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Ann Thorac Surg 2000;69:1722-1724
© 2000 The Society of Thoracic Surgeons

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Original articles: General thoracic

Pleural tent after upper lobectomy: a prospective randomized study

^a Department of Thoracic Surgery, University of Ancona, Ancona, Italy

Address reprint requests to Dr Brunelli, Via S. Margherita 23, Ancona 60129, Italy
e-mail: alexit{at}freemail.it

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. The aim of the present study was to assess the cost/efficacy of the pleural tent procedure after upper lobectomy.

Methods. A prospective randomized analysis was performed on 50 patients submitted to upper lobectomy and divided into two groups: group 1 (25 patients) with pleural tent; group 2 (25 patients) without pleural tent.

Results. The univariate comparison between the two groups did not show any significant difference in terms of age, gender, spirometry, smoking history, chronic obstructive pulmonary disease index, side of tumor, arterial oxygen tension, arterial carbon dioxide tension, size and location of tumor, presence of pleural adhesions, length of the stapled parenchyma, and operative time. Pleural tent significantly reduced the days of postoperative air leak (1.2 versus 5.8, p = 0.01), chest tubes (5.4 versus 10.4, p = 0.01), and hospital stay (6.9 versus 10.8, p = 0.01). Moreover, no difference was noted between the two groups in terms of pleural effusion in the first postoperative 48 hours, need of postoperative blood transfusion, and occurrence of other complications.

Conclusions. Pleural tenting after upper lobectomy is a safe and effective procedure and its routine use is warranted.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Prolonged air leak is still one of the most frequent complications after pulmonary lobectomy, particularly after upper lobectomy. The anatomic configuration of the upper lobes prevents the stapled raw surfaces of the remaining lung to get in apposition with the parietal pleura of the apex, thus leaving a persistent apical space, which, in turn, promotes a prolonged parenchymal air leak from the unsealed lung parenchyma.

The creation of an apical pleural tent at the end of an upper lobectomy has been recently advocated in a retrospective study to be successful in reducing both air leak duration and hospital stay [1].

The aim of the present study was to assess the efficacy of this procedure in a prospective randomized trial.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Fifty consecutive patients undergoing upper lobectomies from June 1998 through March 1999 at our institution were enrolled in the study after given informed consent. They were randomized in two groups: group 1, with pleural tents (25 patients); group 2, without pleural tents (25 patients). Patients undergoing concomitant chest wall resection or requiring postoperative mechanical ventilation were excluded from the study.

All lobectomies were performed by the same surgical team through a muscle-sparing thoracotomy at the fifth or fourth intercostal space. Mechanical stapling devices were used to develop incomplete fissures and to close the bronchus. After completion of the lobectomy and of the mediastinal lymph nodes dissection, a pleural tent was performed in group 1 patients according to the technique described originally by Miscall and colleagues [2] and more recently by Miller [3] and by Robinson and Preksto [1]. Briefly, the parietal pleura was mobilized starting along the upper border of the thoracotomy incision, and it was completely dissected down from the endothoracic fascia of the thoracic wall and apex. The midportion of the free pleural margin was then anchored in one place to the intercostal muscle at the chest wound with a single absorbable suture to obtain a tent configuration with the dissected parietal pleura. In all patients two 28F chest tubes were positioned anteriorly and posteriorly. In group 1 the tubes were directed under the tent. During the postoperative period the chest tubes were placed on moderate suction (-10/-20 cm H₂O) and were removed when no air leak was evident (after a 24-hour clamping trial) and when the effusion was less than 200 mL in 24 hours.

The air leak was considered prolonged if it lasted more than 7 days. Other complications occurring within 30 days after operation or over a longer period if the patient was still in the hospital were recorded.

Statistical analysis
Preoperative, operative, and postoperative variables were used for comparison between the two groups. The unpaired Student’s t test was used for numerical continuous variables, whereas the ² test was used for the categoric variables. All tests were two-tailed with a significant level of 0.05.

The following preoperative variables were considered: age, gender, forced expiratory volume in 1 second (FEV₁), forced vital capacity (FVC), forced expiratory flow at 25% to 75% (FEF_{25% to 75%}), predicted postoperative FEV₁ (ppoFEV₁), FEV₁/FVC, chronic obstructive pulmonary disease index, smoking pack-years, side of tumor, arterial oxygen tension, and arterial carbon dioxide tension.

The FEV₁, FVC, FEF_{25% to 75%}, and ppoFEV₁ were expressed as percentage of predicted for age, gender, and body weight. The ppoFEV₁ was calculated on the basis of functioning segments removed and estimated by means of computed tomographic scan and bronchoscopy findings [4].

The chronic obstructive pulmonary disease index was calculated by adding FEV₁/FVC and ppoFEV₁, according to Korst and colleagues [5].

Operative variables included tumor size, location of tumor (central/peripheral), the presence of pleural adhesions, the length of the stapled parenchyma, and total operative time.

Postoperative variables included air leak duration (days), the presence of prolonged air leak, chest tubes duration (days), pleural effusion in the first 48 hours after operation, units of postoperative blood transfusion, the presence of other complications (including respiratory failure requiring mechanical ventilation, atelectasis requiring bronchoscopy, pneumonia, pulmonary edema, adult respiratory distress syndrome, cardiac failure, arrhythmia, pulmonary embolism, myocardial infarction, metabolic complications), and total hospital stay.

A multivariable stepwise logistic regression analysis was performed using the Systat 5.2 software package (Systat, Inc, Evanston, IL). The level of entry for independent variables was chosen as 0.05 and a tolerance limit of 0.10 was selected. Two models were assessed with a level of significance for the independent variables of less than 0.05. The first model included as a dependent variable the presence of air leak (categoric variable). In the second model we chose as dependent variable the duration of air leak (continuous variable). The independent variables (predictors) for both models were the following: age, size, FEV₁, FVC, FEV₁/FVC, ppoFEV₁, FEF_{25% to 75%}, chronic obstructive pulmonary disease index, pack-years, presence of pleural tent, presence of pleural adhesions, arterial oxygen tension, and arterial carbon dioxide tension.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The univariate comparisons among patients with and without pleural tent are shown in Tables 1, 2, and 3. No significant differences were noted in terms of preoperative and operative characteristics. The comparison of postoperative variables showed a significant reduction in days of air leak (p = 0.01, t = 2.79), cases of prolonged air leak (p = 0.05, ² = 3.70), days of chest tube in place (p = 0.01, t = 3.23), and total hospital stay (p = 0.01, t = 3.11) in the tented group. Moreover, pleural tenting did not increase pleural effusion in the first 48 postoperative hours, the occurrence of other complications, nor the need for more blood transfusions.

The results of the logistic regression analyses are shown in Table 4, in which only the significant independent variables are listed. In model 1, the only significant predictor of prolonged air leak was the absence of pleural tent. In model 2, FEV₁/FVC and the pleural tent were the only significant independent variables associated with air leak duration.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Lately, this procedure gained renewed interest after lung volume reduction procedures in which an enlarged chest cavity and an emphysematous friable parenchyma anticipate persistent apical pleural space and prolonged air leak [8]. A recent retrospective unrandomized study showed that pleural tenting was effective in reducing air leak duration and total hospital stay after upper lobectomy [1].

These observations prompted us to investigate in a prospective randomized fashion this procedure to address the following issues: does pleural tent reduce the incidence of prolonged air leak, the duration of chest tubes in place, and the total hospital stay? Does it prolong operative time? Does it increase pleural effusion or postoperative bleeding? Does it determine the occurrence of other complications?

The present study showed a marked reduction in the mean duration of air leak in the pleural tented group (4.6 days less than the untented patients). Only 1 patient with pleural tent experienced a prolonged air leak (8 days), whereas in group 2, 7 of 25 patients had an air leak lasting more than 7 days. Mean chest duration was 5 days less in the tented group versus the untented patients. This simple procedure reduced the total hospital stay by 4 days, regardless of the fact that 4 patients in group 2 were discharged with a Heimlich valve in place.

Conversely, our study objectively demonstrated that the pleural tent did not lengthen operative time or increase the risk of postoperative bleeding or other complications.

The role of this procedure in preventing prolonged air leak after upper lobectomy was further shown in the results of the logistic regression analyses. In both models, the absence of pleural tenting was the most significant predictor of postoperative air leak.

Although the results generated in the present study need independent confirmation from other investigations, we regard this surgical procedure of great value in reducing the patients’ discomfort of having a chest tube in place for a long time and in cutting hospital costs. Thus, we believe the routine use of pleural tent after upper lobectomy is warranted at least in chronic obstructive pulmonary disease patients who are at higher risk of developing prolonged postoperative air leaks. We are now using it routinely for all upper lobectomies performed at our institution.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Robinson L.A., Preksto D. Pleural tenting after upper lobectomy decreases chest tube time and total hospitalization days. J Thorac Cardiovasc Surg 1998;115:319-327.[Abstract/Free Full Text]
2. Miscall L., Duffy R.W., Nolan R.B., Klopstock R. The pleural tent as a simultaneous tailoring procedure in combination with pulmonary resection. Am Rev Tuberc 1956;73:831-852.[Medline]
3. Miller J. Acute and delayed space problems following pulmonary resection. Chest Surg Clin North Am 1996;6:615-621.[Medline]
4. Brunelli A., Fianchini A. Predicted postoperative FEV₁ and complications in lung resection candidates. Chest 1997;111:1145-1146.[Free Full Text]
5. Korst R.J., Ginsberg R.J., Ailawadi M., et al. Lobectomy improves ventilatory function in selected patients with severe COPD. Ann Thorac Surg 1998;66:898-902.[Abstract/Free Full Text]
6. Hansen J.L. Parietal pleurolysis (the pleural tent) as a simultaneous space-reducing procedure in combination with pulmonary resection. Acta Chir Scand 1957;112:485-488.[Medline]
7. Bell J.W. Management of the postresection space in tuberculosis. III. Role of pre- and post-resection thoracoplasty. J Thorac Surg 1956;31:580-592.
8. Cooper J.D., Patterson G.A., Sundaresan R., et al. Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg 1996;112:1319-1330.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alessandro Brunelli Majed Al Refai Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Brunelli, A. Articles by Fianchini, A. Search for Related Content PubMed PubMed Citation Articles by Brunelli, A. Articles by Fianchini, A.