THE FATE OF THE POSTRESECTION SPACE S.Ramghulam le 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 Benign closed benign space with alveolar seepage with bronchopleural fistula Malignant larger / increasing size contain fluid symptomatic

Institutional Review All lung resections done at one of our operative centres, IALCH between March 2010 – February 2012 Exclusion criteria pneumonectomy lung biopsy

Methods Retrospective analysis of clinical data and radiographs Space considered significant if present > 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 – malignant 18 – 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 spaces 2 emergency for massive haemoptysis 1 elective for recurrent minor haemoptysis 1 post middle lobectomy for foregut duplication cyst *

Results Pathology Extent of resection

Pathology PATHOLOGYN = 89 POST OPERATIVE SPACES FLUID COLLECTION Inflammatory ( sequelar / active TB ) 54 ( 61 % )123 empyema Neoplastic26 ( 29 % )1Serous effusion Misc. 9 ( 10 % )11 empyema

EXTENT OF RESECTION rightupper22 middle4 lower11 bi-lobe7 leftupper25 lower18 Total87

Results Lobectomy 80/89 (90 %) space problems 12/80 (15 %) Bi-lobectomy7/89 (7.9 %) space problems 2/7 (28.5%) Segmentectomy2/89 (2.2%) no space complications

Results Spontaneous resolution9/14 (65%) Intervention 5/14 (35%) 4 tube drainage 1 re-operation

Active TB with massive haemoptysis Right upper lobectomy Conservative treatment

Active TB with massive haemoptysis Right upper and middle lobectomy Treated 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 2/52 1/10 complete resolution by 3/52 1/10 defaulted follow up

Discussion Empyema 2 LUL UL and ML - emergency for massive haemoptysis 1 RUL - elective minor haemoptysis – Bioglue! 1ML - foregut duplication cyst 3/4 pathology – TB 3/4 resolved 1/4 required completion pneumonectomy

Discussion Factors pathology shrunken vs. non-shrunken inflammatory technique fissures air-leaks parenchymal bronchiolar BPF

Intervention Infection BPF Increase (relative) Discussion

Intervention Methods aspiration tube drainage thoracoplasty re-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