Pleural-cutaneous fistula after uniportal non-intubated thoracoscopic lung volume reduction surgery: does the route of the chest tube matter? A two cases report

Abstract

Background
Interventional management of chronic obstructive pulmonary disease of the emphysema phenotype, include uniportal, non-intubated, video-assisted thoracic surgery (UNI-VATS) lung volume reduction surgery (LVRS), which has shown to offer significant clinical benefit and minimized surgery- and anesthesia-related morbidity. Nevertheless, the insertion of the chest tube through the single surgical incision may constitute a trigger-point for wound-related complications. Herein we report on two patients with severe emphysema who developed wound infection and pleural-cutaneous fistula following UNI-VATS LVRS.


Cases presentation
: In both patients the chest tube had been placed through the single surgical incision and the post-operative course was complicated by prolonged air leaks requiring discharge with the tube connected to a Heimlich valve. Following eventual removal of the chest tube, both patients came back to the emergency department on post-operative day 23 and 26, respectively, due to signs of local infection and pain. In one instance a recurrent pneumothorax required surgical debridement and placement of a further chest tube whereas in the other, sole surgical debridement at the surgical site proved curative. In both instances chest computed tomography clearly documented the pleural-cutaneous fistula first, and full recovery with complete lung re-expansion and proper wound healing subsequently.


Conclusions
These cases, which had never been reported so far, highlight a potentially preventable complication of UNI-VATS LVRS and suggest that alternative drainage strategies should be considered in patients at high-risk of prolonged air leaks.