THE FATE OF THE POSTRESECTION SPACE

S.Ramghulamle Roux Institute of Thoracic Surgery 2012

‘ As nature abhors a vacuum, so does the thoracic surgeon abhor a residual space after resecting

lung tissue’

Arthur W Silver. The fate of the post-resection space. Annals of Thoracic Surgery 1966

POINTS TO UNRAVEL

What operative factors result in a space?

With what concerns should these spaces be viewed?

Hazards to the patient?

How vigorous should one be?

Terminology

Benignclosed benign space

with alveolar seepagewith bronchopleural fistula

Malignantlarger / increasing size

contain fluid symptomatic

Institutional Review

All lung resections done at one of our operative centres, IALCH between March 2010 – February 2012

Exclusion criteriapneumonectomy

lung biopsy

Methods

Retrospective analysis of clinical data and radiographs

Space considered significant ifpresent > 7 days

size arbitary

Indications for surgery

Space complications and intervention

Data analysis

158 lung resections on 157 patients

90 – inflammatory, majority sequelar / active TB

49 – malignant18 – miscellaneous

PAVM, hydatid, foregut duplication,foreign body bronchiectasis

69 pneumonectomy (excluded from analysis)89 lobectomy

Results

Significant space 14/89 (15.7%)Infected 4/14 (28 %) *

Infected spaces2 emergency for massive haemoptysis1 elective for recurrent minor haemoptysis1 post middle lobectomy for foregut duplication

cyst *

Results

Pathology

Extent of resection

Pathology

PATHOLOGY N = 89

POST

OPERATIVE SPACES

FLUID COLLECTION

Inflammatory

( sequelar / active TB )

54 ( 61 % ) 12 3 empyema

Neoplastic 26 ( 29 % ) 1 Serous effusion

Misc. 9 ( 10 % ) 1 1 empyema

EXTENT OF RESECTION

right upper 22

middle 4

lower 11

bi-lobe 7

left upper 25

lower 18

Total 87

Results

Lobectomy 80/89 (90 %)space problems 12/80 (15 %)

Bi-lobectomy 7/89 (7.9 %)space problems 2/7

(28.5%)

Segmentectomy 2/89 (2.2%)no space complications

Results

Spontaneous resolution 9/14 (65%)

Intervention 5/14 (35%)4 tube drainage

1 re-operation

Active TB with massive haemoptysisRight upper lobectomyConservative treatment

Active TB with massive haemoptysisRight upper and middle lobectomyTreated with tube drainage

6 week follow up

Follow up

Space persisting > 7 days regarded as significant

10/14 persistent spaces

8/10 complete resolution by 2/521/10 complete resolution by 3/521/10 defaulted follow up

Discussion

Empyema2 LUL

UL and ML- emergency for massive haemoptysis

1 RUL- elective minor haemoptysis – Bioglue!

1 ML - foregut duplication cyst

3/4 pathology – TB3/4 resolved1/4 required completion pneumonectomy

Discussion

Factorspathology

shrunken vs. non-shrunkeninflammatory

techniquefissures

air-leaks

parenchymal

bronchiolar

BPF

Intervention

Infection

BPF

Increase (relative)

Discussion

Discussion

Intervention

Methodsaspiration

tube drainagethoracoplastyre-operation

“The benign nature of post-operative pleural spaces is thus apparent, and it is strongly urged that aggressive treatment of these spaces be withheld unless some urgent indication, such as infection, occurs.”

Conclusion

Arthur W Silver. The fate of the post-resection space. Annals of Thoracic Surgery 1966