Ann Thorac Surg 2005;80:1055
© 2005 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
M. Blair Marshall, MD
Department of Surgery, Thoracic Division, Georgetown University Hospital, 4 PHC, 3800 Reservoir Rd NW, Washington, DC 20007
(Email: mbm5{at}gunet.georgetown.edu).
Prolonged air leaks after pulmonary resection are a source of frustration for both thoracic surgeons and their patients. For most, the day-to-day management of leaks is the management of chest tubes. The optimal management is a source of continued debate.
In general, two theories exist: (1) suction applied to chest tubes prolongs air leaks by increasing the amount of air escaping from the parenchyma, and (2) suction applied to chest tubes decreases the amount of residual space, promoting pleural apposition and healing. Brunelli and colleagues [1] previously demonstrated no advantage to the water seal compared with suction (–20 cm) in patients undergoing lobectomy. This is in direct contrast with studies by Cerfolio and colleagues [2] and others [3], demonstrating an advantage to the water seal; however, the latter studies included patients who underwent wedge resection, segmentectomy, and lobectomy. This is an important difference.
In the present study, the authors adopted an alternating strategy of less forceful suction (–10 cm) overnight and the water seal during the day [4]. They then compare this strategy in a randomized prospective fashion to the water seal alone. Pleural tents were used in all patients undergoing upper lobectomy or bi-lobectomy. The alternating strategy was chosen to recruit the advantages of each strategy: suction (–10 cm) at night to promote pleural apposition and the water seal during the day to allow for patient mobilization. Their data demonstrates that the alternate regimen reduces the number of patients with a prolonged air leak the length of hospital stay, but the duration of air leaks does not appear to be significantly different.
This is an important article that raises several questions: In which patients is suction optimal? Should air leaks be handled the same between patients undergoing different operations (ie, wedge resection, segmentectomy, or lobectomy)? Is less suction better than more? How would an alternating regimen optimize the healing of air leaks?
As the majority of patients undergoing lobectomy leave the hospital by postoperative day 5, the current definition of a prolonged air leak of 7 days is outdated. Should this continue to be our unit of measure? With the data available, the optimal management of chest tubes for air leaks still resembles the art in thoracic surgery. I look forward to continued work in this area by Brunelli and colleagues [1] and others to answer these questions.
 |
References
|
|---|
- Brunelli A, Monteverde M, Borri A, et al. Comparison of water seal and suction after pulmonary lobectomya prospective, randomized trial. Ann Thorac Surg 2004;77:1932-1937.[Abstract/Free Full Text]
- Cerfolio RJ, Bass C, Katholi CR. Prospective randomized trial compares suction versus water seal for air leaks Ann Thorac Surg 2001;71:1613-1617.[Abstract/Free Full Text]
- Marshall MB, Deeb ME, Bleier JI, Kucharczuk JC, Friedberg JS, Kaiser LR, Shrager JB. Suction vs. water seal after pulmonary resectiona randomized prospective study. Chest 2002;121:831-835.[Abstract/Free Full Text]
- Brunelli A, Sabbatini A, Xiume’ F, et al. Alternate suction reduces prolonged air leak after pulmonary lobectomya randomized comparison versus water seal. Ann Thorac Surg 2005;80:1052-1055.[Abstract/Free Full Text]
Top
References