Asian Cardiovasc Thorac Ann 2007;15:54-58
© 2007 Asia Publishing EXchange Ltd
Postoperative Residual Pleural Spaces: Characteristics and Natural History
Panagiotis Misthos, MD,
John Kokotsakis, MD1,
Marios Konstantinou, MD,
Ion Skottis, MD,
Achilles Lioulias, MD1
Thoracic Surgical Department, "SOTIRIA" General Hospital for Chest Diseases, Athens, Greece
1 Thoracic Surgical Department, "Sismanogleio" General Hospital, Athens, Greece
For reprint information contact: Panagiotis Misthos, MD Tel: 30 21 0252 9048 Fax: 30 21 0252 9048, Email: panmisthos{at}yahoo.gr, 7 P. Dimitrakopoulou Street, 11141 Athens, Greece.
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ABSTRACT
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This study was conducted in order to re-define the incidence and natural history of postresectional residual pleural spaces (PRS). From 1997 to 2005, 966 patients who were subjected to less than entire lung resections, were followed and any cases of PRS were recorded. The records of these patients were retrospectively analyzed for age, gender, type of resection, side, apical or basal location, size, PRS wall thickness, empyema as well as for bronchopleural fistula occurence, management, and outcome. Postresectional residual pleural spaces outcome was correlated with space characteristics. A total of 92 cases (9.5%) of PRS were documented which developed frequently ( p < 0.001) after upper lobectomies, malignant disease, at an apical location, and on the right side. Unfavorable outcome was strongly correlated with age > 70 years ( p < 0.001), air leak ( p < 0.001), empyema ( p < 0.001), and thickened pleura ( p < 0.001). Good prognosis of PRS was strongly correlated with male gender, apical location, right side, normal pleura thickness, and small size. Postresectional residual pleural spaces of small size without any associated complications should not prolong hospitalization time.
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INTRODUCTION
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It is well known that any residual intrathoracic space postoperatively is a serious concern for the thoracic surgeon. In the past the incidence of this complication ranged from 22% to 40%, mainly after lobectomy for tuberculosis.1–5 These early reports concluded that postresectional space development was an ominous sign for patient’s prognosis. Many investigators tried to clarify the factors that contributed to postoperative space formation.6–10 The main reason for their occurrence was thought to be bronchopleural fistula. Later studies elucidated the benign nature of this entity.8–10 However, the longer this complication persists, the greater the possibility of serious impact on the patient’s morbidity and mortality rates. A limited number of reports assessing postresectional residual pleural air spaces have been published. The authors conducted this study in order to define the incidence and natural history of postresectional spaces in the modern era.
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PATIENTS AND METHODS
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From January 1997 to December 2005, 1420 patients were subjected to lung resections consisting of 454 (32%) pneumonectomies and 966 (68%) lobectomies/segmentectomies. Non-small cell lung cancer (NSCLC) was the indication for surgery in the majority of cases ( n = 1264, 89%), with bronchiectasis ( n = 135, 9.5%) and infectious process ( n = 21, 1.5%) being the next most common causes. Those patients subjected to less than entire lung resections were followed, and any cases of postresectional residual pleural spaces (PRS) were recorded (Table 1
). Specifically, 869 lobectomies/bilobectomies (90%) and 97 segmentectomies/wedge resections (10%) were performed. The indications for pulmonary resection consisted of malignancies in 889 cases (92%) and of benign disease in 77 cases. No intraoperative measures for PRS prevention were taken such as sealants, phrenic nerve crushing, tailoring thoracoplasty, pleural tent or pneumoperitoneum. For postoperative drainage of the pleural space, two chest tubes were placed to achieve suction to –15 cm H2O. Chest tubes were removed in a routine fashion (precluding development of air leak or empyema) after 3–6 days.
The records of these patients were retrospectively analyzed for age, gender, type of resection (lobectomy or segmentectomy/wedge resection), right or left side occurrence, the malignant or benign nature of the underlying lung disease, occurrence of postresection thoracic empyema or bronchopleural fistula, the use of mechanical ventilation postoperatively, and for metabolic derangements (such as malnourishment and diabetes mellitus).
The cases with PRS were analyzed for the type of resection performed. Upper resections included upper right and left lobectomies or bronchopulmonary segmental resection. Lower resections included the middle, right, and left lower lobes as well as removal of the corresponding segments. In addition, analysis considered location of the PRS (apical or basal), size (large or small), and pleural thickness (normal or increased).
The management for PRS consisted of 4 treatment modalities: (1) no treatment, (2) prolonged chest tube thoracostomy (CTT) with or without the use of a Heimlich valve; (3) CTT with open drainage, and (4) thoracomyoplasty. The therapy endpoint was set as cessation of sepsis and air leak along with almost total elimination of dead space or the occurrence of a small-sized space without any associated complications.
The indications for observation were: (1) no air-leak, (2) no signs of sepsis, and (3) PRS of small size. These patients were managed with frequent bronchial toilet, incentive spirometry, pulmonary physiotherapy, and early ambulation. Chest tubes were removed in a routine fashion (precluding development of air leak or empyema) and the patient was followed up for 48 hours in order to detect any PRS enlargement. In case of air leak, large or enlarging size, or suspicion of empyema, prolonged CTT was instituted. Closed system drainage with negative suction was used for the first three weeks combined with irrigation in septic cases. If after this period air leak or sepsis continued, drainage was converted to open drainage. Indications for chest tube removal were cessation of air leak and sepsis remission. If a large space persisted for several months in association with persistent empyema and/or bronchopleural fistula (BPF), thoracoplasty was performed combined with intrapleural transfer of a muscular flap.
The PRS outcome was classified into 4 categories: (1) elimination: when the pulmonary remnant filled the pleural space, (2) asymptomatic: if the space remained at a steady or diminishing size without further sequelae, (3) symptomatic: when the remaining space was complicated with prolonged air leak, sepsis, thoracic pain etc and, (4) if persisting empyema despite proper drainage was encountered these patients were studied as a separate group. The first two groups were characterized as favorable outcome subclassifications while the latter two were defined as unfavorable. These subclassifications were analyzed and compared for age, gender, side, space location, fistula or empyema occurrence, pleural thickening, location of resection, and underlying disease.
Statistical analysis was performed using Student’s t-test (otherwise the Wilcoxon rank-sum test) and chi-square test (Fisher’s Exact test when needed) where appropriate. For correlation between variables the Pearson or Spearman test was performed upon indications. Multiple logistic regression was used for multivariate analysis.
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RESULTS
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A total of 92 cases (9.5%) with postresectional residual air spaces were documented. Patient characteristics are described in Table 1
. Comparative analysis between the PRS group and all resection cases disclosed that in the former group of patients female gender was significantly more common, lower lobectomies as well as benign underlying diseases were less common, while both empyema and BPF occurred significantly more frequently than among the total number of studied cases. Hospitalization time was longer for the PRS group in a statistically significant manner. Multiple regression analysis revealed no prognostic factors for PRS development.
Space characteristics (Table 2) can be summarized in the following observations: PRS were more frequently documented after upper lobectomies ( p < 0.001) and lower segmentectomies/wedge resection ( p < 0.001). Malignant disease was the most common indication ( p < 0.001). The most frequent location was apical ( p < 0.001) and the right side was more common ( p < 0.001). No statistically significant difference was found between the size of PRS and the occurrence of BPF. Pleural characteristics were within normal limits in the majority of cases ( p < 0.001).
Hospitalization time between apical and basal PRS was comparable except in the open drainage groups, where hospitalization time was significantly longer in the apical group ( p < 0.01). Most cases were managed with closed or open chest tube drainage (Table 3). The outcome of PRS is collectively presented in Table 4. The majority of patients with PRS had a favorable outcome (74%). Comparison between favorable and unfavorable outcome groups disclosed that the former included males of younger age subjected to either lower lobe resection, with postoperative normal pleural thickness, and without air leak or sepsis; in a statistically significant manner (Table 5). Unfavorable outcome was strongly correlated with age > 70 years ( p < 0.001), air leak ( p < 0.001), empyema ( p < 0.001), and thickened pleura ( p < 0.001).
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DISCUSSION
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A residual pleural space may complicate any type of pulmonary resection. After pulmonary parenchyma removal the created dead space is eliminated by remaining lung hyperexpansion, mediastinal shift, hemidiaphragm elevation, and shortening of intercostal spaces. The extent of pulmonary resection, the underlying parenchymal disease as well as the compliance and volume of the remaining lung are the main contributing factors for PRS development.
The incidence of PRS in our series was 9.5%, which is in accordance with previously published reports.11,12 Although multiple regression analysis disclosed no prognostic factors for PRS development, univariate analysis showed that in the space group female gender, right side, and air leak were significantly more frequent, while lower lobectomy and benign underlying disease were less common. Prevention is the best approach for PRS. This is accomplished by careful preoperative evaluation of lung compliance, meticulous air leak management, decortication upon strict indications, proper chest tube placement, and pleural tent creation or tailoring thoracoplasty performance.13–16 Comparative analysis of Tables 2–4 revealed size, location, air leak or/and empyema occurrence, and pleural thickening as significant parameters of PRS outcome. Analytically PRS characterized by two or more of the following criteria were associated with a dismal outcome: (a) large size, (b) air leak, (c) pleural empyema, (d) apical location and, (e) increased space wall pleural thickness. It is widely accepted that most spaces are related to either bronchial or alveolar air leak.1–12 In our study only 52% of cases presented with this feature. As a consequence the rest could be attributed to the above mentioned factors.
In the majority of cases PRS management led either to elimination of dead space (24%) or to a persistent, usually small sized space without any associated complications such as air leak, pleural empyema, and thoracic pain (50%). The natural history of this favorable outcome consists of space filling by the remaining lung parenchyma in the first case and with sterile exudative fluid in the second, along with diaphragm elevation, mediastinal shift, and intercostal space shortening. Pleura remained within normal limits after space elimination, while pleural thickening and finally fibrothorax development was the fate in cases of fluid filling. Consequently, one might suggest that PRS of small size without any associated complications should not prolong hospitalization time.
In 26% of patients the existence of two or more associated complications led to poor results. Although there was no mortality, the hospitalization time for these patients was significantly prolonged. Moreover, the quality of life was severely reduced due to a long drainage period for air leak or empyema. The natural history of this kind of PRS consisted of a medium to large sized space along with air leak and persistent empyema. Both visceral and parietal pleura were thickened in all cases. However thoracoplasty was indicated in only 2 cases. Prolonged open drainage led to air leak cessation and empyema remission. The space was gradually filled by fibrothorax tissue. During follow-up the remaining lung was functioning adequately. No parenchymal changes were attributed to alterations in the pleura cavity.
In conclusion, PRS characterized by two or more of the following criteria were associated with a dismal outcome: (a) large size, (b) air leak, (c) pleural empyema and, (d) increased space wall pleural thickness, while good prognosis was strongly correlated with male gender, apical location, right side, normal pleura thickness, and small size. Almost half of the cases were attributed to air leak.
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ABSTRACT
INTRODUCTION
