Burden of air leak complications in thoracic surgery estimated using a national hospital billing database

Chest tube removal at different gas flows in prolonged air leak: a randomized non-inferiority trial

OBJECTIVES

To evaluate the safety and feasibility of removing drainage tubes at larger size of air leak in patients with prolonged air leak after pulmonary surgery.

METHODS

Ninety-five patients who underwent pulmonary surgery with prolonged air leak in our centre were enrolled in this randomized controlled, single-centre, non-inferiority study. The drainage tube was clamped with a stable size of air leak observed over the last 6 h, which was quantified by gas flow rate using the digital drainage system. The control group (n = 48) and the study group (n = 46) had their drainage tube clamped at 0-20 ml/min and 60-80 ml/min, respectively. We continuously monitored clinical symptoms, conducted imaging and laboratory examinations, and decided whether to reopen the drainage tube.

RESULTS

The reopening rate in the study group was not lower than that in the control group (2.08% vs 6.52%, P > 0.05). The absolute difference in reopening rate was 4.44% (95% confidence interval -0.038 to 0.126), with an upper limit of 12.6% below the non-inferiority margin (15%). There were significant differences in the length of stay [16.5 (13-24.75) vs 13.5 (12-19.25), P = 0.017] and the duration of drainage [12 (9.25-18.50) vs 10 (8-12.25), P = 0.007] between the control and study groups. No notable differences were observed in chest X-ray results 14 days after discharge or in the readmission rate.

CONCLUSIONS

For patients with prolonged air leak, removing drainage tubes at larger size of air leak demonstrated similar safety compared to smaller size of air leak, and can shorten both length of stay and drainage duration.

CLINICAL TRIAL REGISTRATION NUMBER

Name of registry: Gas flow threshold for safe removal of chest drainage in patients with alveolar-pleural fistula prolonged air leak after pulmonary surgery. Registration number: ChiCTR2200067120. URL: https://www.chictr.org.cn/.

Evaluating and developing sealants for the prevention of pulmonary air leakage: A systematic review of animal models

Sealants may provide a solution for pulmonary air leakage (PAL), but their clinical application is debatable. For sealant comparison, standardized animal models are lacking. This systematic review aims to assess methodology and quality of animal models for PAL and sealant evaluation. All animal models investigating lung sealing devices (e.g., staplers, glues, energy devices) to prevent or treat PAL were retrieved systematically from Embase, Pubmed and Web of science. Methodological study characteristics, risk of bias, reporting quality and publication bias were assessed. A total of 71 studies were included (N  =  75 experiments, N  =  1659 animals). Six different species and 18 strains were described; 92% of experiments used healthy animals, disease models were used in only six studies. Lesions to produce PAL were heterogenous, and only 11 studies used a previously reported technique, encompassing N  =  5 unique lesions. Clinically relevant outcomes were used in the minority of studies (imaging 16%, air leak 10.7%, air leak duration 4%). Reporting quality was poor, but revealed an upward trend per decade. Overall, high risk of bias was present, and only 18.7% used a negative control group. All but one study without control groups claimed positive outcomes (95.8%), in contrast to 84.3% using positive or negative control groups, which also concluded equivocal, adverse or inconclusive outcomes. In conclusion, animal studies evaluating sealants for prevention of PAL are heterogenous and of poor reporting quality. Using negative control groups, disease models and quantifiable outcomes seem important to increase validity and relevance. Further research is needed to reach consensus for model development and standardization.

Intrinsic pulmonary sealing, its mechanisms and impact on validity and translational value of lung sealant studies: a pooled analysis of animal studies

Background

No validated and standardized animal models of pulmonary air leakage (PAL) exist for testing aerostatic efficacy of lung sealants. Lack of negative control groups in published studies and intrinsic sealing mechanisms of healthy animal lungs might contribute to a translational gap, leading to poor clinical results. This study aims to address the impact of intrinsic sealing mechanisms on the validity of PAL models, and investigate the conditions required for an ovine model of PAL for lung sealant testing.

Methods

An ovine acute aerostasis model was developed, consisting of a bilateral thoracotomy with lesion creation, chest tube insertion and monitoring of air leaks using digital drains (≥80 minutes), under spontaneous respiration. Healthy mixed-breed adult female sheep were used and all in vivo procedures were performed under terminal anesthesia. Superficial parenchymal lesions were tested post-mortem and in vivo, extended lesions including bronchioles (deep bowl-shaped and sequential lung amputation lesions) were tested in vivo. Experiment outcomes include air leakage (AL), minimal leaking pressure (MLP) and histology.

Results

Two post-mortem (N=4 superficial parenchymal lesions) and 10 in vivo experiments (N=5 superficial parenchymal and N=16 lesions involving bronchioles) were performed. In contrast to the post-mortem model, superficial parenchymal lesions in vivo showed less air leak [mean flow ± standard deviation (SD): 760±693 vs. 42±33 mL/min, P=0.055]. All superficial parenchymal lesions in vivo sealed intrinsically within a median time of 20 minutes [interquartile range (IQR), 10-75 minutes]. Histology of the intrinsic sealing layer revealed an extended area of alveolar collapse below the incision with intra-alveolar hemorrhage. Compared to superficial parenchymal lesions in vivo, lesions involving bronchioles induced significantly higher air leak post-operatively (normalized mean flow ± SD: 459±221 mL/min, P=0.003). At termination, 5/9 (55.6%) were still leaking (median drain time: 273 minutes, IQR, 207-435 minutes), and intrinsic sealing for the remaining lungs occurred within a median of 115 minutes (IQR, 52-245 minutes).

Conclusions

Lung parenchyma of healthy sheep shows a strong intrinsic sealing mechanism, explained pathologically by an extended area of alveolar collapse, which may contribute to a translational gap in lung sealant research. A meaningful ovine model has to consist of deep lesions involving bronchioles of >⌀1.5 mm. Further research is needed to develop a standardized PAL model, to improve clinical effectiveness of lung sealants.

Sealing effectiveness of a novel NHS-POx based patch: experiments in a dynamic ex vivo porcine lung

Background

Sealants are used to prevent prolonged pulmonary air leakage (PAL) after lung resections (incidence 5.6-30%). However, clinical evidence to support sealant use is insufficient, with an unmet need for a more effective product. We compared a novel gelatin patch impregnated with functionalized polyoxazolines (NHS-POx) (GATT-Patch) to commercially available sealant products.

Methods

GATT-Patch Single/Double layers were compared to Progel®, Coseal®, Hemopatch® and TachoSil® in an ex vivo porcine lung model (first experiment). Based on these results, a second head-to-head comparison between GATT-Patch Single and Hemopatch® was performed. Air leakage (AL) was assessed in three settings using increasing ventilatory pressures (max =70 cmH2O): (I) baseline, (II) with 25 mm × 25 mm superficial pleural defect, and (III) after sealant application. Lungs floating on saline (37 ℃) were video recorded for visual AL assessment. Pressure and tidal volumes were collected from the ventilator, and bursting pressure (BP), AL and AL-reduction were determined.

Results

Per sealant 10 measurements were performed (both experiments). In the first experiment, BP was superior for GATT-Patch Double (60±24 cmH2O) compared to TachoSil® (30±11 cmH2O, P<0.001), Hemopatch® (33±6 cmH2O, P=0.006), Coseal® (25±13 cmH2O, P=0.001) and Progel® (33±11 cmH2O, P=0.005). AL-reduction was superior for GATT-Patch Double (100%±1%) compared to Hemopatch® (46%±50%, P=0.010) and TachoSil® (31%±29%, P<0.001), and also for GATT-Patch Single (100%±14%, P=0.004) and Progel (89%±40%, P=0.027) compared to TachoSil®. In the second experiment, GATT-Patch Single was superior regarding BP (45±10 vs. 40±6 cmH2O, P=0.043) and AL-reduction (100%±11% vs. 68%±40%, P=0.043) when compared to Hemopatch®.

Conclusions

The novel NHS-POx patch shows promise as a lung sealant, demonstrating elevated BP, good adhesive strength and a superior AL-reduction.

Asia expert consensus on segmentectomy in non-small cell lung cancer: A modified Delphi study

Objective

Segmentectomy as a parenchymal-sparing surgical approach has been recommended over lobectomy in select patients with early-stage non-small cell lung cancer. This study aimed to address 3 aspects of segmentectomy ("patient indication"; "segmentectomy approaches"; "lymph node assessment") where there is limited clinical guidance.

Methods

A modified Delphi approach comprising 3 anonymous surveys and 2 expert discussions was used to establish consensus on the aforementioned topics among 15 thoracic surgeons (2 Steering Committee; 2 Task Force; 11 Voting Experts) from Asia who have extensive segmentectomy experience. Statements were developed by the Steering Committee and Task Force based on their clinical experience, published literature (rounds 1-3), and comments received from Voting Experts through surveys (rounds 2-3). Voting Experts indicated their agreement with each statement on a 5-point Likert scale. Consensus was defined as ≥70% of Voting Experts selecting either "Agree"/"Strongly Agree" or "Disagree"/"Strongly Disagree."

Results

Consensus from the 11 Voting Experts was reached on 36 statements (11 "patient indication" statements; 19 "segmentation approaches" statements; 6 "lymph node assessment" statements). In rounds 1, 2, and 3, consensus was reached on 48%, 81%, and 100% of drafted statements, respectively.

Conclusions

A recent phase 3 trial reported significantly improved 5-year overall survival rates for segmentectomy compared with lobectomy, proposing thoracic surgeons to consider segmentectomy as a surgical option in suitable patients. This consensus serves as a guidance to thoracic surgeons considering segmentectomy in patients with early non-small cell lung cancer, outlining key principles that surgeons should consider in surgical decision-making.

Prolonged air leak after robotic lung resection: a narrative review

Background and Objective

Prolonged air leak (PAL) following lung resection is related to an increase in morbidity and both direct and indirect costs. In recent years, robotic-assisted thoracic surgery (RATS) has proved to be a safe technique with comparable perioperative outcomes of video-assisted thoracic surgery (VATS), optimal oncological results, and potential advantages in case of sublobar resection. We here focus on the incidence and clinical impact of PAL in the field of robotic surgery and discuss the therapeutic strategies currently available.

Methods

We conducted a search on PubMed/MEDLINE and Scopus database from inception until May 27^th 2022 to select the relevant literature published in English exploring the occurrence of PAL following RATS.

Key Content and Findings

The implementation of robotic surgery led to a significant reduction in PAL occurrence after pulmonary resection compared to open thoracotomy, while there is still no clear advantage with respect to VATS. However, the enhanced dexterity and improved visualization of the robot seem to particularly valuable in case of sublobar lung resection, especially complex ones. Accurate selection of patients based on the presence of risk factors allows the implementation of intraoperative measures in order to reduce the occurrence of PAL.

Conclusions

Robotic lung resection is a safe technique, advantageous compared to traditional open thoracotomy in terms of PAL occurrence reduction and it is a valid alternative to manual VATS. Moreover, with the extension of indications for sublobar resection in the treatment of early stage lung cancer, RATS may prove to be the technique of choice thanks to its intrinsic advantages.

Primary Spontaneous Pneumothorax: Open Thoracotomy vs. Video-assisted Thoracoscopic Surgery: A Single-center Retrospective Cohort Study

Background

Primary spontaneous pneumothorax (PSP) is a spontaneous pneumothorax without underlying lung disease. The main goals of this study were to compare the outcomes of video-assisted thoracoscopic surgery (VATS) and open thoracotomy in patients with PSP.

Methods

The current study is a retrospective cohort study of patients who were admitted to the emergency department or general surgery ward at Dr. Masih Daneshvari Hospital (Tehran, Iran) with the diagnosis of PSP and underwent surgery by open or VATS approach from 2006 to 2012. The groups were compared in terms of the length of operation, the length of hospitalization, recurrence, and postoperative complications. Data were analyzed using SPSS version 18.0, and Student's t test, analysis of variance (ANOVA), Chi square, and Fisher's exact test were employed. P values less than 0.05 were considered statistically significant.

Results

PSP was diagnosed in 90 patients who underwent surgery. Open thoracotomy and VATS procedures were performed in 65 (72.2%) and 25 (27.8%) patients, respectively. VATS was converted to open in seven cases (7.7%). Recurrent pneumothorax was the most common surgical indication for PSP. There was no significant difference between the two groups in terms of mean age, sex, smoking, side of the involved lung, previous pneumothorax history, mean length of hospitalization for recurrence, post-operation bleeding, and failure of lung expansion. However, the length of surgery (P=0.011) and air leakage (P=0.048) significantly differed between the two groups.

Conclusion

When compared to open thoracotomy, VATS could be the primary treatment option in the surgical treatment of PSP due to the shorter length of surgery and decreased complications such as air leakage.

Clinical and Economic Burden Associated with Prolonged Air Leaks Among Patients Undergoing Thoracic Resection: A Retrospective Database Analysis

Purpose

Prophylactic use of lung sealants among patients undergoing thoracic resection has been reported for the management of intraoperative air leaks and is associated with a lower incidence of prolonged air leak (PAL) and a shorter length of stay (LOS). This study estimated the incremental economic and clinical burden of PAL among patients with lung sealants used during thoracic resection in the United States.

Patients and Methods

This retrospective analysis examined hospital data (Premier Healthcare Database) for adults (age ≥18 years) with inpatient thoracic resection between October 2015 - March 2021 (first admission=index) and lung sealant used during their procedure. Follow-up extended through 90 days post-discharge. Patients were grouped by presence/absence of PAL (ie, diagnosis of post-procedural air leak or post-procedural pneumothorax with associated LOS exceeding 5 days). Outcomes included intensive care unit (ICU) days, total index hospital costs, all-cause 30-, 60-, and 90-day readmission, discharge status, and in-hospital mortality. Generalized linear models quantified associations between PAL and outcomes, accounting for hospital-level clustering, and patient, procedure, and hospital/provider characteristics.

Results

Among the 9727 patients included for study (51.0% female, 83.9% white, mean age 66 years), 12.5% had PAL, which was associated with significant incremental increases in ICU days (0.93 days, p<0.001) and total hospital cost ($11,119, p<0.001). PAL also decreased the likelihood of discharge to home (from 91.3% to 88.1%, p<0.001) and increased the risk of readmission within 30, 60, and 90 days by up to 34.0% (from 9.3% to 12.6%;11.7% to 15.4%;13.6% to 17.2%, respectively), all p<0.01. Absolute risk of mortality was low, but two times higher in patients with PAL versus those without PAL (2.4% vs 1.1%, p=0.001).

Conclusion

This analysis demonstrates that despite the prophylactic use of lung sealants, PAL continues to put a burden on the healthcare system, highlighting an unmet need for improved sealant technology.

Pressure-dependent persistent air leak in a patient with secondary spontaneous pneumothorax

An air leak lasting more than 5-7 days (persistent air leak, PAL) can complicate up to 40% of patients with secondary spontaneous pneumothorax. Chronic obstructive pulmonary disease is the most common cause of secondary spontaneous pneumothorax, and early surgical intervention has been recommended for patients with PAL. Bullectomy or blebectomy with concomitant mechanical pleurodesis by medical thoracoscopy or video assisted thoracoscopic surgery is considered definitive therapy. Unfortunately, the perioperative course following lung resection can also be complicated by air leaks leading to worse clinical outcomes. Post lung resection air leak can be pressure independent or pressure dependent (also known as drainage-related air leak). The distinction between these two entities is crucial as the management varies drastically. Pleural manometry may play an important role in the early diagnosis of pressure-dependent PAL preventing further unnecessary surgical procedures from being performed.

Management von Thoraxdrainagen nach elektiven, thorakoskopischen, anatomischen Lungenresektionen an thoraxchirurgischen Zentren in Deutschland . Eine Umfrage über die Deutsche Gesellschaft für Thoraxchirurgie (DGT)

Einleitung Die zunehmende Adaptation minimalinvasiver Techniken sowie der Prinzipien der „Enhanced Recovery After Surgery“ (ERAS) in der Thoraxchirurgie haben zu einer deutlichen Reduktion des perioperativen Risikos nach anatomischen Lungenresektionen geführt. Die persistierende postoperative Luftleckage bleibt allerdings weiterhin eine der Hauptkomplikationen. Ziel dieser Umfrage war es, das Management von Thoraxdrainagen sowie die klinische Praxis der Behandlung persistierender Luftleckagen nach elektiven, thorakoskopischen, anatomischen Lungenresektionen in Deutschland zu analysieren.

Methodik Wir führten über die Deutsche Gesellschaft für Thoraxchirurgie (DGT) eine Online-Umfrage unter thoraxchirurgischen Zentren (n = 160) in Deutschland durch. Die Ergebnisse wurden getrennt nach High-Volume- und Low-Volume-Zentren ausgewertet.

Ergebnisse Die Rücklaufquote betrug 35,6%. Die Mehrheit der Kliniken verwendet als Standard eine einzelne Thoraxdrainage (24 Ch), die an ein digitales Thoraxdrainagesystem unter Sog angeschlossen wird. Eine postoperative Luftleckage wird von 42,1% der Kliniken nach dem 7. postoperativen Tag behandelt. Die Luftleckage wird von der Mehrheit entweder durch eine Reduktion des Sogs oder durch andere konservative Maßnahmen behandelt. Es zeigte sich kein signifikanter Unterschied im Drainagemanagement zwischen High-Volume- und Low-Volume-Zentren.

Schlussfolgerung Die Krankenhausverweildauer nach einer unkomplizierten Lobektomie beträgt heute im Regelfall nur wenige Tage, wobei die untere Grenzverweildauer bei 2 Tagen liegt. Dennoch definieren über 80% der deutschen Zentren eine Luftleckage erst dann als prolongiert, wenn sie nach dem 5. postoperativen Tag besteht; 65% behandeln sie auch erst dann. Die Studienlage hierzu ist nicht richtungsweisend. Weitere prospektive klinische Studien sind nötig, um die Behandlung der häufigsten Komplikation nach Lungenresektionen zu verbessern.

A combination of polyglycolic acid fabric and fibrin glue prevents air leakage from a lung defect

OBJECTIVES

Air leakage after lung resection is a common morbidity that may lengthen hospital stay. Applying sealant to a lesion is an effective prophylaxis in clinical practice. This study aimed to examine the effect of a combination of a bioabsorbable polyglycolic acid (PGA) fabric and fibrin glue (FG) on air sealing by measuring the in vitro mechanical strength and degradation of the fabric, and in vivo histological changes after implantation.

METHODS

A defect was created in the canine left upper lung lobe, and then filled with a fibrinogen solution and covered with a PGA sheet spray-coated with fibrinogen and thrombin. After 1 and 4 weeks, air leakage from the lesion was examined in vivo under airway pressure. Tissue samples were harvested for histological assessment.

RESULTS

The mechanical strength of the PGA fabric remained at 80-90% of the baseline level for 1 week in phosphate-buffered saline, and then rapidly decreased to zero thereafter. Air leakage from the lung defect was prevented by the combination of PGA fabric and FG at 1 and 4 weeks. Histological examinations showed that PGA bundles persisted with a non-specific inflammatory response for 2 weeks and then gradually broke into sparse yarns surrounded by collagen fibres and capillaries by 8 weeks. The lung defect was filled with FG at 1 week and by granulation tissue thereafter.

CONCLUSIONS

These results provide evidence for the efficacy of a combination of PGA fabric and FG for the prevention of air leakage in the critical period after lung surgery.

Successful use of endobronchial valve for persistent air leak in a patient with COVID-19 and bullous emphysema

Patients with SARS-CoV-2 pneumonia can suffer from pneumothorax and persistent air leak (PAL). The pneumothorax occurs with or without pre-existing lung disease. PAL refers to air leak lasting more than 5-7 days and arises due to bronchopleural or alveolopleural fistula. The management of PAL can be challenging as a standard management guideline is lacking. Here we present the case of a 42-year-old smoker with COVID-19 who presented to the hospital with fever, cough, acute left-sided chest pain and shortness of breath. He suffered from a large left-sided pneumothorax requiring immediate chest tube drainage. Unfortunately, the air leak persisted for 13 days before one-way endobronchial valve (EBV) was used with complete resolution of the air leak. We also review the literature regarding other cases of EBV utilisation for PAL in patients with COVID-19.

Air leaks: Stapling affects porcine lungs biomechanics

During thoracic operations, surgical staplers resect cancerous tumors and seal the spared lung. However, post-operative air leaks are undesirable clinical consequences: staple legs wound lung tissue. Subsequent to this trauma, air leaks from lung tissue into the pleural space. This affects the lung's physiology and patients' recovery. The objective is to biomechanically and visually characterize porcine lung tissue with and without staples in order to gain knowledge on air leakage following pulmonary resection. Therefore, a syringe pump filled with air inflates and deflates eleven porcine lungs cyclically without exceeding 10 cmH₂O of pressure. Cameras capture stereo-images of the deformed lung surface at regular intervals while a microcontroller simultaneously records the alveolar pressure and the volume of air pumped. The raw images are then used to compute tri-dimensional displacements and strains with the Digital Image Correlation method (DIC). Air bubbles originated at staple holes of inner row from exposed porcine lung tissue due to torn pleural on costal surface. Compared during inflation, left upper or lower lobe resections have similar compliance (slope of the pressure vs volume curve), which are 9% lower than healthy lung compliance. However, lower lobes statistically burst at lower pressures than upper lobes (p-value<0.046) in ex vivo conditions confirming previous clinical in vivo studies. In parallel, the lung deformed mostly in the vicinity of staple holes and presented maximum shear strain near the observed leak location. To conclude, a novel technique DIC provided concrete evidence of the post-operative air leaks biomechanics. Further studies could investigate causal relationships between the mechanical parameters and the development of an air leak.

Autologous blood pleurodesis for the treatment of postoperative air leaks. A systematic review and meta-analysis

Background

Postoperative air leaks are a common complication after lung surgery. They are associated with prolonged hospital stay, increased postoperative pain and treatment costs. The treatment of prolonged air leaks remains controversial. Several treatments have been proposed including different types of sealants, chemical pleurodesis, or early surgical intervention. The aim of this review was to analyze the impact of autologous blood pleurodesis in a systematic way.

Methods

A systematic review of the literature was conducted until July 2020. Studies with more than five adult patients undergoing lung resections were included. Studies in patients receiving blood pleurodesis for pneumothorax were excluded. The search strategy included proper combinations of the MeSH terms “air leak”, “blood transfusion” and “lung surgery”.

Results

Ten studies with a total of 198 patients were included in the analysis. The pooled success rate for sealing the air leak within 48 h of the blood pleurodesis was 83.7% (95% CI: 75.7; 90.3). The pooled incidence of the post‐interventional empyema was 1.5%, with a pooled incidence of post‐interventional fever of 8.6%.

Conclusions

Current evidence supports the idea that autologous blood pleurodesis leads to a faster healing of postoperative air leaks than conservative treatment. The complication rate is very low. Formal recommendations on how to perform the procedure are not possible with the current evidence. A randomized controlled trial in the modern era is necessary to confirm the benefits.

Variation in incidence, prevention and treatment of persistent air leak after lung cancer surgery

 

OBJECTIVES

Persistent air leak (PAL; >5 days after surgery) is the most common complication after pulmonary resection and associated with prolonged hospital stay and increased morbidity. Literature is contradictory about the prevention and treatment of PAL. Variation is therefore hypothesized. The aim of this study is to understand the variation in the incidence, preventive management and treatment of PAL.

METHODS

Data from the Dutch Lung Cancer Audit for Surgery were combined with results of an online survey among Dutch thoracic surgeons. The national incidence of PAL and case-mix corrected between-hospital variation were calculated in patients who underwent an oncological (bi)lobectomy or segmentectomy between January 2012 and December 2018. By multivariable logistic regression, factors associated with PAL were assessed. A survey was designed to assess variation in (preventive) management and analysed using descriptive statistics. Hospital-level associations between management strategies and PAL were assessed by univariable linear regression.

RESULTS

Of 12 382 included patients, 9.0% had PAL, with a between-hospital range of 2.6–19.3%. Factors associated with PAL were male sex, poor lung function, low body mass index, high American Society of Anesthesiologists (ASA) score, pulmonary comorbidity, upper lobe resection, (bi)lobectomy (vs segmentectomy), right-sided tumour and robotic-assisted thoracic surgery. Perioperative (preventive) management of PAL differed widely between hospitals. When using water seal compared to suction drainage, the average incidence of PAL decreased 2.9%.

CONCLUSIONS

In the Netherlands, incidence and perioperative (preventive) management of PAL vary widely. Using water seal instead of suction drainage and increasing awareness are potential measures to reduce this variation.

Medium-Term Pulmonary Function Test After Thoracoscopic Lobectomy and Segmentectomy for Congenital Lung Malformation: A Comparative Study With Normal Control

Purpose: This study aimed to compare the outcomes and pulmonary function test (PFT) of thoracoscopic segmentectomy and lobectomy in infants with congenital lung malformation and study the result of PFT on a medium-term basis. Methods: The clinical data of 19 infants with congenital lung malformation who underwent thoracoscopic surgery in our hospital from January 2018 to March 2019 were retrospectively studied; these infants were paired with another 19 infants who underwent thoracoscopic lobectomy during the same period using propensity score matching. Age-matched healthy individuals with similar body sizes were recruited for PFT as the control group. Patient characteristics, postoperative PFT, and outcomes were extracted for statistical analysis. Results: The average length of hospital stay did not significantly differ between segmentectomy and lobectomy groups. The segmentectomy group had more chest tube drainage than the lobectomy group. PFT 1 month after the operation showed that the tidal volume of the lobectomy group was lower than that of the segmentectomy group. Time to peak expiratory flow/time of expiration and peak flow/terminal airway velocity (V25%) indicated small airway dysfunction in the lobectomy group, and no obvious abnormalities were found in "time of inspiratory/time of expiration" in either group. Reexamination of pulmonary function 2 years after the operation showed that the small airway function of the segmentectomy group returned to normal, and no significant difference in pulmonary function was noted among the three groups. Conclusion: The short-term pulmonary function recovery was better after segmentectomy than after lobectomy. Patients who underwent thoracoscopic lobectomy and segmentectomy have normal lung function 2 years after the operation.

Management of Complications After Lung Resection: Prolonged Air Leak and Bronchopleural Fistula

Prolonged air leak or alveolar-pleural fistula is common after lung resection and can usually be managed with continued pleural drainage until resolution. Further management options include blood patch administration, chemical pleurodesis, and 1-way endobronchial valve placement. Bronchopleural fistula is rare but is associated with high mortality, often caused by development of concomitant empyema. Bronchopleural fistula should be confirmed with bronchoscopy, which may allow bronchoscopic intervention; however, transthoracic stump revision or window thoracostomy may be required.

Clinical Outcomes And Cost-Effectiveness Of Different Staplers For Lung Lobectomy With Video-Assisted Thoracic Surgery

Purpose

The aim of this study was to compare intra-operative adverse events (AE), post-operative outcomes, and costs of three different types of Echelon staplers (manual activated SC45A and electrical power-activated PSE45A & PSEE60A) used during video-assisted thoracic surgery (VATS) for lung lobectomy.

Patients and methods

We carried out a retrospective chart review of patients undergoing VATS lobectomies using one of three staplers (SC45A, PSE45A, or PSEE60A) during a 2-year period at our institution. We compared intra-operative AEs, post-operative outcomes (drainage volume, chest tube duration, prolonged air leaks [PALs]), endoscopic product costs [ECs], and hospitalization costs [HCs]) amongst the three stapler groups.

Results

In all 204 peripheral lung cancer patients were included in the study (95 in the SC45A group, 72 in the PSE45A group, and 37 in the PSEE60A group). We observed intra-operative AEs in 6 patients of the SC45A group, in 4 of the PSE45A group, and in 1 of the PSEE60A group (P>0.05). Drainage volumes among the three groups were similar. The mean chest tube duration was shorter]st in the PSE45A group followed by those in the PSEE60A and SC45A groups (P<0.05). PALs were lowest in the PSE45A group and highest in the SC45A group (P<0.05). The mean EC in the PSEE60A group was significantly higher than those in the other two groups (P<0.05). We found no statistically significant differences in terms of HCs among groups.

Conclusion

The three endoscopic staplers had similar incidences of intra-operative AEs when used for lobectomy with VATS. Use of the PSE45A stapler was associated with the shortest chest tube duration and least PALs, while use of the PSEE60A resulted in the highest EC rate.

Progel Use is Not Associated with Decreased Incidence of Postoperative Air Leak after Nonanatomic Lung Surgery

CONTEXT

Progel Pleural Air Leak Sealant (CR Bard, Warwick, RI) is a US Food and Drug Administration-approved hydrogel designed for application to surgical staple lines to prevent air leak after lung surgery. This product has demonstrated efficacy in reducing intraoperative air leaks compared with standard air leak closure methods. However, the impact on chest tube duration and length of hospital stay has not been reported.

OBJECTIVE

To evaluate the effect on rates of postoperative air leak, chest tube duration, and hospital stay in surgical patients with and without use of Progel.

DESIGN

Retrospective study of 176 patients aged 18 to 80 years who underwent video-assisted thoracoscopic wedge resections between 2014 and 2016. Eighty-four (48%) cases using Progel were included, as well as a representative sample of non-Progel cases (n = 92; 52%).

MAIN OUTCOME MEASURE

Presence of postoperative lung air leak.

RESULTS

No difference existed between the Progel and non-Progel groups in the rate of postoperative air leak (20/84, 23.81% Progel; 16/92, 17.39% non-Progel; p = 0.33). The length of time patients had a chest tube was similar (23.5 vs 23 hours, p = 0.721), as was percentage of patients with a less than 2-day hospitalization (77.17% non-Progel vs 82.14% Progel, p = 0.414).

CONCLUSION

Our results suggest that Progel, used routinely in patients undergoing nonanatomic lung resection, does not have a significant impact on postoperative air leak, chest tube duration, or length of hospital stay. Further studies are warranted to evaluate the utility of Progel in reducing postoperative complications after thoracoscopic wedge resection in those treated for air leak or in the reduction of postoperative air leak in high-risk patients.

Preclinical quantification of air leaks in a physiologic lung model: effects of ventilation modality and staple design

Purpose

Thoracic air leaks are a common complication following pulmonary resections. Limitations in clinical studies and preclinical models have hindered efforts to understand the pathophysiology of air leaks. With an emphasis on staple-line specific air leaks, we hypothesize that ventilation modality – intraoperative positive pressure vs postoperative negative pressure – and stapler design may play a role in air leaks.

Methods

Using a novel physiologic lung model, air leaks associated with graduated and uniform staple designs were evaluated under positive and negative pressure ventilation, simulating perioperative breathing in porcine lungs. Air leak incidence, air leak volume, and air leak rate were captured along with ventilation pressure and tidal volume.

Results

In all cases, negative pressure ventilation was associated with a higher occurrence of leaks when compared to positive pressure ventilation. Lungs leaked more air and at a faster rate under negative pressure ventilation compared to positive pressure ventilation. Graduated staple designs were associated with higher occurrence of leaks as well as larger leak rates when compared to uniform staples. Tissue thickness was not associated with differences in air leaks when tested with appropriate staple heights.

Conclusion

Using a novel lung model to investigate the pathophysiology of air leaks, we have identified breathing modality and staple design as two important variables that may impact air leaks. This work will help guide device design and drive future studies in human tissue, and it may help inform clinical practice to ultimately improve patient outcomes.

Length of stay and hospitalization costs for patients undergoing lung surgery with Progel pleural air leak sealant

AIM

Progel Pleural Air Leak Sealant (Progel) is currently the only sealant approved by the FDA for the treatment of air leaks during lung surgery. This study was performed to determine whether Progel use improves hospital length of stay (LOS) and hospitalization costs compared with other synthetic/fibrin sealants in patients undergoing lung surgery.

METHODS

The US Premier hospital database was used to identify lung surgery discharges from January 1, 2010 to June 30, 2015. Eligible discharges were categorized as "Progel Sealant" or "other sealants" using hospital billing data. Propensity score matching (PSM) was performed to control for hospital and patient differences between study groups. Primary outcomes were hospital LOS and all-cause hospitalization costs. Clinical outcomes, hospital re-admissions, and sealant product use were also described.

RESULTS

After PSM, a total of 2,670 discharges were included in each study group; baseline characteristics were balanced between groups. The hospital LOS (mean days ± standard deviation, median) was significantly shorter for the Progel group (9.9 ± 9.6, 7.0) compared with the other sealants group (11.3 ± 12.8, 8.0; p < .001). Patients receiving Progel incurred significantly lower all-cause hospitalization costs ($31,954 ± $29,696, $23,904) compared with patients receiving other sealants ($36,147 ± $42,888, $24,702; p < .001).

LIMITATIONS

It is not possible to say that sealant type alone was responsible for the findings of this study, and analysis was restricted to the data available in the Premier database.

CONCLUSIONS

Among hospital discharges for lung surgery, Progel use was associated with significantly shorter hospital LOS and lower hospitalization costs compared with other synthetic/fibrin sealants, without compromising clinical outcomes.

Ex Vivo Modeling of Perioperative Air Leaks in Porcine Lungs

OBJECTIVE

A novel ex vivo model is described to advance the understanding of prolonged air leaks, one of the most common postoperative complications following thoracic resection procedures.

METHODS

As an alternative to in vivo testing, an ex vivo model simulating the various physiologic environments experienced by an isolated lung during the perioperative period was designed and built. Isolated porcine lungs were perfused and ventilated during open chest and closed chest simulations, mimicking intra and postoperative ventilation conditions. To assess and validate system capabilities, nine porcine lungs were tested by creating a standardized injury to create an approximately 250 cc/min air leak. Air leak rates, physiologic ventilation, and perfusion parameters were continuously monitored, while gas transfer analysis was performed on selected lungs. Segmental ventilation was monitored using electrical impedance tomography.

RESULTS

The evaluated lungs produced flow-volume and pressure-volume loops that approximated standard clinical representations under positive (mechanical) and negative (physiological) pressure ventilation modalities. Leak rate was averaged across the ventilation phases, and sharp increases in leak rate were observed between positive and negative pressure phases, suggesting that differences or changes in ventilation mechanics may strongly influence leak development.

CONCLUSION

The successful design and validation of a novel ex vivo lung model was achieved. Model output paralleled clinical observations. Pressure modality may also play a significant role in air leak severity.

SIGNIFICANCE

This work provides a foundation for future studies aimed at increasing the understanding of air leaks to better inform means of mitigating the risk of air leaks under clinically relevant conditions.

Evaluation of hospitalization costs and associated factors among maternity stays involving low-risk and moderate- to high-risk childbirths in the United States

OBJECTIVES

This study aimed to assess the costs of childbirth and to identify factors associated with such hospital costs for low- and moderate/high-risk childbirth groups.

METHODS

All hospitalizations for childbirth between 2010-2014 in the Premier Perspective Hospital Database were identified. Risk category for each birth was defined by the age of the subject and/or presence of specific maternal comorbidities and obstetric risk factors. Hospital childbirth costs were determined and stratified by risk groups. Factors associated with costs for each risk group were evaluated by multiple regression.

RESULTS

Among 2,367,195 hospitalizations for childbirth, vaginal birth was the most common delivery method (n = 1,596,757; 68%). Among women characterized as moderate/high-risk, 42% (n = 642,495) had C-sections, while 11% (n = 90,211) of women categorized as low-risk had C-sections. The proportion of women with serious maternal morbidity among moderate/high-risk vs. low-risk women was 2% (n = 29,496) vs. 0.3% (n = 2749), respectively. The mean costs for moderate/high-risk vs. low-risk hospitalizations were $6145 (median = $5760) and $5397 (median = $5001), respectively (p < 0.0001). Factors significantly associated with costs for moderate/high-risk hospitalizations included delivery type (C-section vs. vaginal birth), LOS, urban/rural hospital status, geographic regions, calendar year of hospitalization, teaching status, payer types and serious maternal morbidity. Similar factors were found to impact costs among low-risk hospitalizations.

CONCLUSIONS

Characteristics such as delivery type, LOS, geographical region, teaching status, serious maternal morbidity and hospital urban/rural status were shown to impact hospital costs of childbirth. Screening and prevention strategies of factors that negatively impact costs may aid in reducing the hospitalization costs associated with childbirths.