including increasing, decreasing, or stopping thoracostomy tube suction and repositioning the chest tube. In all patients, pneumothoraces were observed at the time of fibrin seglant installation (Fig 1 ).
View larger version (93K):
[in this window]
[in a new window]
|
Fig 1. (A) Computed tomogram of the chest demonstrating a persistent pneumothorax after lung reduction operation. Note chest tube (arrowhead) present within cavity. (B) Postoperative computed tomogram of the chest on the same patient performed 2 months after fibrin glue instillation.
|
|
The patients were brought to the operating room and placed in a modified supine position with the involved side slightly elevated under a roll (shoulder 30 degrees from operating table). A 2-cm incision was made over the area of loculated pneumothorax (usually in the anterior apical region of the third to fifth rib), and a thoracoscope was inserted (Fig 2 ). The pleural cavity was irrigated with warm saline. Sites of parenchymal air leak were identified by bubbling saline over the surface of the lung. A double-lumen central venous pressure catheter was cut 3 cm from the tip so that both luminal openings were flush with the end of the catheter. This was done to facilitate site mixing of cryoprecipitate and thrombin at the catheter tip. With the thoracoscope providing direct visualization, the double-lumen central venous pressure catheter was inserted in the pleural space over a guidewire by Seldinger technique. With the guidewire providing stiffness, the catheter end was pointed 1 cm directly above the air leak, and the guidewire removed.
Twenty milliliters of cryoprecipitate and 20 mL of 1,000 U/mL thrombin were drawn into separate syringes that were connected to the ports of the infusion catheter. Under direct visualization, the fibrin sealant mixture was instilled over the site of air leak. This formed a fibrin gel over the lung surface at the site of the leak. In all patients, the air leak bubbling stopped or was greatly diminished. No local decortication of the visceral pleura was performed. The thoracoscope was removed, and a single 28F chest tube was inserted in the port site and directed to the apex. The patient’s thoracostomy tube was placed on 20-cm suction for 24 hours. When the air leak resolved, the tube was removed and the patient discharged from the hospital.
|
Results
|
|---|
Fibrin sealant ablation of pleural air leaks was performed in 12 patients. Seven had undergone previous thoracoscopic or open lung volume reduction operation for severe emphysema, 3 had undergone lobectomy or bilobectomy for carcinoma, and 2 patients had undergone radiologic insertion of a chest tube for drainage of a loculated effusion (Table 1 ). The average duration of preoperative air leak was 15.7 days. Eleven of 12 air leaks were obliterated within 24 hours of instillation of the fibrin sealant. No patients required intubation nor had respiratory distress during the procedure. This may have been due to the fact that our patients had partially loculated pneumonthoraces with some symphysis of lung and chest wall to prevent complete spontaneous deflation of the operative lung.
All 8 patients who had undergone lung volume reduction operation had follow-up chest computed tomographic scans performed within 3 months of their discharge from the hospital. These scans demonstrated complete reexpansion of the lung with no residual pneumothorax. The 4 patients who had undergone either pulmonary resection or drainage of effusion had follow-up chest roentgenograms demonstrating no residual space problems before discharge from the hospital.
No late empyemas or effusions were observed with follow-up ranging from 2 to 21 months (mean, 10.5 months). The single patient whose air leak was not successfully ablated was one in which we could not definitively identify the site of leak on the surface of the lung.
|
Comment
|
|---|
A persistent air leak after a thoracic procedure usually ceases if pleural symphysis is achieved. Prolonged tube thoracostomy drainage with suction, Heimlich valves, chemical or blood pleurodesis, and topical polyglycolic acid sheets have all been used to eradicate persistent air leaks [5, 6]. The goal of management of this problem is to obliterate pulmonary air leak and pneumothorax, and to reduce the chance of empyema or long-term bronchopleural fistula. This translates into decreased patient morbidity, shorter hospital stays without the need for frequent outpatient visits, and lower hospital costs. Using the method described, we estimate the cost of intervention at our institution to be $658, comprised of the cost of fibrin glue at $58, with the cost of the operative time (mean operating room time, 25 minutes at $24.00/minute) at $600.
The advantages of this approach is that it is done under local anesthesia, in a short procedure (usually <30 minutes), with direct visualization and correction of the air leak. In our limited experience, we believe the best success can be achieved when the fibrin sealant is instilled directly onto the site of leak. Indeed, in our 1 patient in whom the technique failed, we were unable to identify the location of the air leak. Pleural symphysis was successfully achieved with no side effects in this otherwise difficult subset of patients to manage.
|
References
|
|---|
-
Matthew T.L., Spotnitz W.D., Kron I.L., et al. Four years’ experience with fibrin sealant in thoracic and cardiovascular surgery. Ann Thorac Surg 1990;50:40-44.[Abstract]
-
Wong K., Goldstraw P. Effect of fibrin glue in the reduction of postthoracotomy alveolar air leak. Ann Thorac Surg 1997;64:979-981.[Abstract/Free Full Text]
-
Mouritzen C., Dromer M., Keinecke H.O. The effect of fibrin glueing to seal bronchial and alveolar leakages after pulmonary resections and decortications. Eur J Cardiothorac Surg 1993;7:75-80.[Abstract]
-
McKenna R.J., Brenner M., Gelb A.F., et al. A randomized, prospective trial of stapled lung reduction versus laser bullectomy for diffusion emphysema. J Thorac Cardiovasc Surg 1996;111:317-322.[Abstract/Free Full Text]
-
Mukaida T., Andou A., Date H., et al. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg 1998;65:924-926.[Abstract/Free Full Text]
-
Yokomise H., Satoh K., Ohno N., Tamura K. Autoblood plus OK432 pleurodesis with open drainage for persistent air leak after lobectomy. Ann Thorac Surg 1998;65:563-565.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
P. Tansley, F. Al-Mulhim, E. Lim, G. Ladas, and P. Goldstraw
A prospective, randomized, controlled trial of the effectiveness of BioGlue in treating alveolar air leaks
J. Thorac. Cardiovasc. Surg.,
July 1, 2006;
132(1):
105 - 112.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. Tacconi, E. Pompeo, and T. C. Mineo
Late-Onset Occult Pneumothorax After Lung Volume-Reduction Surgery
Ann. Thorac. Surg.,
December 1, 2005;
80(6):
2008 - 2012.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Lang-Lazdunski and A. S. Coonar
A prospective study of autologous 'blood patch' pleurodesis for persistent air leak after pulmonary resection
Eur. J. Cardiothorac. Surg.,
November 1, 2004;
26(5):
897 - 900.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Fabian, J. A. Federico, and R. B. Ponn
Fibrin glue in pulmonary resection: a prospective, randomized, blinded study
Ann. Thorac. Surg.,
May 1, 2003;
75(5):
1587 - 1592.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
