Management of air leak in lung volume reduction surgery at a specialized thoracic centre
Highlight box
Key findings
• This 10-year study examines outcomes in 257 patients who underwent lung volume reduction surgery (LVRS) and identifies a prolonged air leak (PAL) rate of 45%. In the majority of cases, the PAL was diffuse and not confined to the stapler line, complicating targeted intervention. Conservative management was employed in 96% of cases and was associated with favourable outcomes, whereas redo surgeries, required in four instances, were linked to a higher mortality rate and did not significantly improve PAL resolution.
What is known and what is new?
• PAL is a recognised complication of LVRS. This study provides evidence that conservative management is generally safer and more effective than redo-operation.
What is the implication, and what should change now?
• These findings highlight the importance of prioritising conservative management strategies for PAL following LVRS, given the high associated morbidity and limited efficacy of surgical re-intervention. Redo surgery was rarely successful and carried a significant risk of complications and mortality. Therefore, a shift towards evidence-based, conservative management should be reinforced in clinical practice, with reoperations reserved only for highly selected cases where clear indications exist. This approach may lead to improved postoperative outcomes, shorter hospital stays, reduced postoperative mortality and healthcare burden.
Introduction
Lung volume reduction surgery (LVRS) has been performed over almost 75 years to treat severe emphysema (1). However, despite advancements in surgical techniques and technologies, prolonged air leak (PAL) remains a significant concern. The global prevalence of PAL following LVRS is approximately around 46% to 80% (2).
PAL has been shown to increase hospital stays and is associated with complications such as chest infections, surgical emphysema, and, in severe cases, respiratory failure and death (3).
Prevention is key in managing PAL. Various surgical techniques have been reported, including nongrasping the lung, using buttressed staplers, avoiding high intraoperative positive end-expiratory pressure (PEEP), and applying sealants. Despite these preventive measures, the incidence of PAL remains high. Moreover, studies have shown that buttressed staplers are not superior to regular staplers (4,5) For instance, Stammberger et al. reported that while buttressed staplers reduced air leaks, they did not significantly decrease hospital stay durations (6).
Lund et al. recently published their experience with PAL after LVRS, noting a high rate of redo operations for air leak, 21 out of 191 patients (11%) (7). Interestingly, in most cases air leak was not associated with the stapler line but was instead diffusely present in the lung parenchyma. This finding is not surprising given that LVRS patients have fragile lung tissue. The tension created by positive pressure and the reduction in parenchyma volume can lead to diffuse air leaks. This raises questions about the traditional approach of using a linear stapler line for large wedges, instead of multiple smaller wedges (8).
Given the possibility of diffuse air leaks not necessarily linked to the stapler line or intraoperative lung injury, the benefit of redo surgery for managing PAL after LVRS needs further exploration. We present this article in accordance with the STROBE reporting checklist (available at https://shc.amegroups.com/article/view/10.21037/shc-2024-34/rc).
Methods
This was a retrospective single-centre analysis of all patients who underwent LVRS between April 2014 and April 2024. Patients were selected following multidisciplinary review at the advanced chronic obstructive pulmonary disease (COPD) meeting and were managed according to an established institutional LVRS pathway, which included defined protocols for preoperative optimisation, intraoperative technique, and postoperative management.
Data were collected from electronic medical records and operative databases. Variables recorded included patient demographics, comorbidities, operative details, need for conversion to open surgery, and postoperative outcomes. The primary outcome of interest was PAL, defined as a postoperative air leak lasting more than 5 days. Based on this, patients were stratified into three predefined groups: (I) no-PAL; (II) PAL managed conservatively; and (III) PAL requiring redo surgery. These groups were compared across various perioperative parameters including hospital length of stay (LOS), and postoperative complications.
Postoperative complications assessed included chest infection, respiratory failure requiring invasive ventilation, empyema, postoperative bleeding requiring intervention or transfusion, and in-hospital mortality. LOS was recorded for all patients, and both mean and median values were calculated along with standard deviations.
The decision to proceed with surgery was made on a case-by-case basis and guided by multidisciplinary team (MDT) discussion rather than a formalised protocol. Our underlying clinical principle is based on the observation that many post-LVRS air leaks are not necessarily located along stapler lines, but instead appear to be diffuse, likely due to re-expansion of diseased emphysematous lung under positive pressure. As such, our preference was always to pursue a conservative approach where feasible. Surgical re-intervention was reserved for patients with PALs showing no trend toward improvement, particularly when the leak significantly impacted recovery (e.g., delayed mobilization, infection risk, nutritional compromise). These cases were judged individually, incorporating patient factors, clinical trajectory, and MDT input.
Patients were discharged home with a chest drain in selected cases where it was clinically safe to do so, based on radiographic evidence of stable lung re-expansion, a low-volume air leak (typically <1 litre per 24 hours), and good general condition and mobility. These patients were followed up in a dedicated post-LVRS chest drain clinic within 1–2 weeks. However, due to the national and international referral nature of our service, some patients could not be discharged with a drain due to lack of access to outpatient follow-up, necessitating a longer inpatient stay until drain removal.
Surgical technique
All operations were initiated via a video-assisted thoracoscopic surgery (VATS) approach. Conversion to open thoracotomy was undertaken where intraoperative findings warranted it. The operative strategy was standardised across all cases, and included the use of buttressed staplers with bovine pericardium to reinforce the staple lines, minimal lung handling, and the placement of two apical chest drains (anterior and posterior). Paravertebral blockade was routinely used for analgesia. Digital chest drainage systems were used in all cases and set to −0.8 kPa for postoperative air leak management.
Patients undergoing redo operations were individually analysed to determine intraoperative findings, the success of air leak control, and their subsequent clinical course. Analysis across the three PAL subgroups was used to explore associations between leak management strategy, LOS, and incidence of postoperative complications.
Statistical analysis
Statistical analysis was performed using IBM Statistical Package for the Social Sciences (SPSS) (version 29.0). Categorical variables were compared using Fisher’s exact test due to small subgroup sizes. Continuous variables were assessed using one-way analysis of variance (ANOVA) to compare means across the three PAL management groups: no-PAL, PAL managed conservatively, and PAL requiring redo surgery. When ANOVA showed statistically significant differences, Tukey’s post-hoc test was used for pairwise comparisons to identify where these differences lay. A P value of less than 0.05 was considered statistically significant for all comparisons. Results were reported as means with standard deviations or medians where appropriate, and findings were interpreted in the context of clinical relevance as well as statistical significance.
Ethical considerations
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional ethics board of Royal Brompton Hospital (No. 007607). Patient consent was waived due to the retrospective nature of the study. Patient confidentiality was maintained by de-identifying all data prior to analysis.
Results
During the study period, a total of 257 VATS LVRS were performed. Intraoperative conversion to open thoracotomy was required in 52 cases (20.2%). PAL, defined as persisting beyond 5 days, occurred in 116 patients (45% of the cohort). Postoperative complications were observed in 73 patients (28.4%). Specifically, 54 patients (21%) developed chest infections, 6 (2.3%) experienced respiratory failure requiring invasive ventilation, 3 (1.2%) developed empyema, 4 (1.5%) had significant postoperative bleeding, and 5 patients (1.9%) died within 30 days of surgery. Postoperative complications are summarized in Figure 1.
The median postoperative LOS for the overall cohort was 11 days, with a mean LOS of 15.4 days (range, 2–147 days). The interquartile range was 8–20 days, and the standard deviation was 13.8 days.
Among the 116 patients with PAL, the majority (111 patients, 96%) were managed conservatively, while 5 patients (4%) required surgical re-intervention. Redo operations were largely unsuccessful in definitively resolving the air leak: only 1 of the 5 cases (20%) demonstrated clear improvement. Intraoperative findings during these redo procedures consistently revealed diffuse parenchymal air leak rather than a discrete focal defect. Importantly, surgical re-intervention was associated with significant risk; 2 of the 5 patients (40%) developed respiratory failure postoperatively, both of whom died. The outcomes of redo operations are summarized in Table 1.
Table 1
| Patient | Days after operation | Findings | Surgery | Air leak improvement | LOS (days) | Comments |
|---|---|---|---|---|---|---|
| #1 | 2 | Air leak close to the stapler line (3 cm), diffuse air leak | Redo VATS, new stapler, drains | No | 20, discharged with portable chest drain bag | |
| #2 | 27/60 | Diffuse air leak, not stapler line | Day 27: redo VATS, air leak sealant, drains. Day 60: redo VATS/thoracotomy lung mobilization, drains | No | 147, without drains | Had EBV at 45 days after surgery. Complicated with PE, aspiration, chest infection |
| #3 | 6 | Diffuse air leak, not stapler line | Redo VATS lung mobilization, drains | No | 30 (death) | Respiratory failure after redo, long term intubation, death |
| #4 | 13 | Diffuse air leak, not stapler line | Redo VATS lung mobilization, air leak sealant, drains | Decreased and persisted | 23, without drains | |
| #5 | 30 | Diffuse air leak, not stapler line | Redo VATS/thoracotomy partial decortication, multiple polypropylene stiches, drains | No | 39 (death) | Type 2 respiratory failure, death after 1 week of redo operation (not for reintubation) |
EBV, endobronchial valves; LOS, length of stay; PE, pulmonary embolism; VATS, video-assisted thoracoscopic surgery.
To assess the impact of PAL and its management on hospital stay, we compared LOS across three subgroups: patients without PAL, those who managed conservatively for PAL, and those with PAL that required redo surgery. Median LOS was 8 days in the no-PAL group, 16 days in the conservatively managed PAL group, and 18 days in the redo PAL surgery group. Mean LOS and standard deviations for each group are provided in Tables 2,3. A one-way ANOVA demonstrated a highly significant difference in LOS across the three groups (P=1.05×10−13). Post-hoc analysis using Tukey’s test revealed significantly longer LOS in both PAL groups compared to those without air leaks: no-PAL versus conservative PAL (mean difference =−7.64 days, P=0.004), and no-PAL versus redo PAL (mean difference =−11.03 days, P<0.001). There was no statistically significant difference in LOS between the conservative and redo PAL groups (mean difference =−3.39 days, P=0.057), though a trend toward longer stay in the redo group was noted. Detailed results are presented in Tables 2,3.
Table 2
| Group | Median LOS (days) | Mean LOS (days) | Standard deviation (days) |
|---|---|---|---|
| No prolonged air leak | 8.0 | 10.18 | 6.64 |
| Prolonged air leak—conservative management | 16.0 | 17.82 | 9.29 |
| Prolonged air leak—redo operation | 18.0 | 21.21 | 12.33 |
ANOVA result: a one-way ANOVA demonstrated a statistically significant difference in LOS across the three groups (P=1.05×10−13). ANOVA, analysis of variance; LOS, length of stay.
Table 3
| Comparison | Mean difference (days) | P value |
|---|---|---|
| No prolonged air leak vs. prolonged air leak—conservative | −7.64 | 0.004 |
| No prolonged air leak vs. prolonged air leak—redo surgery | −11.03 | <0.001 |
| Prolonged air leak—conservative vs. redo surgery | −3.39 | 0.057 |
Analysis of postoperative complications by PAL subgroup revealed increased rates of chest infection and respiratory failure in patients requiring redo operations for PAL. Chest infection occurred in 17.7% of patients without PAL, 24.3% of those with conservatively managed PAL, and 40% of those undergoing redo surgery for PAL (P=0.14). Respiratory failure was notably more common in the redo group for PAL (40%) compared to 2.1% in the no-PAL group and 0.9% in the conservative group, reaching statistical significance (P=0.01). In-hospital mortality was also higher in the redo group (40%), compared to 2.1% in the no-PAL group and 0% in the conservative group (P=0.056). The overall in-hospital mortality rate for the cohort was 1.95%. A full comparison of complications by group is summarized in Table 4.
Table 4
| Condition | No prolonged air leak (n=141), n (%) | Prolonged air leak (conservative) (n=111), n (%) | Prolonged air leak (redo operation) (n=5), n (%) | Fisher’s exact test P value |
|---|---|---|---|---|
| Chest infection | 25 (17.7) | 27 (24.3) | 2 (40.0) | 0.14 |
| Respiratory failure (ventilation) | 3 (2.1) | 1 (0.9) | 2 (40.0) | 0.01 |
| Empyema | 1 (0.7) | 2 (1.8) | 0 (0) | >0.99 |
| Bleeding | 2 (1.4) | 2 (1.8) | 1 (20.0) | 0.25 |
| In-hospital mortality | 3 (2.1) | 0 (0) | 2 (40.0) | 0.056 |
Discussion
LVRS is an established treatment for managing COPD (9). Multiple investigations have demonstrated improvements in lung function, evidenced by decreased residual volume, along with a significant positive impact on quality of life (9,10). However, LVRS is a surgical intervention associated with a high rate of complications and mortality. The 90-date mortality rate reported by the UK Lung Volume Reduction (UKLVR) is 6% (11).
One of the most common complications following LVRS is PAL. While air leaks themselves may not pose a significant problem, the consequences associated with PAL are noteworthy. The primary issue is the extended hospital stay required for patients with PAL, which increases the risk of chest infections, empyema, or other complications due to the prolonged presence of a chest drain.
Additionally, PAL can lead to the development of surgical emphysema. Although surgical emphysema is not life-threatening, it can cause significant anxiety in patients, as well as in non-surgical staff, inexperienced surgeons, and the patients themselves. This anxiety can limit the patient’s ability to participate in essential physiotherapy and rehabilitation.
Preventing air leaks is crucial in their management. However, research by Lund et al. (7) has shown that most air leaks are not necessarily related to surgical techniques, staplers, or iatrogenic damage during operations. Often, air leaks are diffuse and associated with the tension in the remaining lung after LVRS. Lund’s suggestion to perform multiple small wedges instead of a single large wedge with a long linear stapler line aims to reduce the tension in the remaining lung and potentially decrease the risk of air leaks.
Our clinical impression suggests that many post-LVRS air leaks may not be directly associated with identifiable staple line failure or iatrogenic injury but may instead reflect generalized re-expansion of diseased emphysematous lung. However, further research is needed to confirm this hypothesis. Given that we only performed five redo operations in this cohort, it is difficult for us to assert or confirm this theory definitively. However, it is a concept that some researchers continue to maintain or theorize in the literature.
The decision to proceed with surgical re-intervention in our series was made on a case-by-case basis, guided by MDT discussion rather than a formalized protocol. Surgical intervention was reserved for patients with PALs showing no trend toward improvement, particularly when the leak significantly impacted recovery (e.g., delayed mobilization, infection risk, nutritional compromise). These decisions incorporated individual patient factors, clinical trajectory, and MDT input. Nevertheless, we acknowledge the limitation in drawing strong conclusions from a small subset of five patients and have revised our discussion to reflect a more cautious interpretation. We now state that repeat surgery should be avoided if possible and emphasize our general preference for conservative management where feasible.
Our statistical analysis reinforces this conservative approach. Patients without PAL had a significantly shorter median LOS of 8.0 days (mean 10.18 days), compared to 16.0 days (mean 17.82 days) in those managed conservatively for PAL, and 18.0 days (mean 21.21 days) in those undergoing redo surgery. The overall ANOVA P value was highly significant (P=1.05×10−13), and post-hoc analysis using Tukey’s test confirmed significant differences in LOS between patients with no-PAL and those managed conservatively (P=0.004), as well as between those with no-PAL and those undergoing redo surgery (P<0.001). Notably, the difference in LOS between conservatively and surgically managed PAL did not reach statistical significance (P=0.057), suggesting limited added benefit of reoperation in reducing hospitalization.
Furthermore, while rates of chest infection, empyema, and bleeding did not differ significantly between groups, the incidence of respiratory failure and mortality was substantially higher in the redo operation group, both at 40%, compared to ≤2.1% in the other groups. These findings are statistically significant for respiratory failure (P=0.01), and approach significance for mortality (P=0.056), highlighting the potential risks associated with surgical re-intervention.
Endobronchial valves (EBVs) represent a minimally invasive option for PAL management following LVRS (12). In our experience, EBVs have been used on a single occasion, indicating that they remain an underutilized resource in our practice. This limited use reflects a gap in our data and highlights an area for future exploration.
Although our findings support a conservative approach to PAL after LVRS, it is important to note the limitations of this study. Firstly, it is a retrospective analysis, which inherently introduces the risk of selection bias. Additionally, we are a team with a strong preference for conservative management of PAL, and this practice pattern has resulted in a low number of redo operations in our cohort. This means that the patients who were selected for surgical re-intervention represent a highly specific subset, those with PAL and other complicating factors such as respiratory compromise, nutritional failure, or recurrent infections. As such, the worse outcomes seen in the surgical group may in part reflect confounding by indication, that is, sicker or more complex patients are more likely to be selected for surgery, and their poorer outcomes may not be attributable solely to the intervention itself.
In our practice, reoperations have been associated with high rates of respiratory failure and death, further reinforcing the importance of a cautious, patient-centered, and conservative approach to PAL management following LVRS.
Conclusions
PAL following LVRS is not typically associated with staple line failure or intraoperative iatrogenic injury. Rather, it often reflects a physiological consequence of re-expanding an emphysematous lung that has been surgically reshaped and reduced in volume. The altered mechanical properties and geometry of the remaining parenchyma may predispose persistent, diffuse air leaks. In our experience, attempting to address these leaks through redo operations has proven impractical and is associated with significantly increased risks of respiratory failure and in-hospital mortality. Based on our retrospective data, a conservative, watch-and-wait strategy appears to be the safest and most effective approach for managing PAL in this context. This strategy minimizes the risks of further intervention while allowing time for spontaneous resolution in the majority of cases. Further prospective research is warranted to confirm these findings and to optimize management pathways for PAL following LVRS.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://shc.amegroups.com/article/view/10.21037/shc-2024-34/rc
Data Sharing Statement: Available at https://shc.amegroups.com/article/view/10.21037/shc-2024-34/dss
Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-2024-34/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-2024-34/coif). P.D.S. serves as an unpaid editorial board member of Shanghai Chest from December 2023 to November 2025. The other authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional ethics board of Royal Brompton Hospital (No. 007607). Patient consent was waived due to the retrospective nature of the study. Patient confidentiality was maintained by de-identifying all data prior to analysis.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Alvarez Gallesio J, De Sousa P, Proli C, Boyle M, Alshammari A, Chavan H, Choi J, Begum S, Jordan S. Management of air leak in lung volume reduction surgery at a specialized thoracic centre. Shanghai Chest 2025;9:4.
