Interactive Cardiovascular and Thoracic Surgery 2:688-691(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Institutional review - Thoracic general |
Diaphragmatic elevation of a patient with chronic obstructive pulmonary disease after left upper lobectomy
Fengshi Chen,
Masanao Nakai,
Akihiro Aoyama,
Noritaka Isowa and
Koji Chihara*
Division of Thoracic Surgery, Shizuoka City Hospital, 10-93, Ohtemachi, Shizuoka, 420-8630, Japan
* Corresponding author. Tel.: +81-542533125; fax: +81-542520918
echihara{at}mb.infoweb.ne.jp
Received July 8, 2003;
received in revised form August 15, 2003;
accepted August 26, 2003
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Abstract
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Among postoperative pleural space problems after pulmonary resections, it is more difficult and troublesome to manage this space after left upper lobectomy in patients with chronic obstructive pulmonary disease (COPD). We performed a retrospective study focusing on the elevation of ipsilateral hemidiaphragm of the 36 patients with or without COPD after left upper lobectomies, by measuring diaphragmatic dome length (DDL) with a plain posteroanterior roentgenogram. They were divided into two groups: group I (forced expiratory volume in 1 s (FEV1) % predicted <70%,  ); and group II (FEV1) % predicted 70%,  ). Of each group, we investigated the trend of both left and right DDLs perioperatively, calculating DDL index (DDL divided by height, DDLI), and also analyzed several perioperative parameters. The trend of left DDLI after surgery was different in the two groups ( ). In group I, left DDLI became larger gradually in proportion to the postoperative weeks, while in group II it became the largest 2 weeks after surgery and decreased gradually. Left DDLI in group I was smaller than that in group II 2 weeks after surgery ( ). We found that the diaphragm of COPD patients does not elongate easily after left upper lobectomy.
Key Words: Diaphragm; Chronic obstructive pulmonary disease; Lobectomy; Lung cancer
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1. Introduction
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By conventional radiography, 20–40% of all patients having major pulmonary resections will have a residual pleural space [1]. This pleural space has been a concern throughout the history of thoracic surgery because it is believed to invite complications such as infection, bleeding, and prolonged air leak. This space problem may happen after any type of pulmonary resection, but it is more likely after upper lobectomy, in particular, left upper lobectomy [2]. Thus the shift of the surrounding structures, such as elevation of the ipsilateral hemidiaphragm, expansion of the residual lung, mediastinal shift, and narrowing of the intercostal spaces have accounted for obliteration of the space by suction with negative pressure. Pulmonary resection in patients with chronic obstructive pulmonary disease (COPD) predispose to postoperative air leak related complications [3,4]. Therefore, it is more difficult and troublesome to manage the pleural space after left upper lobectomy in the patients with COPD than those without it. In order to manage the residual space more appropriately, herein we report the results of our retrospective study focusing on elevation of the ipsilateral hemidiaphragm of the patients with or without COPD after left upper lobectomies.
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2. Patients and methods
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Left upper lobectomy was performed on 42 patients from January 1991 to December 2000 in our hospital. In all patients, bronchial stumps were closed by suturing (Overholt's method) or by ligation with a silk, and pulmonary ligaments were completely divided. We utilized staplers, buttressing material, and surgical glues to prevent postoperative prolonged air leak. We examined 36 patients, excluding three patients with prolonged air leak for more than 2 weeks after surgery, one patient with pulmonary aspergilloma, and two patients with missing clinical data. There were 21 male and 15 female patients with a mean age of 66±8 years. Left upper lobectomy was performed for lung cancer in 35 patients and bronchogenic cyst in one patient. In all 36 cases, the chest tubes were placed to a suction of –10 to –12 cm H2O. After confirming absence of air leak for at least 24 h after the surgery or the last episode of air leak or confirming the amount of pleural effusion less than 150 ml per day, the tube was clamped. A chest radiograph was obtained more than 12 h later to assure lung expansion, and then the tube was removed.
Optimal assessment and management of COPD by the European Respiratory Society statement categorized COPD patients into subgroups according to their spirometric data, especially forced expiratory volume in one second (FEV1) % predicted [5]. We divided 36 patients into two groups: group I (FEV1 % predicted <70%, ); and group II (FEV1) % predicted70%, ). A mean of FEV1 % predicted of group I was 58±9% and that of group II was 105±18%, respectively. Of each group, we investigated the trend of diaphragmatic dome length (DDL), and several other perioperative parameters, such as age, gender, body mass index, hemoglobin, serum total protein, duration of air leak after surgery, duration of chest tube placement after surgery, and spirometric data. Spirometric data included vital capacity (VC), VC % predicted, forced vital capacity (FVC), FEV1, FEV1 % predicted, and FEV1%=FEV1/FVC.
We measured DDL before surgery, and 2 weeks, 4 weeks, and 12 weeks after surgery. DDL was measured with plain posteroanterior (PA) roentgenograms. All settings to take roentgenograms were consistent for every roentgenogram obtained during this investigation, in order to ensure that the magnification of structures did not influence measurements. As we mentioned before, we excluded three patients with prolonged air leak for more than 2 weeks after surgery from this study group, since there might be inaccurate measurements in these patients. For the same reason, the first diaphragmatic measurements in the postoperative period were done 2 weeks after surgery. To assess DDL, we used roentgenogram at a lung volume with moderate inspiration from functional residual capacity (FRC), with standing upright. On the PA view, the length of left/right hemidiaphragmatic dome silhouettes was measured from its lateral intersection with the rib cage to the midline of the vertebrae (Fig. 1). To correct the magnification factor, the length measured from the roentgenogram was multiplied by 0.92. To standardize comparisons among patients, all DDLs were divided by height and expressed as the corresponding DDL indices (DDLIs) (cm/cm) [6].
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Fig. 1 Diaphragmatic dome length (DDL) measurement on posteroanterior chest roentgenograms. Postoperative chest roentgenogram of a representative patient in group I (A) and group II (B). The length of left/right hemidiaphragmatic dome silhouettes was measured from its lateral intersection with the rib cage to the midline of the vertebrae (left DDL/right DDL=D to E/C to D).
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Statistical analysis was performed using the StatView (version 4.5) software package (Abacus Concepts, Berkeley, CA). Continuous valuables of the two groups were compared by using Student's t-test and categorical values by Fisher's exact test. All numerical data were expressed as mean±1 S.D. As to the trends of left and right DDLIs in the two groups, statistical significance was tested using repeated measures analysis of variance. The trend of right DDLI was tested using one-way analysis of variance. Statistical comparison at each measurement time between groups was made by Student's t-test. A statistical probability of less than 0.05 was considered significant.
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3. Results
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Left DDLIs were 0.089±0.005/0.092±0.007 before surgery, 0.099±0.003/0.116±0.013 2 weeks after surgery, 0.102±0.006/0.112±0.012 4 weeks after surgery, and 0.105±0.006/0.110±0.011 12 weeks after surgery (group I/group II). There was significant difference in the trend of left DDLI in the two groups (). Left DDLIs were similar before surgery in both groups, but left DDLI became greater gradually in proportion to the postoperative weeks in group I, while in group II it became the largest 2 weeks after surgery and decreased gradually (Fig. 2). Left DDLI in group I was smaller than that in group II 2 weeks after surgery (). Right DDLIs were 0.092±0.003/0.092±0.005 before surgery, 0.093±0.005/0.094±0.006 2 weeks after surgery, 0.092±0.005/0.093±0.007 4 weeks after surgery, and 0.094±0.002/0.094±0.007 12 weeks after surgery (group I/group II). There was no significant difference in the trend of right DDLI in the two groups ( ). In addition, the mean of right DDLIs in all patients were 0.092±0.005 before surgery, 0.094±0.006 2 weeks after surgery, 0.093±0.007 4 weeks after surgery, and 0.094±0.007 12 weeks after surgery, showing no significant differences at the four points of roentgenogram examinations ( ). As to perioperative parameters, the duration of air leak after surgery was 5.8±4.3/5.1±4.4 days (group I/group II) ( ). The duration of chest tube placement after surgery was 11.4±5.0/9.3±6.7 days (group I/group II) ( ). No significant differences as to the other perioperative parameters in the two groups were also found, except for some preoperative spirometric data (Table 1).
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4. Discussion
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Postoperative pleural space problem is one of the major issues after pulmonary resections [7]. The rate of this problem may decrease with improvements in surgical techniques and instrumentation, however, it will never be completely removed. Intraoperative maneuvers can be performed to prevent the development of space problems by complete or compensating inflation of the lower lobe, such as minimizing air leaks by using staplers, buttressing material, and surgical glues, decortication of a restrictive pleural peel, and sectioning of the lower pulmonary ligament [8–11]. In some cases, preparation of a pleural tent, phrenic nerve crush, and even thoracoplasty have been reported [1,12]. In spite of using these techniques, the development of spaces in patients, especially with COPD, cannot be completely avoided. In the present series, we utilized staplers, buttressing material, and surgical glues, and performed complete sectioning of the lower pulmonary ligament in all patients.
In the current study, we found that the trend of left DDL was significantly different in the two groups. This indicated that diaphragm of a patient with moderate to severe COPD does not elongate easily, and that the pleural space does not obliterate during an early period after left upper lobectomy. In emphysematous hamsters, the decrease in diaphragmatic length, seen with hyperinflation, is due to a loss of sarcomeres [13]. When the plaster casts were removed from cat's skeletal muscles that had been immobilized in the shortened position, the length–tension curves and sarcomere number of the muscles returned to normal within 4 weeks [14]. We also found that left DDLI in group I returned to a similar value in group II in 4 weeks. If the diaphragm in a patient with COPD has been shortened with a loss of sarcomeres like experimental models [13,14], it might take more time for the diaphragm to follow a maximum upward shift of the lower lobe after upper lobectomy. Furthermore, in a COPD patient, since there is a decrease in extensibility of alveolar walls once stretched [15], it is more difficult for the residual lower lobe to expand so that the pleural space is likely to remain.
In the current study, all settings were intended to be consistent for every roentgenogram during this investigation. There could be some variability in moderate inspiration from functional residual capacity, however, there was no significant difference in right DDLIs in both groups at any measurement times. Therefore, we believed that all roentgenograms during this investigation were taken in almost the same condition. We did not measure the whole length of the left hemidiaphragm, which was the sum of DDL and the zone of apposition to the rib cage. However, since the zone of apposition in a COPD patient from FRC to total lung capacity is also shorter than that in a normal individual, the current data hold true as to the whole length of the diaphragm.
In conclusion, the diaphragm of patients with COPD does not elongate easily after left upper lobectomy. At an early period after left upper lobectomy in those patients, we might recommend allowing the residual pleural space to be present.
doi:10.1016/S1569-9293(03)00206-8
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References
|
|---|
- Wareham EE, Barber H, McGoey JS, Miscall L. The persistent pleural space following partial pulmonary resection. J Thorac Surg. 1956;31:593–600
- Barker WI. Natural history of residual air spaces after pulmonary resection. Chest Surg Clin North Am. 1996;6:585–613[Medline]
- Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg. 1994;57:1038–1039[Abstract]
- Connolly JE, Wilson A. The current status of surgery for bullous emphysema. J Thorac Cardiovasc Surg. 1989;97:351–361[Abstract]
- Siafakas NM, Vermeire P, Pride NM, Paoletti P, Gibson J, Howard P, Yernault JC, Decramer M, Higenbottam T, Postma DS, Rees J, et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). The European Respiratory Society Task Force. Eur Respir J. 1995;8:1398–1420[CrossRef][Medline]
- Braun NMT, Arora NS, Rochester DF. Force–length relationship of the normal human diaphragm. J Appl Physiol. 1982;53:405–412[Abstract/Free Full Text]
- Miller JI Jr. Acute and delayed space problems following pulmonary resection. Chest Surg Clin North Am. 1996;6:615–621[Medline]
- Venuta F, Rendina EA, De Giacomo T, Coloni GF. Prevention of air leaks after pulmonary surgery. Chest. 1999;115:1759–1760[Free Full Text]
- Miller JI Jr, Landreneau RJ, Wright CE, Santucci TS, Sammons BH. A comparative study of buttressed versus nonbuttressed staple line in pulmonary resection. Ann Thorac Surg. 2001;71:319–322[Abstract/Free Full Text]
- Wang K, Goldstraw P. Effect of fibrin glue in the reduction of postthoracotomy alveolar air leak. Ann Thorac Surg. 1997;64:979–981[Abstract/Free Full Text]
- Wain JC, Kaiser LR, Johnston DW, Yang SC, Wright CD, Friedberg JS, Feins RH, Heitmiller RF, Mathisen DJ, Selwyn MR. Trial of a novel synthetic sealant in preventing air leak after lung resection. Ann Thorac Surg. 2001;71:1623–1628[Abstract/Free Full Text]
- Robinson LA, Preksto D. Pleural tenting during upper lobectomy decreases chest tube time and total hospitalization days. J Thorac Cardiovasc Surg. 1998;115:319–326[Abstract/Free Full Text]
- Farkas GA, Roussos C. Diaphragm in emphysematous hamsters: sarcomere adaptability. J Appl Physiol: Respir Environ Exercise Physiol. 1983;54:1635–1640[Abstract/Free Full Text]
- Tabary JC, Tabary C, Tardieu C, Tardieu G, Goldspink G. Physiological and structural changes in the cat's soleus muscle due to immobilization at different lengths by plaster casts. J Physiol. 1972;224:231–244[Abstract/Free Full Text]
- Macklem PT, Eidelman D. Reexamination of the elastic properties of emphysematous lungs. Respiration. 1990;57:187–192[Medline]
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Top
Abstract
1. Introduction
, group I; 
, group II. Trend of left DDLI was significantly different in the two groups (
between group I and group II with Student's t-test.