Keywords
fibrin glue - pleurography - pneumothorax
Introduction
Although a primary spontaneous pneumothorax can be easily treated by excision of blebs, a secondary spontaneous pneumothorax (SSP) is much more difficult to treat.[1]
[2] Despite the development of techniques, excision of bullae in a patient with an SSP and an adhesiotomy could result in a prolonged air leakage or a recurrence of pneumothorax and postoperative pneumonia. Therefore, there is a need for an innovative technique without surgical invasiveness in patients with an SSP. Herein, we introduce the procedure “fibrin glue application under pleurography” (FGAP) and analyze the short-term outcomes of patients who underwent this procedure.
Patients and Methods
Twenty patients were underwent the glue application procedure under pleurography for an intractable persistent air leak in our hospital from November 2016 to March 2018. Of them, 14 patients suffered from a SSP; two for a cancer-related pneumothorax, and the others for emphysema. The other six patients had prolonged air leaks after previous operations; one patient underwent a wedge resection of the right lower lobe and previously had a right upper lobectomy due to lung cancer 3 years ago; two patients had wedge resections of the right lower lobe to exclude a malignancy; one patient was scheduled to undergo esophagectomy but failed the operation because of severe adhesions that developed from tuberculous pleurisy. Two patients had already undergone bullae ligation under epidural anesthesia ([Table 1]).
Table 1
The etiology of persistant pneumothorax
|
Causes of air leakage
|
Underlying disease
|
n
|
|
Secondary spontaneous pneumothorax
|
|
14
|
|
Lung cancer
|
2
|
|
Bullous emphysema
|
12
|
|
Postoperative air leakage
|
|
6
|
|
Wedge resection
|
Lung cancer
|
3
|
|
Exploratory thoracotomy
|
Esophageal cancer with tuberculous pleurisy
|
1
|
|
Bullae ligation under epidural anesthesia
|
Secondary spontaneous pneumothorax
|
2
|
The FGAP was considered in patients with intractable persistent air leakage even after bed-side dextrose pleurodesis who had at least one of the following: poor pulmonary function test results, comorbidities to undergo general anesthesia, such as heart disease, interstitial lung disease, or systemic disease, and expected severe adhesions due to previous surgery.[1]
All medical records were retrospectively reviewed for frequency of bed-side pleurodesis, pre- and postprocedural chest tube drainage, postprocedural complications, postprocedural hospital stay, and hospital death.
This study was approved by the Institutional Review Board of Pusan National University, Busan, Republic of Korea. Informed consent was not required for this retrospective study. Data were analyzed with IBM Statistical Package for Social Sciences software (version 16.0; SPSS Inc., Chicago, Illinois, United States).
FGAP Technique
A Flexor Check-Flo Introducer (Cook Medical Inc., Bloomington, Indiana, United States) was inserted through a chest tube, and contrast media, Xenetix 300 (Roissy, France), was injected through the introducer. To precisely identify the air leak point, the patient was requested to breathe in and out deeply. After the air-leak point was identified by pleurography with contrast medium which was shown as bubbling from the air leak focus depending on respiration, a double lumen catheter was inserted through the introducer and guided to the air-leak point by twisting the introducer and advancing the double lumen catheter through the introducer to the leak point. Fibrin sealant Tisseel (Baxter Healthcare Corp., Deerfield, Illinois, United States) 4 cc consisting with fibrin (2 cc) and thrombin (2 cc), each diluted with contrast media, were alternately dropped slowly at the air-leak point ([Fig. 1]). Then, a 24 F chest tube was reinserted. The chest tube bottles were not under negative suction.
Fig. 1 (A) Schematic illustrations showing the air leak point identified using contrast medium according to image (B); (C) schematic illustrations showing applied the fibrin glue in the air leak point, which was found out to be well covered around the small fistula, but still having air leak from here making us to re-explore (D, arrow).
Postoperative Care
No suction was allowed for 1 to 2 days to prevent the glue from failing. The chest tube was removed when an X-ray showed full expansion and the air leak had stopped for 2 days. The chest tube was clamped for 1 day to detect any minor air leakage. A natural drain was inserted for 2 to 3 days when persistent air leakage continued after the procedure; however, in cases with space, the chest bottles were placed under 20 cm H2O of negative suction. Bedside pleurodesis using 50% dextrose was applied or pleurography was tried again if there was full expansion with continuous air leakage ([Fig. 2]).
Fig. 2 Algorithm for management after applying fibrin glue under pleurography in cases of a secondary spontaneous pneumothorax. AL, air leakage; LPS, low power suction.
Results
Most of patients had bed-side pleurodesis at least twice before FGAP. Mean procedure time was 20.5 ± 5.4 minutes (median: 17.5 minutes, range: 13–29 minutes), and the mean duration of preprocedure drainage was 21.44 ± 3.71 days (range: 16–31 days). The mean duration of postprocedure drainage was 4.17 ± 2.11 days (range: 3–14 days). Nineteen patients had one chest tube and one patient had two chest tubes because of a previous operation. The mean hospital stay was 30.56 ± 7.02 days (range: 21–45 days) and the mean postprocedural hospital stay was 7.93 ± 2.43 days (range: 4–20 days; [Table 2]).
Table 2
Results in patients who underwent the glue application under pleurography
|
Characteristics
|
Mean
|
|
Frequency of dextrose pleurodesis before procedure (n)
|
2.5 ± 0.5
|
|
Operative time (min)
|
20.5 ± 5.4
|
|
Preprocedural drainage (d)
|
21.44 ± 3.71
|
|
Postprocedural drainage (d)
|
4.17 ± 2.11
|
|
Total hospital stay (d)
|
30.56 ± 7.02
|
|
Postprocedural hospital stay (d)
|
7.93 ± 2.43
|
|
Postoperative pain score for the first postprocedure
|
1.7 ± 0.17
|
Air leakage stopped just after the procedure in most cases (n = 18); however, the patient who had previous operation for lung cancer had the decreased air leakage just after FGAP and stopped after 12 days, and another patient suffered from pneumothorax caused by bullous emphysema needed an operation to control the air leakage 16 days after the initial procedure ([Fig. 1]).
No postprocedural complications were detected, such as empyema, acute respiratory distress syndrome, or pneumonia. The mean duration of follow-up was 12.01 ± 5.02 months (range: 4–22 months).
Discussion
An intractable persistent air leak can lead to death due to respiratory insufficiency or combined severe infection, particularly in a patient with an SSP and concomitant lung diseases; thus proper management to control an air leak is necessary and unavoidable. However, it is difficult to decide whether to perform a surgical intervention in high risk patients or patient expecting a prolonged postoperative air leakage.[2]
[3]
[4]
[5] Although awake surgery has been performed worldwide, it is difficult to find the air leak focus in cases with severe adhesions and it is hard for patients to endure the operation.
Some studies have recommended chemical pleurodesis using antibiotics or chemo agents for a prolonged air leak, as it generally induces symphysis between the parietal pleura and visceral pleura to stop the air leak. However, side effects can develop, such as acute respiratory distress syndrome or severe chest pain.[6]
[7]
[8]
[9] Then we usually prefer bed-side pleurodesis using 50% dextrose 50 cc several times.
However, considering an air leak that developed from one minimal focus and a pneumothorax as a visceral disease, development of symphysis between the whole pleura might be an unnecessary procedure and rather cause pleuritic chest pain.[6] FGAP is an option to detect the air leak point and apply a sticking agent, such as fibrin glue, to heal the tear point without additional anesthesia or pain control.
We usually wait to see if a persistent postoperative air leak spontaneously resolves in 10 to 14 days after applying suction with bedside dextrose pleurodesis to avoid a second operation. Considering re-exploring the pleural cavity, many surgeons are reluctant to re-operate due to the high risk of secondary lung injury. FGAP could be convenient in these cases because of no additional dissection of the adhesions.
Although the operation was unavoidable in one case in our series, the air leaks were successfully sealed with fibrin glue in the other cases (19/20, 95%), and there were no complications. Therefore, FGAP should be considered to treat patients with an intractable persistent air leak to prevent a high-risk surgery under general anesthesia or a prolonged postoperative air leak.
Nevertheless, an advanced technique to confirm the air leak focus, place the catheter to deliver the fibrin glue and also to get successful results, FGAP needs to be considered in limited cases, such as expecting fully lung expansion under low power suction, which means there might be no adhesion to prevent lung expansion.
