1. THE FATE OF THE POSTRESECTION SPACE S.Ramghulam le Roux Institute of Thoracic Surgery 2012

2. ‘ 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

3. 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?

4. Terminology Benign closed benign space with alveolar seepage with bronchopleural fistula Malignant larger / increasing size contain fluid symptomatic

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

6. Methods Retrospective analysis of clinical data and radiographs Space considered significant if present > 7 days size arbitary Indications for surgery Space complications and intervention

7. 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

8. 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 *

9. Results Pathology Extent of resection

10. 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

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

12. 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

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

14. Active TB with massive haemoptysis Right upper lobectomy Conservative treatment

15. Active TB with massive haemoptysis Right upper and middle lobectomy Treated with tube drainage

16. 6 week follow up

17. 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

18. 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

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

20. Intervention Infection BPF Increase (relative) Discussion

21. Intervention Methods aspiration tube drainage thoracoplasty re-operation

22. “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