Management and mindset for air leak and intraoperative bleeding in thoracic surgery

We are delighted to have the opportunity to comment on the article “Air leak and intraoperative bleeding in thoracic surgery: a Delphi consensus among the members of Italian society of thoracic surgery” by Cardillo et al., which was recently published in the Journal of Thoracic Disease (1). We would also like to express our gratitude and admiration to the authors for their significant contribution with this article and found their work very intriguing. The consensus they established using the Delphi method demonstrated a high level of agreement among Italian thoracic surgeons, making it an opinion representative of surgical practice in Italy. This consensus is also relevant to thoracic surgeons around the world and in Japan, where we practice, and will serve as a valuable guideline for managing air leaks and bleeding during pulmonary resection surgery.

In recent years, video-assisted thoracoscopic surgery (VATS) has increasingly been used as the preferred approach for early-stage lung cancer. This approach offers several advantages over thoracotomy: it is less invasive, which results in less postoperative pain, shorter duration of chest tube placement, shorter hospital stay, and faster postoperative recovery; moreover, surgical outcomes are superior (2) and it is not inferior to thoracotomy in terms of oncological outcomes (3). VATS is also associated with lower healthcare costs.

In any thoracic surgical operation, including thoracoscopic lung resection, air leakage is a concern. The occurrence of prolonged or persistent air leak (PAL) is a frequent challenge that thoracic surgeons deal with following lung resection. PAL is defined as air loss from the residual lung parenchyma persisting beyond the fifth postoperative day and is the most common postoperative complication after pulmonary resection. Reported incidence rates range from 5% to 25% (4). PAL is usually associated with increased morbidity and mortality as well as prolonged duration of chest tube placement. Consequently, hospital stay is extended, which is associated with its own inherent risks (5). Therefore, effective management of air leaks is crucial.

Malapert et al. demonstrated that the use of surgical sealants and buttressing materials reduces the risk of prolonged air leakage after lung resection and decreases the incidence of postoperative arrhythmias (6). They highlighted the usefulness of adhesives, patches, and buttressing. Additionally, Deguchi et al. emphasized the role of reinforced staplers in preventing PAL, especially in patients with emphysematous lungs (7).

The Italian consensus in Cardillo et al. reaffirmed the benefits of using surgical sealants to reduce the frequency of postoperative air leaks, shorten drainage duration, reduce length of hospital stay, and decrease the need for PAL-related reoperation. It was also emphasized once again that the selection of a surgical sealant after suturing an intraoperative air leak should consider its adhesive properties and ability to persist in the presence of lung expansion. Furthermore, the importance of preventive measures such as fissureless technique, direct suturing, and the use of sealants was re-emphasized and shared.

Most previous postoperative air leak studies have focused on predictive factors for PAL (8-10). A systematic review of PAL management in 2010 reported that previous studies differed in terms of the sealants and methods used and the outcomes evaluated mainly due to availability of products and variability in surgeons’ expertise and confidence (11). As noted in the more recent 2023 systematic review by Aprile et al. (12), many studies have consistently reported that various sealants are safe and effective; however, sealants are only recommended for intraoperative air leak treatment, not PAL prevention, because of cost, availability, and lack of evidence.

The consensus in Cardillo et al. also reaffirmed that air leaks are a well-known clinical issue among thoracic surgeons. However, it is apparent that the criteria for surgical sealant use varies. It is important for thoracic surgeons to remain informed and updated about new developments in surgical sealants and hemostatic agents.

The greatest challenge for thoracic surgeons during open and minimally invasive pulmonary resection is bleeding. Bleeding from the pulmonary artery may be life-threatening and frequently requires conversion to a more extensive lung resection. Although the literature regarding management of significant intraoperative bleeding is limited, two recent reports have addressed troubleshooting for pulmonary artery bleeding during VATS (13) and bleeding during uniportal surgery (14). In general, management relies heavily on surgeon experience and on-the-spot judgment.

Surgical time is longer and intraoperative blood loss is greater in thoracoscopic surgery patients who experience vascular injury than in those who do not (13,15); however, length of hospital stay and incidence of complications do not differ. This suggests that surgeons are generally able to appropriately manage intraoperative bleeding. In addition, it underscores the importance of effective management, which is crucial to ensure optimal patient outcomes. Igai et al. constructed an algorithm for troubleshooting during bleeding episodes (15). We have found it advantageous to use such an algorithm in our facility because it ensures that all team members are well-prepared to handle bleeding situations and enhances our capability.

A thorough preoperative patient assessment which determines comorbidities such as chronic obstructive pulmonary disease, pneumoconiosis, tuberculosis, and aspergillosis in conjunction with a review of imaging studies to identify anatomical abnormalities and calcified lymph nodes can help prevent intraoperative bleeding. Confirming these clinical characteristics is crucial as they can impact the complexity of the surgery. An aggregated scoring system has been developed to stratify the complexity of VATS lobectomy before surgery, which can be used to identify appropriate patient candidates and improve the efficiency and safety of surgeon training (16).

Based on the consensus reached in Cardillo et al., intraoperative bleeding should be managed by compression, clipping or suturing, and use of local hemostatic agents in that sequence. Even when the bleeding is from the pulmonary artery, local suturing should always be considered before using a hemostatic agent. This mindset is indeed crucial. Additionally, when the vascular laceration is large or the bleeding cannot be controlled, the proximal end of the blood vessel should be dissected further and controlled with a clamp forceps. If the laceration is close to the root of the pulmonary artery, it may be necessary to open the pericardium to clamp the main pulmonary artery inside the pericardium (17).

An international expert consensus regarding the management of bleeding during VATS lung surgery (17) has provided various methods for addressing bleeding during lymph node dissection and bleeding from the pulmonary artery, bronchial artery, large vessel and bronchial stumps, lung parenchyma, chest wall, and internal chest wall. This consensus offers valuable insights that can be helpful “in the moment” and is highly recommended to all thoracic surgeons.

In contrast, the opinion in the consensus of Cardillo et al. regarding the use and indications of surgical sealants may be partly controversial. Comorbidities such as chronic obstructive pulmonary disease, preoperative lung impairment, and frailty increase the chance a sealant will be required. In cases of massive intraoperative air leak, it is common to use a surgical sealant in addition to empirical surgical sutures. However, determining the specific circumstances and patient profiles in which a sealant should be used requires considerations based on the individual patient and situation. It is difficult to explicitly prioritize and document these criteria in order of importance. Considering cost considerations and the fact that different facilities serve patients of different clinical backgrounds, individual judgments will vary according to the institution. Reporting and sharing the outcomes of these decisions will contribute to the accumulation of new evidence.

The consensus reached in Cardillo et al. remains within the realm of a textbook-like presentation, provides a general understanding, and is somewhat clinically less impactful than the international consensus, which also reports quality of evidence and grades of recommendation. Nevertheless, in terms of reaffirming the importance of such recognition, the significance of the consensus from Italy is profound and should not be overlooked.

Creating an algorithm that includes the management of bleeding incidents and reconfirms the criteria for using surgical sealants is imperative. Surgeons must be mindful that safety is of the utmost importance and work to attain this goal as part of their daily practice.

Acknowledgments

We thank Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-972/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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