INDICATIONS/CONTRAINDICATIONS

Prolonged air leaks are the most common complication after pulmonary resection and a significant source of morbidity in up to 26% of patients. This often leads to an extended time for a tube thoracostomy to remain in place as well as extended lengths of stay. Various techniques have been championed to prevent air leaks in the operating room and in managing and resolving them in the postoperative period.

PREOPERATIVE PLANNING

There are thought to be several preoperative predictors of persistent air leaks. Patient characteristics such as emphysema, the prolonged use of steroids and poor pulmonary function tests, specifically a diminished FEV/VC ratio. Other risk factors that may be less obvious include preoperative chemoradiotherapy, previous ipsilateral thoracic surgery often leading to the presence of adhesions, incomplete fissures, lung volume reduction surgery, and type of lobectomy.

SURGERY

Intraoperative Techniques

There have been various intraoperative techniques used in an attempt to decrease the incidence of air leaks. At the conclusion of surgery, the lung should be inspected for air leaks by reinflating under water. Attempted repair of air leaks or raw surfaces should be undertaken. Simple horizontal mattress sutures or running sutures buttressed by strips of pleura or “surgicel” is preferred. For those patients at higher risk, multiple mechanical stapler companies have created “buttressed” stapler lines, often with a biologic addition such as bovine pericardium. These are either applied to the stapling device or come as an intrinsic part of the stapler.

Many surgeons advocate for a “fissureless” resection where minimal dissection is done in the fissures lessening the incidence of parenchymal tears. With this technique, there is no dissection in an incomplete fissure, instead the dissection starts in the hilum with the vein being taken first followed by the artery and finally the bronchus. The fissure is divided last, completing the lobectomy.

The options for visceral pleural sealants are numerous and include both synthetic- and fibrin-based products. Often pleural sealants come with the disadvantage of poor handling, cumbersome activation techniques, poor adhesion, and degradation. A recent Cochrane review determined that sealants reduce postoperative air leaks and time to chest drain removal but this reduction may not be associated with a reduction in length of postoperative hospital stay. Typically, sealants are applied at the conclusion of the case with the lung partially inflated so air leaks can be identified. Some have advocated the use of strips of “surgicel” to create a patch with sealant.

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