Abstract
Intraoperative alveolar air leaks occur in patients with non-small-cell lung cancer (NSCLC) following a pulmonary resection using thoracoscopic surgery. We showed the efficacy of covering damaged lung tissue with a subcutaneous fat pad for preventing postoperative air leak. Thoracoscopic surgery was performed for NSCLC patients with three incisions along with a 3–4 cm anterior utility incision. When an air leak originated from deep within the pulmonary parenchyma or was large, a subcutaneous fat pad ∼2 × 2 cm in size was harvested from the utility incision and placed on the damaged lung tissue with fibrin glue and 2–3 mattress sutures. Subcutaneous fat pads were used for 50 patients with NSCLC during thoracoscopic surgery procedures. There were no intraoperative complications in any of the patients. A prolonged air leak (>7 days) was noted in 3 (6%) of the 50 patients. Air leak was diminished at 1.5 ± 2.6 postoperative days and the chest tubes removed at 3.2 ± 2.8 postoperative days. Reinforcement of damaged lung tissues by use of subcutaneous free fat pads is a safe and intriguing procedure in NSCLC patients who underwent a pulmonary resection in thoracoscopic surgery.
Intraoperative alveolar air leaks can occur following a pulmonary resection procedure [1]. Air leak that persists for >7 days after surgery has been defined as a prolonged air leak and often results in increased complications and length of hospitalization [2]. In fact, one of the most common complications encountered after thoracoscopic surgery for patients with non-small-cell lung cancer (NSCLC) is a prolonged air leak and the rate of occurrence in such cases is 16.9% [3]. At our institution, a subcutaneous fat pad is used for covering injured pulmonary parenchyma to repair damaged lung tissue.
OPERATIVE PROCEDURE
The thoracoscope incision was performed in the seventh intercostal space (ICS) along the midaxillary line and a 2-cm incision was then made in the seventh ICS in the auscultatory triangle. An access thoracotomy was also located in the fourth ICS in the anterior axillary line (3–4 cm). After resection, mediastinal lymph node dissection was performed, followed by an air leak test under a pressure loading of 25 cmH2O. In cases with alveolar air leak occurring from a deep location or a large area of pulmonary parenchyma, subcutaneous fat pads ∼2 × 2 cm in size were harvested from the access thoracotomy (Fig. 1A, Supplementary Video 1) and placed on the damaged lung tissue with fibrin glue in combination with two or three mattress sutures (Fig. 1B–D, Supplementary Video 2). All of the patients received 24-F chest tubes at the end of the operation and suction at −10 cmH2O was applied. The chest tubes were removed when pleural drainage decreased to <200 cc/day and no air leak was detected.
(A) Photograph showing subcutaneous fat pads harvested from the thoracotomy access. (B) Thoracoscopic view showing air leak from lung parenchyma (arrow). (C) Thoracoscopic view showing management of injured pulmonary parenchyma around stapled lines with fibrin glue. (D) Thoracoscopic view showing harvested subcutaneous fat pads attached to damaged lung tissue with fibrin glue in combination with two mattress sutures.
RESULTS
Subcutaneous fat pads were used for 50 patients with NSCLC during thoracoscopic surgery procedures from January 2010 to March 2013. Thirty-nine patients underwent lobectomy and 11 segmentectomy, and 35 patients had Stage IA disease, 13 Stage IB and 2 patients Stage IIA. The operation time was 212 ± 54 min and blood loss was 83 ± 84 g. There were no intraoperative complications in any of the patients. A prolonged air leak (>7 days) was noted in 3 (6%) of the 50 patients. Air leak was diminished at 1.5 ± 2.6 postoperative days and the chest tubes were removed at 3.2 ± 2.8 postoperative days. In addition, computed tomography (CT) findings obtained after 6 months showed the continuing existence of the fixed free fat pads on the stapling line (Fig. 2).
Representative chest CT images showing existence of fixed free fat pad 3 (A and D), 6 (B and E) and 12 (C and F) months after operation (arrow). (A–C) CT findings of a patient who underwent a lobectomy. (D–F) CT findings of a patient who underwent a segmentectomy.
DISCUSSION
Postoperative air leaks occur after closure of the chest wall despite water seal test findings showing no such leak. It is difficult to find the exact location of the air leak, because the procedure is performed in a closed space and the infiltrated lung obstructs the thoracoscopic view. Another mechanism of air leak recurrence may be over-inflation of the residual lung, which stretches the dissected lung parenchyma, thereby reopening the alveolar fistula [4]. In our method, the free subcutaneous fat pads applied to damaged lung tissues are fixed by mattress sutures such as a pledgeted suture to protect the fragile parenchyma. It is also difficult to perform continuous sutures during a thoracoscopic surgery procedure, and thus, we consider that free subcutaneous fat pads are advantageous, as they can be easily fixed. In addition, it is easier to prepare the free fat pads from the working port during thoracoscopic surgery compared with harvesting intrathoracic pleura or pericardial fat pads. The use of fat pads harvested from the patient during the procedure has advantages including no cost or adverse effects when compared with commercially available non-autologous materials.
SUPPLEMENTARY MATERIAL
Supplementary material (Videos 1 and 2) is available at EJCTS online.
Video 1: Subcutaneous fat pads were harvested from the thoracotomy access.
Video 2: The harvested subcutaneous fat pads were attached to damaged lung tissue with two mattress sutures.
Conflict of interest: none declared.
