Ann Thorac Surg 2001;72:1716-1719
© 2001 The Society of Thoracic Surgeons
Original article: general thoracic
Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections
Tiziano De Giacomo, MD*a,
Erino A. Rendina, MDa,
Federico Venuta, MDa,
Federico Francioni, MDa,
Marco Moretti, MDa,
Francesco Pugliese, MDa,
Giorgio Furio Coloni, MDa
a Department of Thoracic Surgery, University of Rome "La Sapienza," Rome, Italy
Accepted for publication June 22, 2001.
* Address reprint requests to Dr De Giacomo, Department of Thoracic Surgery, University of Rome "La Sapienza," Policlinico Umberto I, Viale del Policlinico, 00161 Rome, Italy
e-mail: tdegia{at}tin.it
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Abstract
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Background. The use of pneumoperitoneum to treat prolonged air leaks or space problems, or both, after pulmonary resection has been recently resurrected and used successfully.
Methods. During the last 3 years, 14 patients experienced short-term pleural space problems associated with prolonged air leaks after pulmonary resection for lung cancer. All patients, under sedation and local anesthesia, had a mean of 2,100 mL of air injected under the diaphragm, using a Veres needle after a mean time of 7 days (range, 5 to 10 days) from the operation. In 3 patients talc slurry was added to help control the air leak.
Results. No patients experienced complications during the induction of the pneumoperitoneum. No patients complained of dyspnea, although blood gas analysis showed a slight increment of carbon dioxide partial pressure (p < 0,0004). Obliteration of the pleural space was observed in all cases after a mean time of 4 days (range, 1 to 7 days). Air leaks stopped in all patients after a mean time of 8 days (range, 4 to 12 days). The mean postoperative hospital stay after lung resection was 18 days (range, 14 to 22 days). No patients had significant complications or long-term sequelae. We found that patients who had undergone induction chemotherapy had longer air leak durations than observed in noninduction patients (p = 0.03).
Conclusions. Our experience supports the use of postoperative pneumoperitoneum whenever a space problem associated with prolonged air leaks is present. The procedure is effective, safe, and easy to perform.
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Introduction
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The prevention of postoperative pleural space problems is one of the major issues after pulmonary resection. Papers published in the 1960s reported the incidence of space problems after lung operation to be in the range of 11% to 12% [1, 2]. During the last 20 years, this incidence has been reduced with improvements of surgical techniques and instrumentation. However, an unoccupied pleural space when associated with air leaks can still represent a source of serious complications. This requires longer hospital stay with patient’s discomfort, exposes to the risks of infection, and can require reoperation when the conservative approach is unsuccessful. Furthermore, in patients with lung cancer who need adjuvant treatment, the start of chemotherapy or radiation therapy may be delayed. In our practice, some oncologists prefer to start the treatment after chest tube removal because of the higher risk of infectious complications. Pneumoperitoneum has been successfully used to manage short-term space problems associated or not with air leaks after lung resection [3–5]. Although its use has been suggested especially to treat prolonged air leaks in patients with a basilar pneumothorax, this report describes our experience with the application of pneumoperitoneum to manage apical as well as basal pleural spaces associated with air leaks after pulmonary resection for lung cancer.
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Material and methods
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Between January 1998 and December 2000, 360 patients underwent major pulmonary resections for lung cancer at the Department of Thoracic Surgery of the University of Rome "La Sapienza." After the operation, 14 patients (3.8%) experienced short-term space problems associated with significant air leaks and subsequently underwent the creation of pneumoperitoneum. This group of patients forms the basis of this report. Ten patients were men, 4 women, with a mean age of 62 years (range, 50 to 78 years). Six patients underwent lung resection after induction chemotherapy for locally advanced non–small cell lung cancer and 1 also received radiation therapy. In this subgroup, 5 patients were initially staged as T4 and 1 as N2. The resection performed was upper lobectomy in 8 patients (5 on the left side and 3 on the right side), bilobectomy (upper and middle) in 2, lower lobectomy in 4 (2 on the right side and 2 on the left side). All patients underwent complete resection with negative bronchial margins, and all had complete mediastinal and hilar lymphadenectomy. During the operation, all uncompleted fissures were completed using staplers, and care was taken to minimize air leaks before chest closure. Bovine pericardium was used in 8 patients for buttressing staple lines. Routinely release of the inferior pulmonary ligament was accomplished in all patients. A space problem was predictable only in 2 patients. This was possible on purely anatomic grounds in patients such as the one showed in Figure 1. In these cases, all standard maneuvers to prevent the development of a residual space were used such as section of the lower pulmonary ligament, phrenic nerve crush, and adequate position of two chest tubes. The creation of an apical pleural tent was not possible because of diffuse and tight pleural adhesions that made the pleura unusable. The residual space was apical in 10 patients and combined apical and basilar in the remaining 4 patients. Attempts were made to obtain complete lung reexpansion with intensive postoperative rehabilitation activities, modifying pleural suction or putting the patients on water seal. Fiberoptic bronchoscopy was performed in all patients to clean the airway and to rule out any bronchial problem. The bronchial suture was normal in all cases. After a mean time of 7 days (range, 5 to 10 days), we decided to use pneumoperitoneum to reduce the pleural space and to control air leaks. The procedure was performed in the operating room, under sedation using intravenous infusion of propofol (1 to 2 mg · kg-1 · h-1) or midazolam (00.1 mg · kg-1 · h-1). Supplemental oxygen was delivered with a facial mask. Intraoperative monitoring included continuous electrocardiogram, noninvasive arterial pressure control, and percutaneous oxygen saturation. After local infiltration of the periumbilical area with a solution of lidocaine 2% and bupivacaine 5%, pneumoperitoneum was induced by instilling 30 mL/kg of air in the peritoneal cavity. A mean of 2,100 mL (range, 1,800 to 2,400 mL) of air, using a Veres needle, was injected. In 2 patients the quantity of air instilled was limited by the development of pain. In 1 of them, it was necessary to refill the pneumoperitoneum (1,000 mL) 1 week after the first treatment, because of persistent apical space and air leak. Prophylactic antibiotic therapy was maintained; therapy with low doses of steroids was started after the procedure with the aim of limiting the peritoneal inflammation. In 3 patients in whom air leak was reduced but persisted in the absence of any residual pleural space, talc slurry was performed using 3 g of asbestos-free talc solution. Two of them were discharged from the hospital with a Heimlich valve. Arterial blood gas determinations were performed immediately before the pneumoperitoneum and after the procedure on room air and statistically compared. Statistical analysis was performed using Student’s t test, and values less than 0.05 were considered significant.
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Fig 1. (A) Chest roentgenogram showing a lung cancer located in the lingula. Emphysematous changes of the lung and chest wall are clearly evident. The patient underwent left upper lobectomy. Intraoperatively it appeared evident that space problems could be anticipated. (B) Postoperative chest roentgenogram in the same patient shows apical and basal pleural space with fluid level. Significant air leak was noted. (C) Chest roentgenogram 4 days after instillation of intraperitoneal air. All residual intrathoracic air spaces were obliterated. (D) Chest roentgenogram after the removal of pleural drainages. A residual pneumoperitoneum is still present.
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Results
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No patients had complications develop during the induction of pneumoperitoneum. Two patients had mild fever for 2 days after the procedure. Three patients complained of moderate abdominal pain and dyspepsia. One patient had atrial fibrillation successfully treated with antiarrhythmic drugs. Although no patients complained of dyspnea, the comparison of blood gas analysis values showed a slight increment in the values of carbon dioxide partial pressure, and the difference was statistically significant (p = 0.0004). Selected values of blood gas analysis are shown in Table 1. Obliteration of the pleural space was observed in all patients after a mean time of 4 days (range, 1 to 7 days; Fig 1). Air leaks stopped in all cases after a mean time of 8 days (range, 4 to 12 days). Two patients were discharged after the placement of a Heimlich valve, which was removed as soon as air leak stopped. The mean of the postoperative hospital stay after the operation was 18 days (range, 14 to 22 days). No recurrence of air leak and spaces were observed during a follow-up of 3 months after hospital discharge. No patients had long-term sequelae, and we observed the complete resolution of pneumoperitoneum after a mean time of 26 days (range, 18 to 40 days). In the group of 6 patients who had undergone induction chemotherapy, we observed that the length of air leak duration was longer than that observed in the noninduction group, and the difference was statistically significant. Although the obliteration time and length of hospital stay were longer in the induction therapy group, the differences were not statistically significant (Table 2).
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Table 2. Comparison of Results Between Patients Undergoing Induction Chemotherapy (Group 1) and Without Induction Chemotherapy (Group 2)a
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Comment
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The use of pneumoperitoneum to treat prolonged air leaks in patients with basal spaces after lung resection is not new. Recently some authors recommended its use after lung volume reduction surgery to manage apical spaces and prolonged air leaks [3, 6]. Expansion of the residual lung, mediastinal shift, narrowing of the intercostal spaces, and elevation of ipsilateral hemidiaphragm represent the physiologic mechanisms working to compensate the removal of lung tissue. A space problem may result after any type of pulmonary resection, but it is more likely after lobectomies or bilobectomies. Factors that predispose to space problems are a persistent large air leak, restrictive lung disease, fixed mediastinum secondary to radiation or other disease, previous thoracic operation, and probably the effects of induction therapy (chemotherapy or radiation therapy) in patients with locally advanced non–small cell lung cancer. Intraoperative maneuvers can be performed to prevent the development of space problems, such as minimizing air leaks (using staplers, buttressing material, surgical glues) [7–10], decortication of a restrictive pleural peel, sectioning of the lower pulmonary ligament, preparation of a pleural tent [11], phrenic nerve crush, and even thoracoplasty [12]. Notwithstanding the use of these techniques, the development of spaces can be unpredictable. In our experience it was foreseeable only in 2 patients. The mere presence of space does not necessarily mean a serious problem because a high percentage of cases can achieve a spontaneous remission, especially when an air leak is not associated [13]. The presence of a residual space associated with prolonged air leaks can be difficult to treat, exposes to high risk of infection, prolongs hospitalization, and in some cases mandates reoperation. Pneumoperitoneum is effective in both apical and basal air spaces, is easy to perform, and most importantly allows temporary elevation of the diaphragm with no long-term sequelae. Talc pleural sclerosis can be added to help control air leaks, and we believe that it should be used only when the lung is fully reexpanded and there is no residual space. Although some authors [3, 4] suggest the placement of a temporary catheter under the diaphragm to insufflate air several times during the postoperative period, we do not recommend this maneuver because of risk of infection and displacement. In our experience it was necessary to refill the pneumoperitoneum only in 1 patient in whom we probably injected a too small amount of air. In this study, we also noted that air leaks and pleural space problems were more difficult to treat among patients who underwent induction chemotherapy. This observation might be explained because of the effects of chemotherapy or radiotherapy. Major tissue fragility, fibrosis, and diffuse desmoplastic reaction, especially when marked shrinking of the tumor is obtained, are very common, and surgeons who deal with these patients are aware that the operation can be technically demanding and associated with a higher morbidity [14, 15]. These effects could compromise the physiologic mechanism of lung healing and reexpansion, and the more fixed mediastinum could not shift enough to compensate the portion of lung removed.
Our experience supports the use of pneumoperitoneum, and we suggest that it should be used whenever a space problem associated with prolonged air leak is present, because of the moderate effects on the respiratory status and the low rate of complications.
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Abstract
Introduction
