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Ann Thorac Surg 2000;70:942-946
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

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

^a Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
^b Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA

Address correspondence to Dr Cerfolio, Department of Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd, THT 712, Birmingham, AL 35294
e-mail: robert.cerfolio{at}ccc.uab.edu

Presented at the Thirty-sixth Annual Meeting of the Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 27–Feb 2, 2000.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
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.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
In 1924 Reich [1] first described the use of pneumoperitoneum for patients with emphysema. He observed an increase in respiratory volume and decrease in dyspnea when patients underwent diaphragmatic elevation with air. Since then others have found similar results. In 1950, Carter [2] placed up to 1000 mL of helium and air under the diaphragm of 22 patients and found improved exercise tolerance and decreased dyspnea. The air was introduced through a percutaneous catheter placed intraabdominally. However, because patients had to be continuously "refilled" and often complained of pain with insufflation, the concept was abandoned. The idea has been recently resurrected to treat prolonged air leaks, space problems, or both after pulmonary resection [3–5].

We hypothesized that it might be easier to place air under the diaphragm at the time of thoracotomy through a small opening in the diaphragm. We choose to study patients who underwent bilobectomy (a procedure known to be associated with space problems and air leaks) to see if we could reduce the incidence of both of these complications. We also theorized that by performing the pneumoperitoneum at the time of thoracotomy, we could avoid both the morbidity associated with percutaneously placed abdominal catheters as well as perhaps the pain that accompanies insufflation of air in a nonanesthetized patient.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The University of Alabama at Birmingham approved this trial for randomization in December 1996. Between January 1997 and December 1999 all patients with either primary bronchogenic carcinoma or metastatic lesions who could potentially undergo resection of both the right middle and right lower lobes were preoperatively randomized. Patients who underwent right upper and right middle lobectomy were not included. The preoperative decision to randomize a patient was based on the location and size of the lung mass and the patient’s pulmonary function. One group was randomized to receive a pneumoperitoneum and the other group did not. All attempts were made to save as much pulmonary parenchyma as possible and to avoid bilobectomy if possible. If bilobectomy was necessary to completely resect all disease, the code to the randomization was broken in the operating room just before closure and after all air leaks were controlled as best as possible and the patient was entered into one group or the other. Of the 181 patients preoperatively randomized, only 16 patients were included in the trial, all of whom had concomitant right middle and right lower lobectomy.

Standard preoperative, intraoperative, and postoperative techniques were followed. All attempts were made to repair residual pulmonary parenchymal air leaks before chest closure using 4-0 polypropylene sutures (Prolene, Ethicon, Somerville, NJ), as we have described previously [6]. All fissure repairs that were incomplete were completed with staples. A single general thoracic surgeon (RJC) performed all operations.

Pneumoperitoneum was accomplished after the right middle and right lower lobes were passed off the operating room table. Two separate 1-0 polypropylene stitches were placed about 2 cm apart on either side of the dome of the right hemidiaphragm. This area is easily accessible when the chest is entered over the top of the fifth or sixth rib. The stitches were retracted cephalad. A small 1-cm opening was made in between the stitches with a knife. The dome of the liver and the free peritoneal cavity were visualized. The tip of an 18F red rubber catheter was placed through this small opening, and a 60-mL catheter-tipped syringe was attached to the other end. The syringe was sequentially filled with 60 mL of room air, which was then injected under the diaphragm. This was repeated 20 times. In this manner 1,200 mL of air was placed under the right hemidiaphragm. The progressive elevation of the diaphragm was evident with each injection. The catheter was removed and the polypropylene stitches were tied together. A 1-0 polypropylene stitch was then placed to secure the diaphragmatic closure. All patients had a 28F right-angle chest tube placed along the diaphragm and a 28F straight chest tube placed in the anterior apex.

All patients were extubated in the operating room and monitored on the floor. Air leaks were classified daily as forced expiratory, expiratory, inspiratory, or continuous, utilizing the classification system for air leaks that we have developed and described previously [6, 7]. We also measured leaks using the air leak meter that is part of the pleural vac system (Deknatel, Boston USA). The air leak meter quantifies air leaks from 1 (smallest) to 7 (largest). Thus all air leaks were classified both qualitatively and quantitatively. Chest roentgenograms were performed daily for each patient. Chest tubes were kept on 20 cm of suction on the day of surgery and converted to water seal on the morning of postoperative day 1. If the patient had an enlarging pneumothorax on water seal, the tubes were placed on -10 cm of suction.

Operative mortality was defined as any death that occurred during hospitalization or within 30 days of the operation. Late mortality was defined as any subsequent death. Follow-up data were obtained from clinic visits, by telephone interview, or from correspondence from other health care providers. All data are reported as medians and range. Univariant comparisons were performed using ², Fisher’s exact test and Student’s t test and multivariable analysis.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The median age of the 8 patients (5 men and 3 women) in the group who received a pneumoperitoneum (P group) was 63 years (range, 57 to 78 years). The median age of the 8 patients (6 men and 2 women) in the nonpneumoperitoneum group (N-P group) was 65 years (range, 55 to 74 years). Preexisting conditions were present in 3 patients in the P group: 1 patient had hypertension and diabetes. In addition, 1 patient had a history of both congestive heart failure and atrial fibrillation. Two patients in the N-P group that had preexisting conditions: 1 patient had a history of hypertension and another had a history of a myocardial infarction. Although the numbers are small, there was no statistically significant difference between these two groups in age (p = 0.80), gender (p = 0.86), or in preexisting conditions (p = 1.0).

Pulmonary function testing and arterial blood gas determinations were performed in all 16 patients before resection. Selected values are shown in Table 1. Differences between the groups were not statistically significant. All patients underwent right middle and right lower lobectomy without intraoperative complications. All had negative bronchial margins, and all had complete thoracic lymphadenectomy performed if they had primary bronchogenic carcinoma. The final pathology was primary bronchogenic carcinoma in 7 patients in the P group and in 7 patients in the N-P group. In the P group, 1 patient had a 9-cm metastatic cervical carcinoma mass removed that could not be wedge excised and was only removable by bilobectomy. In the N-P group, 1 patient had a metastatic sarcoma that was resected by bilobectomy, as well. There was no statistically significant difference in pathology between the two groups (p = 1.0).

There was no operative mortality. Morbidity occurred in 5 patients, 1 in the P group and 4 in the N-P group. The patient in the P group had atrial fibrillation. In the N-P group 1 patient had urinary retention and 3 had prolonged air leaks. The median follow-up time was 14 months (range, 7 to 26 months). No pneumothoraces occurred in either group.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The idea of placing air under the diaphragm is not new. It became apparent to us that it was an effective way to treat prolonged air leaks in the patient with a basilar pneumothorax. Initially, we treated 2 patients transferred to our institution who had had pulmonary resections, residual basilar pneumothoraces, and prolonged air leaks, percutaneously placing a small peritoneal catheter at the bedside with local anesthesia, insufflating air into the free peritoneal cavity, and placing the patient on his or her side with the affected side up. This technique successfully stopped the air leak in both patients.

After this experience we postulated that a subset of patients might benefit from the prophylactic creation of a pneumoperitoneum at the time of thoracotomy. Although placement of a diagnostic peritoneal catheter is relatively straightforward in most patients, there is a small risk that is increased in those who have had previous abdominal surgery. The catheter placement itself can also be painful. Moreover, the air may never get to the desired position necessary to elevate the hemidiaphragm (just under it) if adhesions have compartmentalized the peritoneal cavity. Because of these disadvantages and because the hemidiaphragm is easily accessible at time of thoracotomy, we developed the idea of performing pneumoperitoneum at the time of thoracotomy.

We first considered performing this randomized trial on patients who underwent either right or left lower lobectomies. However, few of these patients experience air leaks, basilar pneumothoraces, or both, and we therefore believed it might have been difficult to show a statistically significant difference in that patient population. Therefore we choose only patients undergoing concomitant right lower and right middle lobectomy. Because that procedure is so rare in our experience, it took several years to recruit enough patients. During this time period this procedure represented only 0.89% of the total operative experience of the sole general thoracic surgeon who performed the operations in this series (419 operations in 1997, 573 operations in 1998, and 801 operations in 1999). Most patients were able to undergo either right middle lobectomy with a segmentectomy or wedge resection of the right lower lobe or a right lower lobectomy with a segment or wedge of the right middle lobe. Patients with benign disease, such as destroyed lung from tuberculosis, were also excluded from this trial in an attempt to make the groups as comparable as possible.

We found a significant difference between the groups, evenly matched demographically at baseline, in the length of hospital stay and in the prevalence of air leaks and pneumothoraces. The results favored the pneumoperitoneum group. Because of the small numbers, multivariable analysis is not meaningful, but it might be expected that the higher prevalence of air leaks and hospital stay are probably secondary to the higher prevalence of pneumothoraces. Review of Tables 2 and 3 shows that the patients who had air leaks were those who had a pneumothorax. When the pneumothorax resolved, as seen in the patient labeled 1 in Table 2, the air leak often resolved as well.

A number of processes can help reduce space after pulmonary resection or volume loss, including mediastinal shift, intercostal narrowing, diaphragmatic elevation, and fluid accumulation. We only studied one of these mechanisms. We believe pneumoperitoneum works by achieving visceral and parietal pleural apposition. The air under the diaphragm temporarily elevates the diaphragm. This probably allows the visceral pleura of the lung to adhere to the parietal pleura of the diaphragm. We have also observed that the air under the diaphragm is slowly absorbed, usually over the 7 to 14 days following insufflation. The diaphragm then slowly descends, bringing with it the remaining lung that is now stuck. This process helps eliminate the residual space. Other techniques that help eliminate pleural space problems include pleural tents and muscle flaps. We reserve pleural tents to palliate upper pleural space problems that are often present after upper lobectomies with concomitant lower lobe superior segmentectomies or after lung volume reduction surgery. We usually employ intercostal and serratus anterior muscle flaps for space problems associated with an infected upper pleural space. Elimination of a residual pleural space after pulmonary resection, in and of itself, is probably not that important, since almost all fill with noninfected fluid and are inconsequential. But in the patient with an air leak, we believe it is critical to seal the leak. This study also supports the findings of our previous studies (publication pending) that air leaks classified as expiratory 3 or greater will probably not seal within the typical 3- to 4-day hospital stay. Moreover, we have shown that suction makes air leaks larger. Therefore if for patients with a persistent space with a concomitant air leak, we favor little to no suction, since most spaces are benign but air leaks are associated with increased hospital stays, prolonged necessity for chest tube placement, or both.

We also observed differences in the degree of diaphragmatic elevation, despite having placed the same amount of air and removed the same amount of lung in each patient. Diaphragmatic elevation is probably influenced by many factors, some of which may be compliance of the remaining right upper lobe, compliance of the hemidiaphragm, compliance of the mediastinum and left lung, and the actual distribution of air after insufflation.

Because of our findings in this prospective randomized trial, we now prefer to use pneumoperitoneum after lower lobectomy when small air leaks occur in the remaining lung that we cannot control in the operating room. We also use pneumoperitoneum routinely in the patient with poor pulmonary function after pulmonary resection. Patients who undergo lung volume reduction surgery may benefit from prophylactic pneumoperitoneum from a physiologic standpoint as well. We currently use it as a standard part of our armamentarium in these patients as well. Randomized prospective trials are needed to further assess these issues.

Another idea that we and others [3] have had is to place a temporary catheter under the diaphragm and bring it out through the skin. One could then insufflate air under the diaphragm, each day postoperatively, to theoretically help the patient with poor pulmonary function recover after pulmonary resection. For simplicity sake we did not do this in this trail but it is something to consider, especially in the patient with flattened diaphragms, a low postoperative predicted FEV₁%, or both who undergoes pulmonary resection. An advantage to this technique may be the ability to raise the diaphragm to a desired level and to continue to do so in the postoperative period. This is something we could not accomplish with the intraoperative technique used in this trial.

In conclusion, pneumoperitoneum after removal of the right upper and middle lobes is safe and easy to perform. It can be done as a transthoracic procedure, through a small opening in the right (or probably in the left) hemidiaphragm before closure of the chest. The procedure carries no morbidity and decreases the incidence of air leaks and pneumothoraces. Pneumoperitoneum thus has the potential to shorten hospital stay or decrease the need for a Heimlich valve. We recommend performing pneumoperitoneum after bilobectomy and believe it is easier and safer to accomplish transthoracically at time of pulmonary resection than postoperatively by way of the abdomen. It is especially useful if the patient has small parenchymal air leaks that cannot be closed at the time of resection. Although we favor the use of pneumoperitoneum in other pulmonary surgical settings, further investigation is needed to evaluate its benefit in patients with poor pulmonary function who undergo pulmonary resection or in patients who undergo lung volume reduction surgery.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We thank Ms Jeannette Whitehead for her help in the preparation of this manuscript.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

1. Reich L. Der Einfluss des Pneumoperitoneums auf das Lungen-emphysem. Wien Arch Finn Med 1924;8:245-260.
2. Carter M.G., Gaensler E.A., Kyllonen A. Pneumoperitoneum in the treatment of pulmonary emphysema. N Engl J Med 1950;243:549-558.
3. Handy J.R., Judson M.A., Zeliner J.L. Pneumoperitoneum to treat air leaks and spaces after lung volume reduction operations. Ann Thorac Surg 1997;64:1803-1805.[Abstract/Free Full Text]
4. Yusen R.D., Littenberg B. Technology assessment and pneumoperitoneum therapy for air leaks and pleural spaces. Ann Thorac Surg 1997;64:1583-1584.[Free Full Text]
5. Carbognani P., Spaggiari L., Solit P., Rusca M. Pneumoperitoneum for prolonged air leaks after lower lobectomies. Ann Thorac Surg 1998;66:600-612.[Free Full Text]
6. Cerfolio R.J., Tummala R.P., Holman W.L., et al. A prospective algorithm for the management of air leaks after pulmonary resection. Ann Thorac Surg 1998;66:1726-1731.[Abstract/Free Full Text]
7. Cerfolio, RJ, Holman WL, et al. A prospective randomized trial comparing chest tubes on wall suction versus water seal for air leaks after pulmonary resection. Presented at The American Association for Thoracic Surgeons, April 1999, publication pending.
8. Kirschner P.A. "Provocative clamping" and removal of chest tubes despite persistent air leaks [Letter]. Ann Thorac Surg 1992;53:740-741.[Free Full Text]

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