**6. Injuries to surrounding structures**

Injuries can happen to the oesophagus, phrenic nerve, recurrent laryngeal nerve, dural lacerations and spinal cord injury and peripheral embolisation of tumour.

#### **6.1. Injury to the phrenic nerve**

prospectively to treat chylothorax was curative in patients' with demonstratable duct leakage [115] however reproducibility and success have varied in different centres. Surgical therapy [115] is recommended in cases where despite conservative management the patient drains more than 1.5 l/day in an adult or >100 ml/kg body weight per day in a child, leaks chyle at a rate of >1 l/day for5 days or has persistent chyle flow for more than 2 weeks. Surgery is also recommended if there has been a rapid decline in nutritional status despite conservative management. Thoracic duct ligation can be performed during thoracotomy or by thoraco‐ scopic intervention. [116], [117] The main problem is identifying the chyle leak. Ligation of the thoracic duct is successful in 90% of patients when performed just above the right hemidiaphragm. [118] Ligating here, also has the advantage of halting flow from any unidentified accessory ducts. Collateral circulation redirects the chyle around the ligation point ensuring that the chyle still completes its journey to the circulation. In cases of loculated or complicated

One of the common problems after thoracic surgery is prolonged postoperative air leak. Not all patients have an air leak after pulmonary resection. However, many patients having a lobectomy, segmentectomy, or a complicated wedge resection will leave the operating room

The vast majority of postoperative air leaks, however, are alveolar air leaks, and therefore initial management should be aimed at treating this entity. The management of bronchopleural fistulas is substantially different than that of alveolar air leaks, often requiring early surgical

Air leaks that persist beyond a certain point may prolong the hospital length of stay. The Society of Thoracic Surgeons database mentions air leaks are those which are typically present when the patient could otherwise be discharged were it not for a continued air leak. The STS Thoracic Surgery Database defined prolonged air leak as lasting >5 days. Prolonged air leak may be associated with an increased complication rate and certainly may increase length of stay. Okereke et al. [120] found complications in up to 30% for patients with any air leak but only 18% in patients without, but this may have been a marker of extent of surgery or disease. Varela and colleagues [121] found that air leak lasting at least 5 days was associated with greater pulmonary morbidity, such as atelectasis, pneumonia, and empyema. They also found that the length of stay was extended by 6 days. Most leaks will stop within 2 to 3 weeks

By far the most common treatment of airleaks is watchful waiting with continuous drain‐ age through a tube thoracostomy. More than 90% of air leaks seemed to stop within sev‐ eral weeks after operation with this form of management alone, with only rare development of an empyema. [119]A valved, outpatient system, such as a Heimlich, can only be considered in patients who have no more than a small, stable, asymptomatic

Blood patch or chemical pleurodesis may be considered as the next step. Experience with these techniques is variable. The instillation of sclerosing materials into the pleural space through

chylothorax pleural decortication with pleurodesis may be performed. [115]

**5.12. Prolonged air leak**

72 Principles and Practice of Cardiothoracic Surgery

with a leak

intervention. [119]

pneumothorax on water seal. [119]

Thoracic surgical procedures can produce phrenic nerve injury. It happens when there are adhesions or in redo surgeries. Surgeries like anterior mediastinal tumor excision, re‐ section of superior sulcus tumours, repair of thoracic outlet syndrome, or right-sided me‐ diastinal lymph node dissection could all cause phrenic nerve injury. Such injuries may be temporary or permanent. Presenting features are shortness of breath on exertion and impaired exercise tolerance [136]. If patients are on a ventilator then there may be diffi‐ culty in weaning of ventilator. X-ray shows elevation of the affected hemi diaphragm. This is confirmed by ultrasound or fluoroscopy, which is the diagnostic study of choice in evaluation of these injuries. The best method of management of unilateral palsy is dia‐ phragmatic plication [136].

#### **6.2. Injury to the recurrent laryngeal nerve**

Injury to the recurrent laryngeal nerve generally present in the postoperative phase with a weak hoarse and whispery voice. They nay describe a voice, which gets weaker as the day progresses, which may cause aspiration or impaired physiotherapy due to inability to cough effectively. A laryngoscopy is done to confirm the diagnosis and adduction of the affected vocal cord or sluggish motion will be absent. Treatment depends on whether the injury is temporary or permanent. A fibre optic evaluation is necessary to test swal‐ lowing and sensation. To assist with pulmonary physiotherapy and decrease the risk of aspiration, medialization laryngoplasty may be suggested [136]. This can be done as an office procedure with the aid of autologous fat, Gel foam, collagen, or polytetrafluoro‐ ethylene. [136]

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