Management of Subcutaneous Emphysema After Pulmonary Resection

Transcription

1 Management of Subcutaneous Emphysema After Pulmonary Resection Robert J. Cerfolio, MD, Ayesha S. Bryant, MSPH, MD, and Lee M. Maniscalco Division of Cardiothoracic Surgery, University of Alabama, Birmingham, Alabama Background. Subcutaneous emphysema (SE) after pulmonary resection is troublesome and has been poorly within 24 hours in all patients except 1. These 64 patients chest tube placement, which successfully resolved the SE studied. had a significantly shorter hospital stay (6 versus 9 days, p Methods. A retrospective review was made of a prospective database. Patients who underwent pulmonary resec- patients. 0.02) and less time with recalcitrant SE than the other 21 tion and in whom clinically detected SE were studied. Conclusions. Subcutaneous emphysema is more likely in Results. Of 4,023 patients between January 1999 and June patients who have an FEV 1 % less than 50% and who 2006, 255 patients (6.3%) had clinically apparent SE. Predic-undergtors of developing SE by multivariate analysis were preop-(se that persists despite increasing chest tube suction) is a redo thoracotomy. Recalcitrant SE emphysema erative forced expiratory volume of air in 1 second 1%) (FEV more likely in patients who undergo lobectomy and is best less than 50%, having an air leak, and having had treated a by video-assisted thorascopic surgery with pneumolysis between the leaking lung, which is usually partially previous thoracotomy. Despite maximizing chest tube suction, 85 patients (33%) had recalcitrant SE. These patientsadhered to the previously opened intercostal space. This with recalcitrant SE were more likely to have a lowerdirects the air leak back into the pleural space and out of the median FEV 1 %(p 0.037), a previous ipsilateral thoracotomy, and have undergone a lobectomy p < ( 0.001). Re- of SE and hospital stay. subcutaneous space. This procedure shortens the duration cently, 64 of the 85 patients underwent single-incision, (Ann Thorac Surg 2008;85: ) video-assisted thorascopic surgery with pneumolysis and 2008 by The Society of Thoracic Surgeons a small incision at the base of the neck (we prefer supracla- Although subcutaneous emphysema (SE) is a nonlethal vicular), which serves as a pop-off valve through which air condition, it is often troubling to patients and theircan be pressed out of the eyelids, down the face, and out the families. Once air enters the subcutaneous space of thesmall incision [5]. We reviewed our experience with patients chest wall, it dissects into the soft tissues of the face, neck, who had SE and recalcitrant SE after pulmonary resection. upper chest, and shoulders. That results in cosmetic deformities but rarely results in any physiologic problems such Material and Methods as tension pneumomediastinum, pneumothorax, or pneumopericardium [1]. Although it is relatively common, it has This is a retrospective cohort study using a prospective been poorly studied. We can only locate two peer-reviewedoperative database over an 8-year period from one surgeon. articles in the literature (excluding case reports) on thepatients who underwent elective pulmonary resection were treatment of this relatively common clinical problem [2, 3]. eligible for inclusion into this study. Entry criteria required Usually a patent functioning chest tube in the pleural spacepatients to have a patent, functioning chest tube in the on high suction alleviates the problem. However, some pleural space and attached to a pleural drainage system. patients have progressive SE despite this care 4], [ what we Patients had to have undergone either a lobectomy, segmentectomy, wedge resection (either through thoracotomy define as recalcitrant SE. Once into the subcutaneous space, air can dissect from the chest into the face and then into the or through video-assisted thorascopic surgery [VATS]) and eyelids. The eyelids can easily swell and lead to the inabilityhave clinically symptomatic SE as defined below. Lobec- and anatomic segmentectomy were only performed to see. When this occurs, a second chest tube is oftentomy inserted and also placed to high 40 ( cm of water) wall through open thoracotomy. Patients who underwent pneumoperitoneum or pleural tent (which we rarely use) were suction. However, sometimes this maneuver also fails to eradicate the problem. Some then find it necessary to createeliminated from this study. In addition, patients less than 19 Accepted for publication Dec 31, Presented at the Fifty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 7 10, Address correspondence to Dr Cerfolio, Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, th St S, ZRB 739, Birmingham, AL 35294; rcerfolio@uab.edu. years of age and those who underwent pneumonectomy were excluded. Chest tubes placed at the completion of the elective operation were straight 28F soft chest tubes (Deknatel; Genzyme Biosurgery, Cambridge, Massachusetts) This study was approved by the University of Alabama at Birmingham s Institutional Review Board. Patient consent was obtained for entry into the operative and clinic databases, and patients were informed that their data might 2008 by The Society of Thoracic Surgeons /08/$34.00 Published by Elsevier Inc doi: /j.athoracsur

2 1760 CERFOLIO ET AL Ann Thorac Surg MANAGEMENT OF SUBCUTANEOUS EMPHYSEMA 2008;85: Fig 1. Patient flow in this study. (CT chest tube; SE subcutaneous emphysema; VATS videoassisted thorascopic surgery.) be used for research purposes. Separate consent for this specific study was waived. Definitions Clinically symptomatic SE was defined as air under the skin that was perceptible by the clinician, patient, or family member, or a change in voice. Patients who had SE that was only radiologically apparent were not included in this study. Persistent or recalcitrant SE was defined as SE that did not resolve despite the presence of a patent, functional chest tube on high suction in the pleural space. Surgical Technique of VATS Pneumolysis for Recalcitrant SE Patients with recalcitrant SE who were taken back to the operating room underwent the following procedure. A Table 1. Patient Characteristics and Outcomes for Patients in Whom Subcutaneous Emphysema Did and Did Not Develop No Subcutaneous Emphysema Subcutaneous Emphysema p Value Number of patients 3, Age (median) 67 (19 84) 62 (23 72) Male sex 2,524 (67%) 179 (70%) Type of resection Lobectomy/bilobectomy 1,207 (32%) 105 (41%) Segment 1,055 (28%) 57 (22%) Wedge/VATS wedge 603 (16%) 42 (16%) Exploratory thoracotomy 903 (24%) 51 (20%) Initial procedure 3,692 (98%) 233 (92%) Median hospital day of subcutaneous emphysema initial presentation NA 1.2 NA Patients with preoperative FEV 1 % 50% 3,278 (87%) 187 (73%) Patients with preoperative DLCO% 50% 3,127 (83%) 183 (72%) Air leak 339 (9%) 40 (16%) Median length of stay (days) DLCO% diffusion capacity of lung for carbon monoxide; FEV 1 % forced expiratory volume of air in 1 second; NA not applicable; VATS video-assisted thorascopic surgery.

3 Ann Thorac Surg CERFOLIO ET AL 2008;85: MANAGEMENT OF SUBCUTANEOUS EMPHYSEMA 1761 Table 2. Patient Characteristics and Outcomes for Those Patients With and Without Recalcitrant Subcutaneous Emphysema Subcutaneous Emphysema Resolved With Chest Tube Suction Recalcitrant Subcutaneous Emphysema p Value Number of patients Age, years (median) Male sex 116 (68%) 63 (74%) History of smoking 145 (85%) 76 (89%) Type of resection Lobectomy/bilobectomy 57 (34%) 48 (56%) Segment 44 (26%) 13 (15%) Wedge/VATS wedge 32 (19%) 10 (12%) Exploratory thoracotomy 37 (22%) 14 (16%) Initial procedure 160 (92%) 73 (86%) Median hospital day of subcutaneous emphysema initial presentation Patients with preoperative FEV 1 % 50% 133 (76%) 54 (63%) Patients with preoperative DLCO% 50% 126 (74%) 57 (67%) Air leak 20 (13%) 20 (24%) Median length of stay (days) DLCO% diffusion capacity of lung for carbon monoxide; FEV 1 % forced expiratory volume of air in 1 second; VATS video-assisted thorascopic surgery. bronchoscopy was performed to ensure there was no bronchopleural fistula, and usually the procedure was done with a single-lumen endotracheal tube only. One single 2- to 3-cm incision was made between the previous thoracotomy incision and the previous chest tube incision (thus inferior to the initial thoracotomy incision but superior to the previous chest tube incisions). Video-assisted thorascopic surgery was carried out through this sole incision, and the lung, which was commonly found to be adhered to the part of the chest that had been previously opened, was taken down using a sucker, as these adhesions were usually only a few days old. That caused the pulmonary alveolar leak (which was a pulmonary alveolar-subcutaneous fistula) to now drain into the pleural space instead of the subcutaneous space (making it an alveolar-pleural fistula). A new 28F soft chest tube (Deknatel) was placed through the incision, and it was placed on 40 cm of wall suction. Once the subcutaneous emphysema resolved or diminished, patients were placed on an Atrium Express (Atrium Medical Corporation, Hudson, New Hampshire) and discharged home after 1 day of observations to ensure the SE did not return on this compact home portable device. Statistics A 2 analysis or Fisher exact test was used to evaluate discrete dichotomous variables. Analysis of variance (ANOVA) was used for discreet nondichotomous variables. For continuous variables, Student s t test or the Mann- Whitney U test was used to compare means. All comparisons were two-sided with a p value of less than 0.05 used to indicate statistical significance. Univariate analyses were performed with a two-sided log-rank test [6]. Variables with a significant difference between groups based on results of the univariate analyses were entered as candidate variables in a multivariate analysis with both forward and backward stepwise inclusion of factors, with an inclusion criterion of p All statistical analysis was performed using SAS v. 9.0 (SAS Institute, Cary, North Carolina). Results Between January 1999 and June 2006, in 255 (6.3%) of 4,023 patients who underwent pulmonary resection, clinically noticeable SE developed. Eighty-five (38%) of these 255 patients had recalcitrant SE, defined as SE that did not resolve after the chest tube suction was maximized to 40 cm of suction. There was no statistically significant difference in the incidence for patients who underwent upper lobe procedures compared with those who had lower lobe procedures performed. There was no difference in the incidence of preoperative steroid usage in the two groups. Figure 1 shows the patient flow in this series. Table 1 shows the patient characteristics and outcomes and compares patients who did and did not have SE after resection. Univariate analysis showed patients who had SE were more likely to be younger (p 0.046), have had a lobectomy (p 0.015), have forced expiratory volume of air in 1 second (FEV 1 %) less than 50% (p 0.001), have a lung diffusion capacity for carbon monoxide (DLCO%) predicted less than 50% (p 0.001), have an air leak (p 0.001), and have had a previous ipsilateral thoracotomy (p 0.001). Previous thoracotomy (p 0.014), low preoperative FEV1% predicted (p 0.023), and having an air leak (p 0.005) remained significant predictors of predictors of developing subcutaneous emphysema on multivariate analysis. Eighty-five (33%) of the 255 patients who had SE had recalcitrant SE. Table 2 shows the characteristics and outcomes of these patients. Univariate analysis showed these 85 patients were likely to be younger (p 0.041), have had a previous ipsilateral thoracotomy (p 0.009), a lobectomy (p 0.001), have SE that was noticeable sooner (p 0.012), have a lower FEV1% (p ), and have an air leak (p

4 1762 CERFOLIO ET AL Ann Thorac Surg MANAGEMENT OF SUBCUTANEOUS EMPHYSEMA 2008;85: ) than patients whose SE resolved with maximizing chest tube suction. Not surprisingly, patients with recalcitrant SE were also likely to have a significantly greater hospital length of stay (p 0.037). Smoking status and sex did not impact the development of recalcitrant SE. Multivariate analysis showed that a lower median FEV1%, having a previous ipsilateral thoracotomy, and having had a lobectomy were significant predictors of having recalcitrant SE. Initially, the first 21 of these 85 patients with recalcitrant SE underwent placement of an additional chest tube at the bedside when increasing the suction on the existing chest tube failed to alleviate the SE. After that, the remaining 64 patients all went directly for VATS. Single-incision VATS was performed with pneumolysis and chest tube placement instead of bedside chest tube placement. The median time of the operation was 16 minutes (range, 9 to 43). All but 1 patient was relieved of their symptomatic SE within 24 hours. These 64 patients had a significantly shorter hospital stay (6 versus 9 days, p 0.02) and less time with recalcitrant SE than the other 21 patients. Both groups of patients were sent home with a chest tube attached to a portable device. Comment Prevention of Subcutaneous Emphysema Subcutaneous emphysema, like air leaks, represents a nonlethal postoperative complication. Yet, even though it may not be fatal, it adds significant morbidity and prolongs hospital stay. It also causes anxiety and erodes the confidence patients and family members have in their physicians. There are several types of treatments, including observation, the creation of pop-off valves, the use of computed tomography scans to identify an air pocket and guide percutaneous catheters to help achieve pleural pleural apposition or the placement of a new chest tube. The optimal therapy has not been defined, however. This study imports some science into these decisions. It is difficult for a patient to hear that the air under the skin is not a problem, don t worry, it will all get better when their eyelids are swollen shut and they cannot see or when their voice becomes high pitched secondary to air dissecting into their larynx. Interestingly, we have noted an increased incidence in our practice of clinically apparent and recalcitrant SE over the past few years. This trend may be true for others as well based on our discussion with thoracic surgeons across the country although there is no published literature that supports this claim. In our practice, the incidence is rising, and this is probably attributable to several factors. One important possible variable for this increase may be that we are operating on more patients with low FEV1% and DLCO%. As shown in this paper, both the FEV1% and DLCO% were predictors of developing SE, and they were also predictors of having recalcitrant SE on univariate analysis. Another cause may be that we, like others, have changed to placing only one chest tube after lobectomy instead of two. In addition, we now use a softer tube (a 28F chest tube), which, although it may be less painful, it is also more susceptible to kinking with patient movement. We now prefer two tubes for patients who have nonsewable air leaks and those with a large pleural space deficit noted after reexpanding the lung at the time of chest closure. If there is a significant pleural space deficit and concomitant nonsewable air leaks, a pleural tent for upper space problems [7] should be performed and a pneumoperitoneum for lower space problems. We have shown in a prospective study that pneumoperitoneum created at the time of the thoracotomy is safe and effective after concomitant lower and middle right lobectomies [8] and reduces air leak duration and hospital stay. In addition, Brunelli and colleagues [7] have shown that the use of pleural tents after upper lobectomy may reduce the incidence of air leaks as well. Recall that patients who underwent pleural tents or pneumoperitoneum were eliminated from this study. We now also advocate the placement of a subcutaneous drain over the intercostal space and position it extrathoracically in selected patients to further help prevent SE. Yet despite all of these intraoperative techniques, patients still have air leaks and SE. The final, and perhaps most important cause of the rising incidence of SE and recalcitrant SE, is the almost exclusive use of water seal in patients with air leaks after postoperative day 1. Chest Tube Management Many use water seal for patients with air leaks because of our previous prospective randomized studies as well as those of Marshal and coworkers [9 12]. These studies suggest that water seal is the optimal chest tube setting in patients with air leaks after lung resection. The presence of a pneumothorax and an air leak is not an indication for suction, as we have shown in 2005 [13]. However, in some patients, such as those with a large leak (greater than an E3 on the RDC classification system) some suction is needed. When SE or voice changes develop secondary to SE, we believe this is an absolute indication to add suction to the chest tube. We use the least amount of suction required (as we believe the more the suction, the larger the leak gets) to eliminate the SE. We prefer to start with 10 cm of suction and observe the patient for 4 to 6 hours. Brunneli and colleagues [14] have also presented strong, provocative randomized data that suggest that use of intermittent suction (they prefer it at night when patients are not walking) may be best for pulmonary air leaks. If the SE continues despite adding as much as 40 cm of suction, then another chest tube is indicated. The placement of a new chest tube at the bedside can be successful in most patients, but it is painful and can be difficult to position ideally because of the SE and the previous surgery. It also does not work in some patients, and it was those patients who we took to the operating room and discovered the reason. As shown in this paper, we have found that a common etiology of SE is that the part of the lung that is leaking air is often adhered to the intercostal space that had been previously opened. This is true for patients that had a thoracotomy or a VATS. The air leak from the lung goes into the SE tissue and not into the pleural space, and thus another chest tube is not effective at reducing the SE. Once

5 Ann Thorac Surg CERFOLIO ET AL 2008;85: MANAGEMENT OF SUBCUTANEOUS EMPHYSEMA 1763 in the extrathoracic space at the intercostal opening, the air follows the path of least resistance, and it easily dissects through the recently surgically disrupted tissue planes into the subcutaneous fascia. It can then traverses into the face, eyelids, or larynx or even downward into the groin. As seen in this series, once we made this discovery (after the first 21 patients with recalcitrant SE), we started to offer VATS more quickly in these patients if increasing the suction on the existing chest tube did not improve the SE within 24 hours instead of placing another chest tube at the bedside. In this study, we have shown that a single-incision VATS, using a single-lumen tube only, is safe, easy, quick, and effective. It is not difficult to lyse or take down these 3- to 5-day-old adhesions using only one incision and by placing a sucker alongside the VATS camera. This maneuver drives the leak back into the pleural space where it can be controlled with the new chest tube. We have not used glues or sealants over the part of the lung or tried to restaple that area because the tissue is usually very inflamed. A new chest tube is then placed through this incision and placed on suction overnight. That eradicated the SE in all but 1 of the 64 patients in this series. We then send the patient home a few days later with the chest tube still in the chest and attached to a closed portable outpatient device, as previously described [9]. When VATS was performed immediately in these 64 patients, instead of trying a bedside chest tube first, the length of stay was significantly shorter (6 days compared with 9, p 0.02), and they had less time with recalcitrant SE than the other 21 patients. All 85 patients went home with chest tubes attached to a home portable compact device but discharge was not permitted for patients until the SE was resolved. The strengths of this study include the reduction of confounding factors by the use of one surgeon and the near 100% follow-up of patients. However, the limitations are significant. First, the data are retrospective and nonrandomized. Second, the majority of our data are related to our experience. Additionally, the technique of VATS pneumolysis was employed in only the latter half of this study. Ideally, from a scientific standpoint, we should have randomly allocated the patients to a bedside chest tube or to a VATS procedure, but our experience and intraoperative observations now strongly biase us toward preferring VATS. We would no longer condone a trial that randomly assigned patients to an additional bedside chest tube over a VATS reexploration and chest tube placement. In conclusion, the management of SE, like air leaks, should be based on scientific objective data. Our algorithm for this problem is to first ensure the existing chest tube is in the pleural space, is patent, is correctly attached to the drainage system, and is not clogged, twisted, or clamped. If the tube is patent and the addition of high wall suction does not resolve the SE, then an additional bedside chest tube is a reasonable option. However, it is no longer our next procedure of choice. As shown from the data above, we have found that most common cause of SE is from a leaking portion of the lung, which is often adhered to the part of the chest that was previously opened. This causes the air that is leaking from the lung to dissect into the subcutaneous space instead of the pleural space. Once in the subcutaneous space, it can easily travel through the already surgically dissected tissue planes and lead to SE in the face, eyelids, larynx, or groin area. Single-incision VATS using a singlelumen tube is safe, quick, and effective. It almost always will successfully eradicate the problem within 6 to 12 hours. That avoids the delays and morbidity associated with a bedside chest tube or computed tomography guided catheters, which although at times is effective, takes longer to eliminate the SE. Video-assisted thorascopic surgery allows the patients with air in the eyelids to see sooner, and that helps restore the confidence of the patient and family in the physician s care. The use of small supraclavicular incisions to help evacuate the air is rarely needed and should be reserved for the very rare patient who has failed a VATS procedure and all other measures. References 1. Tonnesen AS, Wagner W, Mackey-Hargadine J. Tension subcutaneous emphysema. Anesthesiology 1985;62: Abu-Omar Y, Catarino P. Progressive subcutaneous emphysema and respiratory arrest. J R Soc Med 2002;95: Herlan DB, Landreneau R, Ferson PF. Massive spontaneous subcutaneous emphysema. Acute management with infraclavicular blow holes. Chest 1992;102: Mattox KL, Allen MK. Systematic approach to pneumothorax, hemothorax, pneumomediastinum and subcutaneous emphysema. Injury 1986;17: Herlan DB, Landreneau RJ, Ferson PF. Massive spontaneous subcutaneous emphysema: acute management with infraclavicular blow holes. Chest 1992;102: Cox DR. Regression models and life-tables. J R Stat Soc 1972;34: Brunelli A, Refai MA, Monteverde M, et al. Pleural tent after upper lobectomy: a randomized study of efficacy and duration of effect. Ann Thorac Surg 2002;74: Cerfolio RJ, Holman WL, Katholi CR. Pneumoperitoneum after concomitant resection of the right middle and lower lobes (bilobectomy). Ann Thorac Surg 2000;70: Cerfolio RJ, Bass CS, Pask AH, et al. Predictors and treatment of persistent air leaks. Ann Thorac Surg 2002;73: Cerfolio RJ, Tummala RP, Holman WL, et al. A prospective algorithm for the management of air leaks after pulmonary resection. Ann Thorac Surg 1998;66: Cerfolio RJ, Bass CS, Katholi CR, et al. Prospective randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg 2001;71: Marshall MB, Deeb ME, Bleier JI, et al. Suction vs water seal after pulmonary resection. A randomized prospective study. Chest 2002;121: Cerfolio RJ, Bryant AS, Singh S. The management of chest tubes in patients with a pneumothorax and an air leak after pulmonary resection. Chest 2005;128: Brunelli A, Monteverde M, Borri A, et al. A. Comparison of water seal and suction after pulmonary lobectomy: a prospective, randomized trial. Ann Thorac Surg 2004;77:

6 1764 CERFOLIO ET AL Ann Thorac Surg MANAGEMENT OF SUBCUTANEOUS EMPHYSEMA 2008;85: DISCUSSION DR STEPHEN C. YANG (Baltimore, MD): Dr Schipper and Dr Meyers, colleagues of the Society, good afternoon. Cerf, again, that was a great talk, as you always do, and I congratulate you and your colleagues. Again, we commend your group for always looking at common problems that we don t really have any evidence-based medicine data for, and always trying to improve our daily practice in such a thoughtful and organized fashion. My first point addresses your statement in the abstract, the incidence of the subcutaneous emphysema is increasing. In your paper on the treatment of persistent air leaks that you actually presented here 6 years ago, in that paper of nearly 700 patients, your incidence of subcutaneous emphysema was actually 0.9%. You state the risk factors that are indeed the real causes for this. It is inferred that with a lower FEV 1 that these patients may be more emphysematous, yet in your manuscript that you kindly provided to me, these patients who had to go to surgery were actually almost 10 years younger than those ones who actually had no problems with subcutaneous emphysema. So what is the explanation? Is it because they will tolerate a second operation better? Is there a change in your surgical technique such as going to video-assisted thorascopic surgery (VATS)? For instance, I don t really find this problem that often in my practice. I actually still use these blowholes that my teacher, Jamie Olak, taught me. I find that these blowholes actually take care of things. They do decompress the air leak, and then obviously we try to avoid the second operation. DR CERFOLIO: Thank you for your kind comments and since I am a hockey player I enjoy scoring a hat trick in any game or having three papers or more on at one meeting. It is my team that gets the credit for that, not I. We have had an increased incidence of subcutaneous emphysema. I took out the possible reasons for this in my slides, for time s sake, but it is in the manuscript, and we enumerate some reasons. One, I have gone to one chest tube after a lobe instead of two; two, I use a 28F chest tube that is soft; I use a little softer tube than I did 5 or 6 years ago. I don t have data that it decreases pain, I suspect it does, but I also think it is more susceptible to kinking, especially as we have increased the physical therapy of our patients and they move around a lot in bed and in chairs postoperatively. So they now move more, walk more, do more activities. I think you are more likely to get problems there. So I think those are two potential factors for the increased incidence. DR YANG: My second point addresses the operative procedure itself. Perhaps you can elaborate more on who you would not offer the procedure to and would want to treat conservatively, which you may not want to after hearing the talk. In the occasional patient in whom we see subcutaneous emphysema after lung reduction surgery, as I said, we still use these blowholes, and I say anecdotally, we don t have to do another operation. In the manuscript you state that you use a single-lumen tube to intubate these patients, first, to make sure that there is no bronchial stump leak. But wouldn t that, based on your mechanism that you propose, increase the subcutaneous air during the induction of the anesthesia? And why create another incision? You state you are making another incision between the thoracotomy site and the chest tubes. You have got two chest tube sites already from your second DR CERFOLIO: One chest tube. DR YANG: I thought these patients had a second chest tube. DR CERFOLIO: There may be a second bedside chest tube placed, but I almost never use that or the old chest tube site to do the VATS. I make a new clean incision. DR YANG: Again, so sometimes you could use those holes for your camera site. So why do another chest tube? DR CERFOLIO: I will answer the second question first. I guess you probably could. I am very much into cosmetics so I don t like to make lots of incisions, but I consider that incision dirty; it has had a tube in it for 3 days. But you are right, I probably could put a camera through there and just another tube through. We haven t done that. One of the reasons is the diaphragm comes up a little bit after a resection, and I always tell the resident, you know, when a lobe has been removed you have a little diaphragmatic elevation, and I make my chest tube incision very, very low at the time of the first operation and very anterior to decrease pain the space between the ribs is greatest here and, really, if I put in a camera, I would have to come over the diaphragm. That is the reason I make this new incision higher. The second reason that I do a single-lumen tube is because I want to do this quick and efficiently. I mean, there are a couple of patients who have massive subcutaneous emphysema and I think you do need to place a double lumen, but if they are not blown up with subcutaneous air, it is easy to intubate them. Then we use a short period of apnea. And I have been impressed with how much VATS you can do with a single-lumen tube. For instance, the patient with interstitial lung disease in the intensive care unit on 100% oxygen, I do VATS lung biopsies all the time on them with a single-lumen tube and just a short period of apnea. So I have gotten very, very comfortable doing VATS with single lumens. Many of my hyperhydrosis patients get a single lumen. It just goes on and on and on. I think that is the reason. I have no problem with using the double lumen. DR YANG: Okay. So great talk, and again, I thank the Program Committee for the invitation to discuss this. DR JOSEPH B. ZWISCHENBERGER (Lexington, KY): Cerf, as always, there is a lot to be learned from your presentations, but it appears what you have taught us today is to routinely use two chest tubes after pulmonary resection. DR CERFOLIO: Zwisch, thanks, your point is a good point. I would say I believe in science, and there is not one but two and maybe three prospective studies done by authors I believe who have shown a single chest tube works as well in their hands as two tubes. So when I come to a meeting like this and I see a study like that, I go back and I change my practice. I really do, and those presentations changed my practice. And as I mentioned yesterday in my lecture in the postgraduate course, honestly, I have been burned a little bit with this increasing subcutaneous emphysema since going to one tube. Maybe I am putting the one tube in the wrong spot, maybe I am doing something else wrong, I don t know. But maybe you are right. And so as I mentioned yesterday in the postgraduate, what I do now, I fill the chest with water, bring the lung up. If I see a big residual space and I can t do a pleural tent because I have already gone extrapleurally or it is not a lower lobe thing where I am not going to do a pneumoperitoneum and they got air leaks I can t control, the patient gets two tubes. But this is very rare. I hardly ever use a pleural tent and almost only perform a pneumoperitoneum after a bilobectomy with removal of the right middle and lower lobes. But I use it selectively. If I don t see an air leak in the operating room, the lung is normal, its compliance is good, the DLCO is good, I give them one tube. So I am a selective one-tuber

7 Ann Thorac Surg CERFOLIO ET AL 2008;85: MANAGEMENT OF SUBCUTANEOUS EMPHYSEMA 1765 now after a lobectomy. I am not dogmatic about anything, and each patient is different, and we change our protocol based on each patient s characteristics. DR SHANDA HALEY BLACKMON (Houston, TX): Dr Cerfolio, I was wondering if your VATS pneumolysis patients were also included in your muscle dangle trial, and if so, were they equally distributed among the two groups? DR CERFOLIO: That is a great question. I don t know the answer to that. I would have to go back and look, to be honest. I don t know. But that is a very interesting question because I wondered if the muscle flap led to more space between the ribs and thus increased the incidence of subcutaneous emphysema. It does not if you close correctly, and if I do not transpose it into the chest to buttress the bronchus or some other structure. If it dangles, it just goes back to its normal place when we close, and you cannot even tell we harvest it. If I cut it and do not transpose it in the chest, I place it back in its normal position in between the ribs. However, when I cut it and put it on a bronchus as I showed you yesterday with those intraoperative pictures, I don t put the ribs together those patients may have a much higher incidence of subcutaneous emphysema. I can tell you now that over the last 6 to 9 months, I have been placing a small flat drain over the rib opening and under the serratus that I preserve and leave it in for about 1 or 2 days after surgery to help prevent subcutaneous air. So that is a very good point. DR JOHN A. HOWINGTON (Cincinnati, IL): So, Cerf, my question would be, you have seen this increased incidence of subcutaneous emphysema and to avoid it you say you put the JP drain. Is that helping you? Are you having a higher incidence of subcutaneous emphysema because you are dangling or cutting the intercostal muscle, or both, and is that the source and not a single chest tube? I am a single chest tube user, and I have not seen that high an incidence of subcutaneous emphysema. DR CERFOLIO: But maybe you do a better job with your stapler and air leaks than I do or perhaps there are other reasons for your better results. When we talk about the intercostal muscle, I think one of the risks is subcutaneous emphysema if you transpose the muscle into the chest and close leaving a space between the ribs. A lot people would say no, because when they close, they put the ribs right against one another, and I don t like to do that. I believe they rub and that hurts. I put them back the way God had them initially, just minus the muscle in between them. We have written an abstract for, I think the AATS wasn t it, Ayesha? about this exact issue after pneumonectomy, where I always use an intercostal muscle to buttress the bronchus. In that case, I worry about not only air but also fluid coming out of the pneumonectomized space and show that we do a better job with subcutaneous emphysema since using this subcutaneous drain. DR DANIEL L. MILLER (Atlanta, GA): I think one of the most important aspects about subcutaneous emphysema is that you need to educate the patient and the family, because usually it gets worse before it gets better. Also, I know you do a lot of cases at UAB, but now we know why: you are operating on your patients twice. DR CERFOLIO: Actually three times, because I do often do a mediastinoscopy under a separate anesthetic as well that is why my numbers are so artificially inflated and why I will do more than 1,200 operations this year and did more than 1,150 last year. DR MILLER: I think it all goes back to technique, and the lung is stuck to your intrathoracic incision. So if you do a VATS lobectomy you wouldn t have that problem. DR CERFOLIO: I disagree, because we get subcutaneous emphysema after VATS procedures as well. DR MILLER: The big question is, was there a difference in regard to which lobe was operated on, because a lot of times I will use a single tube for a lower lobe with just a right angle, whereas for an upper lobe, the majority of the time I still use two tubes because of superior space issues, and I think it is something to look at in your patients. Also, in regard to your dangle flap, as we learned about yesterday, at any time has the lung been trapped, in that it did not allow the lung to expand completely. That dangle actually might be a problem. DR CERFOLIO: No, no. The dangle just hangs down as we do the case. When we finish it, we put it right back to where it was when we started, we just do not crush it with the retractor during spreading. The muscle goes right back to its normal positions, where God had it. Because, remember, we re putting intercostal sutures in, thus the sutures go through the sixth rib, under the intercostal muscle, and then over the top of the fifth rib, and when we close, we bring the muscle right back to where it was. So we are very, very teleologic in terms of the closure. I want to put everything back the way I found it. DR MILLER: Teleologic? DR CERFOLIO: Yes, teleologic. You can look it up. It is the right word. DR MILLER: Is that above or below the dangle? DR CERFOLIO: Your second question is a great question. I had the same impression, but our analysis did not show a higher problem after upper lobectomy. But that surprised me, because I assumed that they would have. But as usual, the data proved my assumption wrong. DR RUSSELL R. KRAEGER (St. Louis, MO): I have just two questions for you. In your initial procedure, are you using any sealants at all, because we are and we don t see this incidence that you see. And my second question, on your redo, would you use a sealant or a talc? DR CERFOLIO: Two good questions. First question, I don t use a sealant, have not in probably 6 or 7 years. There is no FDAapproved sealant for the lung. But some use Tissela a glue. So I would say to you, what does it cost? How many patients really needed it? Are you sure they are not going to have other problems from this material 20 years down the road? Have you looked at the molecules in Tissela, and so forth? And do you really need it in everybody, is the big question. I mean, that is fine and maybe you are doing a good job, but those are questions to consider. Your second question was? DR KRAEGER: The use of sealant or talc. DR CERFOLIO: Well, as I mentioned, I haven t done that, because I still think that this is a problem that we can take care of just by driving the air leak back into the pleural space and managing them with a tube, and I leave that tube in. They go home on an Atrium, one of these little portable devices that fits on your belt. I like that little compact Atrium, and they go home with that. But they buy a tube for a week or two even if they have no air leak, because a lot of them never had an air leak initially because the leaks were not intrapleural, they were leaking into the subcutaneous. They go home on that, on Keflex twice a day for 2 weeks, and then we pull them out in the clinic.