Anile, Marco

Diso, Daniele

Mantovani, Sara

Poggi, Camilla

Venuta, Federico

English

Archivio della ricerca- Università di Roma La Sapienza

the authors aware of any evidence that this sealing ofthe pleural space has ever occurred, let alone that thisaction has been the mechanism behind the “clinical”success of all such procedures? The pleural changesreported at subsequent thoracotomy or postmortemexamination, following previous “clinically successfulpleurodesis,” have been clearly described and accepted;that is, pleural thickening associated with fibrinproduction, collagen deposition and fibrosis, plusvariable adhesions. However, despite the very largenumber of “clinically successful pleurodeses” achievedover the last 80 years, there appear to be no similarreports demonstrating sealing or obliteration of thepleural cavity. It should be remembered that pleuraladhesions do not prevent tethered pneumothoraces inthe case of air leaks (or loculated effusions associatedwith pleural malignancy). In an age of evidence-basedmedicine, such an absence of evidence suggests amedical myth. Should the “success” of the procedure bemore accurately attributed to those pleural changes thatwe know do occur?Vincent Acton, MBBS (Syd)Sydney, NSW, AustraliaAFFILIATIONS: Private practice.FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.CORRESPONDENCE TO: Vincent Acton, MBBS (Syd), 1202 Highgate,127 Kent St, Sydney, NSW 2000 Australia; e-mail: vinacton@bigpond.comCopyright  2017 American College of Chest Physicians. Publishedby Elsevier Inc. All rights reserved.DOI: https://doi.org/10.1016/j.chest.2017.05.048Reference1. Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management ofpersistent air leaks. Chest. 2017;152(2):417-423.The Surgical Point of ViewAbout Persistent Air LeaksPrevention First!To the Editor:We read with interest the paper by Dugan et al1recently published in CHEST (August 2017) about themanagement of persistent air leaks (PAL). We haveappreciated the attention of CHEST regarding thiscomplication that affects numerous pulmonarypatients and which represents a daily challenge forthoracic surgeons. The review performed by theauthors is exhaustive, including different aspects of1352 Correspondencethe problem and reporting the most populartherapeutic strategies to solve it.2,3 However, the firstlesson learned in the operating theater is that“prevention is better than cure.” Thus, a carefulintraoperative management of pulmonaryparenchyma should be stressed because it representsthe most efficient strategy to prevent PAL. Themanipulation of the pulmonary parenchyma duringsurgery, in particular when marked pleural adhesionsare present or in the case of emphysematous lungs,might be gentle to avoid air leakage.One of the most important risk factors for thedevelopment of PAL in patients undergoing lobectomyis the absence of interlobar fissures, which eventualityobliges surgeons to work inside the parenchyma to reachthe interlobar branches of the pulmonary artery, oftencreating minor damage to the remaining lobe. It couldbe resolved by using specific surgical techniques such asfissure-less lobectomy (the separation of fissures withmechanical staplers occurs after the resection of vascularand bronchial elements).4 This technique is almostalways used during video-assisted lobectomy. In the caseof lung volume reduction surgery or wedge resectionsperformed in patients with other underlying pulmonarydisease (eg, idiopathic pulmonary fibrosis), it could behelpful to use patches of pericardial tissue to wrap theloads of staplers and thus reinforce the staple lines.Furthermore, numerous sealants and glues are routinelyused to cover lung parenchyma to avoid PAL, inparticular when microlesions on the visceral pleuralsurface are present.5 Although these precautions do noteliminate the problem of PAL (they must be treated, asreported in the review1), they dramatically decrease theincidence of PAL, with better postoperative recovery aswell as a reduction in health costs.Federico Venuta, MDSara Mantovani, MDDaniele Diso, MDCamilla Poggi, MDMarco Anile, MDRome, ItalyAFFILIATIONS: From the Department of Thoracic Surgery,University of Rome Sapienza.FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.CORRESPONDENCE TO: Marco Anile, MD, University of RomeSapienza, Department of Thoracic Surgery, Viale del Policlinico 15500161 Rome, Italy; e-mail: marco.anile@uniroma1.itCopyright  2017 American College of Chest Physicians. Publishedby Elsevier Inc. All rights reserved.DOI: https://doi.org/10.1016/j.chest.2017.09.051[ 1 5 2 # 6 CHE ST D E C EM B E R 2 0 1 7 ]References1. Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management ofpersistent air leaks. Chest. 2017;152(2):417-423.2. Andreetti C, Venuta F, Anile M, et al. Pleurodesis with an autologousblood patch to prevent persistent air leaks after lobectomy. J ThoracCardiovasc Surg. 2007;133(3):759-762.3. Anile M, Venuta F, De Giacomo T, et al. Treatment of persistent airleakage with endobronchial one-way valves. J Thorac Cardiovasc Surg.2006;132(3):711-712.4. Anile M, Diso D, Rendina EA, Venuta F. A simple technique to avoidpostoperative air leakages after right upper lobectomy. Eur JCardiothorac Surg. 2013;43(4):e99-e100.5. Venuta F, Diso D, De Giacomo T, Anile M, Rendina EA, Coloni GF.Use of a polymeric sealant to reduce air leaks after lobectomy.J Thorac Cardiovasc Surg. 2006;132(2):422-423.Does the Time of Day aPulmonary EmbolismResponse Team Is ActivatedAffect Time to Interventionor Outcome?To the Editor:In this letter, we evaluate how the activation time of thePulmonary Embolism Response Team affects treatmentdecisions and time to intervention. Prior studies havedemonstrated higher mortality rates for patients whooriginally presented with acute pulmonary embolism(PE) on a weekend as well as diverging survival curvesafter the first day of care, highlighting that earlydecision-making regarding treatment for PE may affectTABLE 1 ] Characteristics of Day and Night GroupsVariableAll patientsAge, mean (SD), yFemale sex, No. (%)Race, No. (%)WhiteAfrican AmericanAsianHispanicOtherHighest heart rate, mean (SD), beats/minLowest systolic blood pressure, mean (SD), mm HgHighest respiratory rate, mean (SD), breaths/minTroponin value, median (Q1-Q3), ng/mL 0.0BNP value, median (Q1-Q3), pg/mL 87Simplified PESI score, median (Q1-Q3)30-day mortality, No. (%)BNP ¼ brain natriuretic peptide, PESI ¼ Pulmonary Embolism Severity Index.chestjournal.org30-day mortality.1,2 We evaluate how day and nightgroups, or “on-hours” and “off-hours” activations, couldcontribute to different treatment decisions as well asdifferent times to intervention and 30-day mortality.Of the 457 Pulmonary Embolism Response Teamactivations at the Massachusetts General Hospital, 317occurred during the day and 140 during the night.Table 1 describes the demographics of the patients aswell as characteristics at time of presentation. The dayand night patients were similar in, sex, PE severity, andother clinical characteristics.3 The data collection andanalysis was approved by the Human ResearchCommittee of Partners Health Care (protocol No.2012P002257).We found no difference in the rate of interventionswithin 24 hours of activation between the day and nightgroups (13% vs 15%; P ¼ .62). Among those whoreceived interventions within 24 hours, the distributionfor the type of intervention was slightly differentbetween the two groups: Catheter-directed therapyaccounted for 81% of interventions in the night groupbut only 55% of interventions in the day group, andsystemic IV thrombolysis and surgical embolectomywere more common in the day group (P ¼ .06) (Fig 1).When limited to interventions that occurred within 6hours (early intervention), the distribution of the type ofintervention was similar between the two groups(P ¼ .99). Among those who received interventionsDay Night P Valuen ¼ 317 n ¼ 140 .62 (16) 61 (15) .50140 (44) 71 (51) .20266 (84) 108 (77) .1625 (8) 13 (9)4 (1) 3 (2)8 (3) 2 (1)14 (4) 14 (10)106 (22) 107 (23) .74115 (24) 115 (21) .7622 (5) 23 (7) .143 (0.01-0.12) 0.04 (0.01-0.11) .307 (215-3001) 1313 (356-3810) .931 (1-2) 1 (0-2) .8136 (12) 19 (16) .321353

The surgical point of view about persistent air leaks: prevention first

Federico Venuta

Sara Mantovani

Daniele Diso

Camilla Poggi

Marco Anile

Crossref

CHEST Journal

The Surgical Point of View About Persistent Air Leaks

https://iris.uniroma1.it/bitstream/11573/1035481/2/Venuta_Surgical-point-view_2017.pdf

The surgical point of view about persistent air leaks: prevention first

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