Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial.
BACKGROUND
Although staple line buttressing is advocated to reduce air leak after lung volume reduction surgery (LVRS), its effectiveness is unknown. We sought to identify risk factors for air leak and its duration and to estimate its medical consequences for selecting optimal perioperative technique(s), such as buttressing technique, to preempt or treat post-LVRS air leak.


METHODS
Detailed air leak data were available for 552 of 580 patients receiving bilateral stapled LVRS in the National Emphysema Treatment Trial. Risk factors for prevalence and duration of air leak were identified by logistic and hazard function analyses. Medical consequences were estimated in propensity-matched pairs with and without air leak.


RESULTS
Within 30 days of LVRS, 90% of patients developed air leak (median duration = 7 days). Its occurrence was more common and duration prolonged in patients with lower diffusing capacity (p = 0.06), upper lobe disease (p = 0.04), and important pleural adhesions (p = 0.007). Duration was also protracted in Caucasians (p < 0.0001), patients using inhaled steroids (p = 0.004), and those with lower 1-second forced expiratory volume (p = 0.0003). Surgical approach, buttressing, stapler brand, and intraoperative adjunctive procedures were not associated with fewer or less prolonged air leaks (p >/= 0.2). Postoperative complications occurred more often in matched patients experiencing air leak (57% vs 30%, p = 0.0004), and postoperative stay was longer (11.8 +/- 6.5 days vs 7.6 +/- 4.4 days, p = 0.0005).


CONCLUSIONS
Air leak accompanies LVRS in 90% of patients, is often prolonged, and is associated with a more complicated and protracted hospital course. Its occurrence and duration are associated with characteristics of patients and their disease, not with a specific surgical technique.
DeCamp
Malcolm M
MM
Section of Thoracic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02115, USA. mdecamp@bidmc.harvard.edu
Blackstone
Eugene H
EH
Naunheim
Keith S
KS
Krasna
Mark J
MJ
Wood
Douglas E
DE
Meli
Yvonne M
YM
McKenna
Robert J
RJ
D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use; D000368:Aged; D000818:Animals; D001705:Bioprosthesis; D002417:Cattle; D005260:Female; D015718:Fibrin Tissue Adhesive / Q000627:therapeutic use; D005541:Forced Expiratory Volume; D006801:Humans; D008297:Male; D016555:Matched-Pair Analysis; D008875:Middle Aged; D010496:Pericardium / Q000637:transplantation; D010995:Pleural Diseases / Q000150:complications; D018700:Pleurodesis; D011013:Pneumonectomy; D011030:Pneumothorax / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D011138:Polytetrafluoroethylene; D011183:Postoperative Complications / Q000209:etiology* / Q000517:prevention & control; D015995:Prevalence; D011656:Pulmonary Emphysema / Q000601:surgery; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D013528:Surgical Staplers; D017792:Surgical Stapling; D013536:Suture Techniques; D020775:Thoracic Surgery, Video-Assisted; D000267:Tissue Adhesions / Q000150:complications; D044465:White People
D000305:Adrenal Cortex Hormones; D015718:Fibrin Tissue Adhesive; D011138:Polytetrafluoroethylene