What happened, in summary

This 67-year-old man had diabetes and emphysema before being treated for lung adenocarcinoma in the right upper lobe. His tumor was described as T2bN0M0, meaning no nodal or distant metastasis was reported. He underwent thoracoscopic right upper lobectomy. During the operation, the interlobar fissures were divided with a stapler and the staple lines were covered with a cellulose patch. A water-submersion test showed no air leak during surgery, and a chest drain was left in place. On postoperative day 2, however, air began leaking into the pleural space. A digital pleural drainage device was used to measure the leak objectively. The flow decreased enough that, on postoperative day 11, he was discharged with a Heimlich valve. The leak did not resolve. Forty-five days later, he was readmitted. Imaging showed a residual apical space, and bronchoscopy showed the bronchial stump had healed without a visible defect. The drainage device showed the leak had worsened from 70 mL/min at discharge to 350 mL/min. He underwent a second minimally invasive operation using the prior incisions. Surgeons found an alveolar fistula in the apical segment of the lower lobe where the original patch had detached from the staple line. They closed the fistula with sealant, created a pleural flap from the chest-wall lining, and fixed the flap over the repaired area. Talc pleurodesis completed the operation. Recovery was smooth: the air leak stopped by postoperative day 3, the chest tube was removed after clamping, and he was discharged on day 7. At 2 months, the air leak had not returned.