Mastering the maze: navigating prolonged air leak in thoracic surgery

Despite technological advancements, prolonged air leak (PAL) remains a significant complication in thoracic surgery. PAL, indicative of an alveolar-pleural fistula (APF), impacts patient recovery, quality of life, and healthcare costs. Risk factors such as smoking and surgical techniques predispose patients to PAL, highlighting the importance of preoperative risk assessment. Segmentectomies, while beneficial for early-stage lung neoplasms, pose challenges due to increased PAL risk. Intraoperative techniques like the submersion test aid in PAL detection and categorisation. Standardising intraoperative management through initiatives like the Delphi consensus enhances PAL management. Studies on aerostatic interventions show promise in reducing PAL incidence. Postoperatively, chest drainage strategies play a crucial role, with digital chest drains offering improved monitoring and management precision. Long-term PAL management includes watchful waiting, chemical pleurodesis, and surgical interventions, with autologous blood patching emerging as a cost-effective intervention. Despite the array of interventions available, the lack of standardised guidelines underscores the multifactorial nature of PAL. In the context of visualised thoracic surgery, PAL remains a significant concern, impacting patient outcomes and healthcare costs. Visualised thoracic surgery, which encompasses minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS), offers several advantages, including reduced postoperative pain, shorter hospital stays, and faster recovery. However, despite these benefits, PAL remains a common complication, particularly in procedures involving lung resection or pleural interventions. Advanced visualisation technology in thoracic surgery allows for precise identification and management of PAL intraoperatively. Techniques such as intraoperative near-infrared fluorescence imaging enable real-time visualisation of air leaks, facilitating prompt intervention and potentially reducing the risk of PAL development. Additionally, adopting enhanced recovery protocols tailored to visualised thoracic surgery may help mitigate PAL risk by optimising perioperative care and promoting early mobilisation. Addressing PAL requires a comprehensive, individualised approach and continued research efforts in thoracic surgery. This review provides an overview of the challenges and strategies in navigating PAL, particularly on APF, emphasising the need for collaborative efforts and tailored approaches to optimise patient outcomes and reduce healthcare costs.