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University of Rome Rome, Italy
To the Editor:
We read with interest the paper from Abolhoda and colleagues (June 1998).1 The authors must be commended for reporting on a common and potentially serious complication. Air leakage after major pulmonary resections is a well-known problem which occurs more frequently when interlobar fissures are incomplete or absent, and if the pulmonary resection is performed in older patients with emphysema. A number of reports in the literature corroborate the hypothesis that the ideal treatment begins with prevention; in fact, when the fissures are incomplete, meticulous attention should be given to anatomic planes of interlobar dissection and staplers should be used. However, notwithstanding these measures, air leaks may still occur, compromise lung reexpansion, prolong hospitalization, and lead to the onset of other complications.
The resurgence of interest in lung volume reduction surgery in patients with COPD has been accompanied by a recognition of the importance of preventing postoperative air leaks. Various materials have been used to buttress the staple line and the use of this reinforcement technique is generally accepted as an effective means of prevention in this subset of patients. Patients receiving pulmonary resections generally present other problems; however, in our opinion, incomplete fissures should be approached using all the skills learned from lung volume reduction surgery.
Abolhoda and colleagues stated that this group of patients does not present with the typical pulmonary pathologic changes found in end-stage emphysema and, thus, the routine use of such staple-reinforcing techniques is neither cost-effective nor justified. There is indeed evidence in the literature that these measures can improve the postoperative course in this group of patients. We would like to draw attention to some experimental and clinical studies recently published. Robertson and colleagues2 have demonstrated in a canine model that the use of reinforcing materials to buttress the stapler line can help in preventing postoperative air leaks in normal lungs. In a prospective clinical randomized study,3 we have compared different techniques to complete interlobar fissures during pulmonary lobectomies. The use of GIA staplers (Ethicon, Inc; Somerville, NJ) and pericardial sleeves was compared to that of TA-55 staplers and the "old-fashioned" silk, crile, and cautery. Staplers and bovine pericardium sleeves significantly reduce the duration of postoperative air leaks and hospital stay. No complications were associated with the use of this technique. Only a small number of patients could be enrolled in our prospective study, but the results were statistically significant in favor of the use of bovine pericardium buttressing.
We would also like to stress the importance of creating a pleural tent after upper lobectomy and lung volume reduction surgery. Creation of the pleural tent is also technically feasible using thoracoscopy4 ; this dynamic and reversible tailoring of the postresectional pleural space may contribute to improving the outcome of patients receiving a partial or complete resection of the upper lobes.
One can also inject air within the peritoneal cavity (pneumoperitoneum) to elevate the diaphragm and reduce postresectional pleural spaces, pulling the residual lung towards the chest wall. This technique has recently gained new acceptance and has been described after standard pulmonary resections and lung volume reduction surgery.5 ,6
In conclusion, the surgical procedure and the measures adopted to prevent, reduce, and treat postoperative air leaks must be tailored patient by patient. The use of staplers and buttressing to create interlobar fissures must be encouraged. Additional measures, like the creation of a pleural tent and pneumoperitoneum, should be taken into consideration.
Correspondence to: Federico Venuta, MD, Cattedra di Chirurgia Toracica, Policlinico Umberto I, University of Rome "La Sapienza," V.le del Policlinico, 00100 Rome, Italy; e-mail: Fevenuta@tin.it
References
This article has been cited by other articles:
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  J. M Cooper and J. A Beckman Massive pulmonary embolism: a remarkable case and review of treatment Vascular Medicine, August 1, 2002; 7(3): 181 - 185. [Abstract] [PDF]
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