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Asian Cardiovasc Thorac Ann 1998;6:115-117
© 1998 Asia Publishing EXchange Pte Ltd

ORIGINAL CONTRIBUTION

Use of a Pericardial Fat Pad for Alveolar Air Leaks After Pulmonary Resections

Osamu Kawashima, MD, Toshikazu Hirai, MD, Mitsuhiro Kamiyoshihara, MD, Susumu Ishikawa, MD1, Yasuo Morishita, MD1

Department of Surgery National Sanatorium Nishigunma Hospital Shibukawa, Japan
1 Second Department of Surgery Gunma University School of Medicine Maebashi, Japan
For reprint information contact: Osamu Kawashima, MD Department of Surgery National Sanatorium Nishigunma Hospital 2854 Kanai Shibukawa, Gunma 377-0027, Japan Tel: 81 279 23 3030 Fax: 81 279 23 2740

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 TECHNIQUE
 RESULTS
 DISCUSSION
 REFERENCES
 
To investigate the effectiveness of using a free pericardial fat pad to control air leaks from residual raw parenchymal surfaces after pulmonary resections, 30 consecutive patients were studied. There were 23 males and 7 females with a median age of 69 years. The indication for this technique was any alveolar air leak from a residual raw parenchymal surface which could not been controlled by suturing. There were 25 lobectomies with incomplete fissure and 5 cases of segmentectomy. None of the patients exhibited air leaks beyond 2 days, post-operative space problems, or infections. All patients had chest drains removed within 2 days after the operation. The application of a free pericardial fat pad is a promising new method of treating air leaks from residual raw parenchymal surfaces after pulmonary resections.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 TECHNIQUE
 RESULTS
 DISCUSSION
 REFERENCES
 
The presence of raw parenchymal surfaces with resulting air leakage is a common occurrence after a segmentectomy or a lobectomy with incomplete fissure.1–3 The leak usually stops within a few days with complete reexpansion of the lung during the postoperative period.4 However, the condition sometimes persists for a week or more and is troubling to both surgeons and patients. Once a persistent air leak occurs, there is no standard procedure to manage it and the condition may cause postoperative space problems and serious infection leading to empyema.5,6 Ideally, the problem should be addressed during the operation. We present our experience with a simple surgical technique for preventing air leaks from residual parenchymal raw surfaces after pulmonary resection.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
TECHNIQUE
 RESULTS
 DISCUSSION
 REFERENCES
 
A total of 121 pulmonary resections were performed at our institution from August 1995 to March 1997. Within this group, we used a free pericardial fat pad to control air leaks from residual raw parenchymal surfaces after pulmonary resections in 30 consecutive patients in whom the technique was indicated. There were 25 cases of lobectomy with incomplete fissure and 5 cases of segmentectomy. The indication for this surgical technique was any alveolar air leak from a residual raw parenchymal surface, which could not been controlled with suturing. The mean age of the patients was 69 years, ranging from 45 to 78 years. There were 23 men and 7 women. The types of pulmonary resection are presented in Table 1Go. To evaluate the efficacy of this technique, we noted the postoperative duration of air leakage and space problems on discharge from hospital.


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  		Table 1. Types of Pulmonary Resection in 30 Patients with Alveolar Air Leaks
 

   TECHNIQUE
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 TECHNIQUE
RESULTS
 DISCUSSION
 REFERENCES
 
Pulmonary resection was performed by a combined sharp and blunt dissection or by using a stapling device in cases of incomplete fissure. After removal of the specimen, the integrity of the bronchial stump was tested by the application of positive pressure of approximately 20 cm H2O to the endotracheal tube in a saline-filled thorax. Bleeding from small blood vessels and air leakage from small bronchi were controlled completely by suturing because these may cause persistent problems in the postoperative period. We used a free pericardial fat pad as a sealant to control alveolar air leaks from residual raw parenchymal surfaces (Figure 1Go). A pericardial fat pad was resected according to the size of the raw surface area measured while the lung was inflated. The pericardial fat pad was placed on the raw parenchymal surface and sutured to the margins of the visceral pleural defect without tension, using nonabsorbable monofilament. The raw surface was completely covered (Figures 2 and 3GoGo). Fibrin glue was not used in this method. Two thoracostomy tubes were placed through stab wounds in the anterior axillary line. After closure of the chest, negative suction with 15 cm H2O was applied to a drainage system and postoperative care was managed according to conventional techniques.



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  		Figure 1. A residual raw parenchymal surface with alveolar air leaks after resection with incomplete fissure of the left lower lobe. Ao = aorta, LUL = left upper lobe, PA = pulmonary artery.

 


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  		Figure 2. After control of bleeding from small vessels and of air leakage from peripheral small bronchi by suturing, a resected pericardial fat pad is placed over the residual raw parenchymal surface as a sealant and sutured to the margins of the visceral pleural defect with nonabsorbable monofilament. Ao = aorta, LUL = left upper lobe, PA = pulmonary artery.

 


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  		Figure 3. Intraoperative photograph of a left lower lobectomy with a grade 2 incomplete fissure. The raw parenchymal surface was completely covered with a free pericardial fat pad to seal alveolar air leaks.

 

   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 TECHNIQUE
 RESULTS
DISCUSSION
 REFERENCES
 
Twenty-five of the 30 patients in whom the pericardial fat pad technique was applied for control of alveolar air leaks, underwent lobectomy with incomplete fissure over grade 2 according to the grading of Craig and Walker1 where grade 1 is complete fissure with entirely separate lobes, grade 2 is complete visceral cleft but parenchymal fusion at the base of the fissure, grade 3 is visceral cleft evident for part of the fissure, and grade 4 is complete fusion of the lobes with no evident fissure line. None of the 30 patients exhibited air leaks beyond 2 days and all patients had their chest drains removed within 2 days after the operation. All patients had an uneventful post-operative course. None had evidence of space problems during chest radiography screening at 4 weeks postoperatively.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 TECHNIQUE
 RESULTS
 DISCUSSION
REFERENCES
 
Because of the increased usage of stapling devices, it is easy to carry out not only a lobectomy with incomplete fissure but also a segmentectomy.7,8 However, postoperative persistent air leaks from residual raw parenchymal surfaces remain one of the major concerns after pulmonary resections and may predispose the patient to postoperative space problems and infections.4–6 Jensik and colleagues3 advocated covering raw surfaces with pleural flaps or reconstituting the lung by bridging the adjacent segments together after pulmonary resections, especially in the case of segmentectomy. However, such a step may lead to increased postoperative problems such as diminution of lung volume or distortion of the remaining lobes. Recently, the application of fibrin glue to control air leaks from residual raw parenchymal surfaces has been generally accepted and the outcome has been positive.9–12 On the other hand, it has been reported that the routine use of fibrin glue after a lobectomy is not effective in reducing the duration of air leaks.13 Although the pericardial fat pad used in our method is a free nonvascularized graft and it would necrotize within a few days, it is an effective temporary sealant during the early postoperative period. We speculate that the mechanism of stopping air leaks involves fibrin from the pulmonary parenchyma, which could seal its surface during a few days of covering with the pericardial fat pad. The use of fibrin glue for raw parenchymal surfaces may be cost-effective but fibrin glue has some side-effects such as chest pain, viral infection, and immunological reactions, although these are rare.10 Our method avoids these problems and we detected no side-effects. To confirm the effectiveness of a free pericardial fat pad for preventing alveolar air leaks after pulmonary resections, further clinical studies are necessary. However, this new concept is promising and secure sealing of residual raw parenchymal surfaces could be achieved with a free pericardial fat pad in all cases in this series.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 TECHNIQUE
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Craig SR, Walker WS. A proposed anatomical classification of the pulmonary fissures. J R Coll Surg Edinburgh 1997; 42:233–4.

  2. Mouritzen C, Dromer M, Keinecke HO. 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]

  3. Jensik RJ, Faber LP, Kittle CF. Segmental resection for bronchogenic carcinoma. Ann Thorac Surg 1979;28:475–83.[Abstract]

  4. Shields TW. General features and complications of pulmonary resections. In: Shields TW, editor. General thoracic surgery. 4th ed. Baltimore: Williams & Wilkins, 1994:391–414.

  5. LeRoux BT. Suppurative diseases of the lung and pleural space: part 1. Empyema thoracis and lung abscess. Curr Probl Surg 1986;23:1–89.[Medline]

  6. Snider GL, Saleb SS. Empyema of thorax in adults: review of 105 cases. Dis Chest 1968;54:410–5.

  7. Hood RM. Stapling techniques involving lung parenchyma. Surg Clin North Am 1984;64:469–80.[Medline]

  8. Lewis RJ. Simultaneously stapled lobectomy: a safe technique for video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1995;109:619–25.[Abstract/Free Full Text]

  9. Matthew TL, Spotnitz WD, Kron IL, et al. Four years experience with fibrin sealant in thoracic and cardiovascular surgery. Ann Thorac Surg 1990;50:40–3.[Abstract]

  10. Kjaergard HK, Weis-Fogh US, Sorensen H, Thiis J, Rygg I. Autologous fibrin glue preparation and clinical use in thoracic surgery. Eur J Cardio-thorac Surg 1992;6:52–4.[Abstract]

  11. Grunenwald D, Vouje RR, Neveux JY. The use of fibrin sealant (Tissucol, Tisseel) in thoracic surgery. In: Schlag G, Redl H, editors. Fibrin sealant in operative medicine. Thoracic surgery-cardiovascular surgery. Berlin: Springer, 1986:63–7.

  12. Orlowski TM, Kolodziej J, Domagala J. The use of fibrin adhesive in thoracic surgery. In: Schlag G, Redl H, editors. Fibrin sealant in operative medicine. Thoracic surgery-cardiovascular surgery. Berlin: Springer, 1986:68–75.

  13. Fleisher AG, Evans KG, Nelems B, Finley RJ. Effect of routine fibrin glue use on the duration of air leaks after lobectomy. Ann Thorac Surg 1990;49:133–40.[Abstract]





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