Division of Thoracic Surgery, Stanford School of Medicine, Stanford Hospitals and Clinics, Stanford, California 94305-5407, USA.
Ann Thorac Surg. 2011 Sep;92(3):1076-81; discussion 1081-2. doi: 10.1016/j.athoracsur.2011.04.082.
A fall in the postpneumonectomy fluid level is considered a sign of bronchopleural fistula (BPF) requiring surgical intervention. We have discovered however that in rare asymptomatic patients, this event may not require aggressive surgical treatment.
After seeing a case of benign emptying of the postpneumonectomy space (BEPS), we surveyed 28 surgeons to determine its incidence and characteristics.
Forty-four cases of BEPS were reported by 23 survey respondents. Among 7 fully documented cases from 4 institutions, we defined the following criteria: the patient must be asymptomatic (no fever, white cell count elevation, or fluid expectoration), negative culture results if fluid sampled (patient not receiving antibiotics), no BPF at bronchoscopy or ventilation scintigraphy scan (or both), and recovery without drainage, or retrospective assessment that the intervention was unnecessary. BEPS occurred between 5 days and 152 days after pneumonectomy (6 cases right pneumonectomy and 1 case left pneumonectomy). Four patients underwent no treatment, 1 patient underwent thoracoscopic exploration (sterile) and closure after antibiotic irrigation, 1 patient underwent thoracoscopic exploration alone, and 1 patient underwent open window thoracostomy (sterile) with eventual closure. In all 7 patients (except the patient who underwent the open window procedure) the space refilled within 8 weeks; no patient experienced a subsequent empyema/BPF. Four patients who met the initial criteria for BEPS went on to experience empyema. The incidence of BEPS appears related to pneumonectomy volume, particularly extrapleural pneumonectomy. Using surgeon volume assumptions, the incidence of BEPS is 0.65%.
To our knowledge, BEPS is a previously unreported occurrence. We hypothesize that it results from postoperative intrapleural pressure shifts, with or without a microscopic BPF, that drive fluid out of the pleural space while failing to cause contamination. Awareness of BEPS' existence may allow surgeons to safely avoid open drainage procedures occasionally in patients who experience an asymptomatic fall in fluid level.
肺切除术后液体水平下降被认为是支气管胸膜瘘（BPF）需要手术干预的标志。然而，我们发现，在极少数无症状患者中，这种情况可能不需要积极的手术治疗。
在观察到一例良性排空术后胸膜腔（BEPS）病例后，我们调查了 28 名外科医生，以确定其发生率和特征。
23 名调查答复者报告了 44 例 BEPS。在来自 4 个机构的 7 例完全记录的病例中，我们定义了以下标准：患者必须无症状（无发热、白细胞计数升高或液体渗出），如果取样的液体为阴性培养结果（患者未接受抗生素治疗），支气管镜或通气闪烁扫描无 BPF（或两者均无），且无需引流即可恢复，或回顾性评估干预是不必要的。BEPS 发生在肺切除术后 5 天至 152 天之间（右肺切除 6 例，左肺切除 1 例）。4 例患者未接受治疗，1 例患者接受胸腔镜探查（无菌）和抗生素冲洗后关闭，1 例患者仅接受胸腔镜探查，1 例患者接受开胸窗（无菌），最终关闭。在所有 7 例患者中（接受开胸窗手术的患者除外），该空间在 8 周内重新填充；无患者发生后续脓胸/ BPF。4 例符合 BEPS 初始标准的患者随后发生脓胸。BEPS 的发生率似乎与肺切除术的体积有关，尤其是胸膜外肺切除术。根据外科医生的手术量假设，BEPS 的发生率为 0.65%。
据我们所知，BEPS 是一种以前未报道过的情况。我们假设它是由术后胸腔内压力变化引起的，伴或不伴有微小的 BPF，导致液体从胸膜腔排出，而不会引起污染。了解 BEPS 的存在，可能使外科医生能够安全地避免在偶尔出现无症状液体水平下降的患者中进行开放性引流手术。
