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Balakrishnan B, Payanam U, Laurent A, Wassef M, Jayakrishnan A. Efficacy evaluation of an in situforming tissue adhesive hydrogel as sealant for lung and vascular injury. Biomed Mater 2021; 16. [PMID: 33902022 DOI: 10.1088/1748-605x/abfbbf] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/26/2021] [Indexed: 12/26/2022]
Abstract
In situforming tissue adhesives based on biopolymers offer advantages over conventional sutures and staples in terms of biocompatibility, biodegradability, ease of application and improved patient compliance and comfort. Here, we describe the evaluation ofin situgelling hydrogel system based on dextran dialdehyde (DDA) obtained by periodate oxidization of dextran and chitosan hydrochloride (CH) as tissue adhesive. The hydrogel was prepared by reacting aldehyde functions in DDA with the amino functions in CH via Schiff's reaction. The gelation reaction was instantaneous and took just 4 s. The DDA-CH hydrogel as tissue adhesive was evaluated on a sheep lung parenchymal injury model and a pig aortic model and was compared with the commercially available tissue sealant, Bioglue®. The DDA-CH glue could completely seal the sheep lung incision site even at inflation with air way pressure of 30 cm of H2O with no air leak observed in the incision sites (n= 8) in any of the animals. Histological analyses showed mild inflammation after 2 weeks, comparable to Bioglue®. Resorption of test material by giant cells with no adverse effect on lung parenchyma was seen after 3 months. The DDA-CH glue was also very effective in sealing aortic incisions in a pig model (n= 4) with no failures and aneurisms. The endoluminal surface of the sealed incision in all cases showed intact apposition with adequate healing across the incision. No tissue necrosis or inflammation of endothelial surface could be seen grossly. Our studies show that the DDA-CH hydrogel could function as an effective sealant for the prevention of air and blood leaks following lung and vascular surgery.
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Affiliation(s)
- Biji Balakrishnan
- Nanotherapeutics and Biosensor Section, Chemistry Division, Bhabha Atomic Research Centre, Trombay 400 085 Maharashtra, India
| | - Umashanker Payanam
- In Vivo Models and Testing Division, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala 695012, India
| | - Alexandre Laurent
- Department of Interventional Neuroradiology, APHP, Hôpital Lariboisière, 2 rue Ambroise Paré, 75010 Paris, France
| | - Michel Wassef
- Department of Pathology, APHP, Hôpital Lariboisière, 2 rue Ambroise Paré, 75010 Paris, France
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Gondé H, Le Gac C, Gillibert A, Bottet B, Laurent M, Sarsam M, Hervouët C, Varin R, Baste JM. Feedback on the use of three surgical sealants for preventing prolonged air leak after robot-assisted anatomical lung resection. J Thorac Dis 2019; 11:2705-2714. [PMID: 31463097 DOI: 10.21037/jtd.2019.06.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Prolonged air leak (PAL) is the most common complication after lung resection. Several surgical sealants have been developed to reduce PAL, including fibrin-based (FS), polyethylene glycol-based (PEGS) and polyglycolic acid-based (PGAS) sealants. In this work we report our experience of surgical sealant use after robot-assisted lung resection. Methods A 7-year retrospective study was conducted, including patients who had robot-assisted lobectomy or segmentectomy. Data were collected using a prospective national database. The use of surgical sealants was recorded in traceability sheets. Results PAL occurred in 60 of the 299 patients included. American Society of Anesthesiologists score (ASA) and index of prolonged air leak (IPAL) were higher for patients with sealants. In this group, operative time, chest drain duration and length of stay were significantly longer. PAL occurrence was significantly associated to sealant in univariate analysis (odds ratio =1.88, 95% CI: 1.07 to 3.36, P=0.03) but the association was slightly decreased when adjusting on IPAL and ASA score (Odds ratio =1.70, 95% CI: 0.94 to 3.10, P=0.08). Comparing sealants, more segmentectomies were performed in patients with PGAS (P=0.0013) and their operative time was shorter (P=0.0002). PAL occurrences were not different. Length of stay (P=0.0045) and operative time (P=0.0002) were longer in patients with PEGS who had more postoperative complications (P=0.024). Conclusions This study did not identify a positive effect of surgical sealants for preventing PAL. However it highlighted the need to rationalize their use.
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Affiliation(s)
- Henri Gondé
- Department of Pharmacy, Rouen University Hospital, Normandie Univ, UNIROUEN, U1234, F 76000 Rouen, France
| | - Constance Le Gac
- Department of Pharmacy, Rouen University Hospital, F 76000 Rouen, France
| | - André Gillibert
- Department of Biostatistics, Rouen University Hospital, Normandie Univ, UNIROUEN, F 76000 Rouen, France
| | - Benjamin Bottet
- Department of General and Thoracic Surgery, Rouen University Hospital, F 76000 Rouen, France
| | - Marc Laurent
- Department of Pharmacy, Rouen University Hospital, F 76000 Rouen, France
| | - Matthieu Sarsam
- Department of General and Thoracic Surgery, Rouen University Hospital, F 76000 Rouen, France
| | - Charles Hervouët
- Department of Pharmacy, Rouen University Hospital, F 76000 Rouen, France
| | - Rémi Varin
- Department of Pharmacy, Rouen University Hospital, Normandie Univ, UNIROUEN, U1234, F 76000 Rouen, France
| | - Jean-Marc Baste
- Department of General and Thoracic Surgery, Rouen University Hospital, Normandie Univ, UNIROUEN, U1096, F 76000 Rouen, France
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Lacour M, Caviezel C, Weder W, Schneiter D. Postoperative complications and management after lung volume reduction surgery. J Thorac Dis 2018; 10:S2775-S2779. [PMID: 30210831 DOI: 10.21037/jtd.2018.08.75] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The aim of lung volume reduction surgery (LVRS) for patients suffering from severe emphysema is to improve lung function and palliate dyspnea. Careful patient selection in a multidisciplinary approach in a high-volume center is mandatory for a successful outcome. Pulmonary complications including air leak and pneumonia as well as cardiac complications are the most common complications after LVRS. The following article will focus on most common complications observed after LVRS and review the management strategies to improve surgical outcome.
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Affiliation(s)
- Max Lacour
- Department of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
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Droghetti A, Marulli G, Vannucci J, Giovanardi M, Bottoli MC, Ragusa M, Muriana G. Cost analysis of pulmonary lobectomy procedure: comparison of stapler versus precision dissection and sealant. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:201-206. [PMID: 28408847 PMCID: PMC5384707 DOI: 10.2147/ceor.s115322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the direct costs of pulmonary lobectomy hospitalization, comparing surgical techniques for the division of interlobar fissures: stapler (ST) versus electrocautery and hemostatic sealant patch (ES). METHODS The cost comparison analysis was based on the clinical pathway and drawn up by collecting the information available from the Thoracic Surgery Division medical team at Mantova Hospital. Direct resource consumption was derived from a previous randomized controlled trial including 40 patients. Use and maintenance of technology, equipment and operating room; administrative plus general costs; and 30-day use of postsurgery hospital resources were considered. The analysis was conducted from the hospital perspective. RESULTS On the average, a patient submitted to pulmonary lobectomy costs €9,744.29. This sum could vary from €9,027 (using ES) to €10,460 (using ST). The overall lower incidence (50% vs 95%, P=0.0001) and duration of air leakage (1.7 days vs 4.5 days, P=0.0001) in the ES group significantly affects the mean time of hospital stay (11.0 days vs 14.3 days) and costs. Cost saving in the ES group was also driven by the lower incidence of complications. The main key cost driver was staff employment (42%), then consumables (34%) and operating room costs (12%). CONCLUSION There is an overall saving of around €1,432.90 when using ES patch for each pulmonary lobectomy. Among patients undergoing this surgical procedure, ES can significantly reduce air leakage incidence and duration, as well as decrease hospitalization rates. However, further multicenter research should be developed considering different clinical and managerial settings.
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Affiliation(s)
| | | | - Jacopo Vannucci
- Thoracic Surgery Division, University of Perugia, Perugia, Italy
| | | | | | - Mark Ragusa
- Thoracic Surgery Division, University of Perugia, Perugia, Italy
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Xu Y, Thall PF, Müller P, Mehran RJ. A Decision-Theoretic Comparison of Treatments to Resolve Air Leaks After Lung Surgery Based on Nonparametric Modeling. BAYESIAN ANALYSIS 2016; 12:639-652. [PMID: 28959372 PMCID: PMC5613677 DOI: 10.1214/16-ba1016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We propose a Bayesian nonparametric utility-based group sequential design for a randomized clinical trial to compare a gel sealant to standard care for resolving air leaks after pulmonary resection. Clinically, resolving air leaks in the days soon after surgery is highly important, since longer resolution time produces undesirable complications that require extended hospitalization. The problem of comparing treatments is complicated by the fact that the resolution time distributions are skewed and multi-modal, so using means is misleading. We address these challenges by assuming Bayesian nonparametric probability models for the resolution time distributions and basing the comparative test on weighted means. The weights are elicited as clinical utilities of the resolution times. The proposed design uses posterior expected utilities as group sequential test criteria. The procedure's frequentist properties are studied by extensive simulations.
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Affiliation(s)
- Yanxun Xu
- Dept. of Statistics and Data Sciences, University of Texas at Austin
- Dept. of Applied Mathematics and Statistics, Johns Hopkins University
| | - Peter F Thall
- Dept. of Biostatistics, University of Texas, M.D. Anderson Cancer Center
| | - Peter Müller
- Dept. of Mathematics, University of Texas at Austin
| | - Reza J Mehran
- Dept. of Thoracic Surgery, The University of Texas M.D. Anderson Cancer Center
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Van Schil PE, Hendriks JM, Lauwers P. Focus on treatment complications and optimal management surgery. Transl Lung Cancer Res 2015; 3:181-6. [PMID: 25806298 DOI: 10.3978/j.issn.2218-6751.2014.06.07] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 06/19/2014] [Indexed: 11/14/2022]
Abstract
Thoracic surgery comprises major procedures which may be challenging, not only from a technical point of view but also regarding anesthetic and postoperative management. Complications are common occurrences which are also related to the comorbidity of the patients. After major lung resections pulmonary and pleural complications are often encountered. In this overview more surgically related complications are discussed, focusing on postpneumonectomy pulmonary edema, thromboembolic disease including pulmonary embolism, prolonged air leak, lobar torsion, persistent pleural space, empyema and bronchopleural fistula. Prevention, timely recognition, and early adequate treatment are key points as complications initially considered to be minor, may suddenly turn into life-threatening events. To this end multidisciplinary cooperation is necessary. Preoperative smoking cessation, adequate pain control, attention to nutritional status, incentive spirometry and early mobilization are important factors to reduce the incidence of postoperative complications.
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Affiliation(s)
- Paul E Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Belgium
| | - Jeroen M Hendriks
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Belgium
| | - Patrick Lauwers
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Belgium
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Rosso L, Parazzi V, Damarco F, Righi I, Santambrogio L, Rebulla P, Gatti S, Ferrero S, Nosotti M, Lazzari L. Pleural tissue repair with cord blood platelet gel. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 12 Suppl 1:s235-42. [PMID: 23736928 PMCID: PMC3934292 DOI: 10.2450/2013.0214-12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 01/09/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prolonged air leak is the major cause of morbidity after pulmonary resection. In this study we used in vitro and in vivo experiments to investigate an innovative approach based on the use of human umbilical cord blood platelet gel. MATERIALS AND METHODS In vitro, a scratch assay was performed to test the tissue repair capability mediated by cord blood platelet gel compared to the standard culture conditions using human primary mesothelial cells. In vivo, an iatrogenic injury was made to the left lung of 54 Wistar rats. Cord blood platelet gel was placed on the injured area only in treated animals and at different times histological changes and the presence of pleural adhesions were evaluated. In addition, changes in the pattern of soluble inflammatory factors were investigated using a multiplex proteome array. RESULTS In vitro, mesothelial cell damage was repaired in a shorter time by cord blood platelet gel than in the control condition (24 versus 35 hours, respectively). In vivo, formation of new mesothelial tissue and complete tissue recovery were observed at 45±1 and 75±1 hours in treated animals and at 130±2.5 and 160±6 hours in controls, respectively. Pleural adhesions were evident in 43% of treated animals compared to 17% of controls. No complications were observed. Interestingly, some crucial soluble factors involved in inflammation were significantly reduced in treated animals. DISCUSSION Cord blood platelet gel accelerates the repair of pleural damage and stimulates the development of pleural adhesions. Both properties could be particularly useful in the management of prolonged air leak, and to reduce inflammation.
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Affiliation(s)
- Lorenzo Rosso
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Parazzi
- Cell Factory, Centre of Transfusion Medicine, Cellular Therapy and Cryobiology, Department of Regenerative Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Damarco
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Righi
- General and Thoracic Surgery Unit, Legnano Hospital, Legnano, Italy
| | - Luigi Santambrogio
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Rebulla
- Cell Factory, Centre of Transfusion Medicine, Cellular Therapy and Cryobiology, Department of Regenerative Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Gatti
- Centre for Surgical Research, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ferrero
- Department of Pathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenza Lazzari
- Cell Factory, Centre of Transfusion Medicine, Cellular Therapy and Cryobiology, Department of Regenerative Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Fuller C. Reduction of intraoperative air leaks with Progel in pulmonary resection: a comprehensive review. J Cardiothorac Surg 2013; 8:90. [PMID: 23590942 PMCID: PMC3658883 DOI: 10.1186/1749-8090-8-90] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 11/02/2012] [Indexed: 11/10/2022] Open
Abstract
Intraoperative alveolar air leaks (IOALs) occur in 75% of patients during pulmonary resection. Despite routine use of sutures and stapling devices, they remain a significant problem in the daily practice of thoracic surgery. Air leaks that persist beyond postoperative day 5 often result in increased costs and complications. Several large meta-analyses have determined that sealants as a class reduce postoperative air leak duration and time to chest drain removal, but these results did not necessarily correlate with a reduction in length of postoperative hospital stay. These analyses grouped surgical sealants together of necessity, but differences in efficacy may exist due to the differing product characteristics, study protocols, surgical procedures, and study endpoints. Progel, currently the only pleural surgical sealant FDA-approved for use in lung resection, has demonstrated efficacy and safety in two controlled clinical studies and superiority over standard air leak closure methods in reducing IOALs and length of hospital stay. This paper will review these findings and report on real-world experience with this recently approved pleural sealant.
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Affiliation(s)
- Clark Fuller
- Esophageal Center, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA.
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Ueda K, Tanaka T, Hayashi M, Li TS, Hamano K. Verification of early removal of the chest tube after absorbable mesh-based pneumostasis subsequent to video-assisted major lung resection for cancer. World J Surg 2012; 36:1603-7. [PMID: 22422172 DOI: 10.1007/s00268-012-1557-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND We previously reported that the combined use of absorbable mesh and fibrin glue is superior to the use of fibrin glue alone to stop intraoperative air leaks. However, concern remains about whether mesh-based pneumostasis can induce the recurrence of air leaks after chest tube removal. METHODS We reviewed our prospective database of selected patients (n = 206) who underwent video-assisted major lung resection for cancer. Exclusion criteria included simultaneous combined resection, induction radiotherapy, entire intrathoracic adhesion, or a history of prior ipsilateral thoracotomy. We sealed any intraoperative air leaks with absorbable mesh and fibrin glue and then carried out prophylactic chest-tube drainage for 1 day. RESULTS Intraoperative air leaks were detected in 133 (65%) patients. Overall, air leaks were not detected postoperatively in 186 (91%) patients, allowing chest tube removal on the day after the operation. The mean length of time for chest tube drainage was 1.2 days. A prolonged air leak (>7 days) was observed in one (0.5%) patient, and this leak resolved by itself. After chest tube removal, an air leak recurred in six (2.9%) patients during the 30 day follow-up period, necessitating chest tube reinsertion. Although the recurrence was observed more frequently after segmentectomy than after lobectomy (p = 0.04), the recurrence was not observed more frequently in patients who had an intraoperative air leak than in patients who did not (p = 0.3). CONCLUSION Early removal of the chest tube after pneumostasis with absorbable mesh is verified in selected patients who underwent video-assisted major lung resection for cancer. However, further attempts should be made to prevent air leaks after anatomical segmentectomy.
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Affiliation(s)
- Kazuhiro Ueda
- Department of Surgery and Clinical Science, Division of Chest Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan.
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Gonfiotti A, Santini PF, Jaus M, Janni A, Lococo A, De Massimi AR, D'Agostino A, Carleo F, Di Martino M, Larocca V, Cardillo G. Safety and effectiveness of a new fibrin pleural air leak sealant: a multicenter, controlled, prospective, parallel-group, randomized clinical trial. Ann Thorac Surg 2011; 92:1217-24; discussion 1224-5. [PMID: 21958767 DOI: 10.1016/j.athoracsur.2011.05.104] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 04/19/2011] [Accepted: 05/27/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND This study evaluated the sealing capacity and safety of a new fibrin sealant (FS) to reduce alveolar air leaks (AALs) after pulmonary resections in a randomized controlled clinical trial conducted in 3 Italian centers. METHODS The study randomized (1:1) 185 patients with an intraoperative AAL graded 1 to 3 according to the Macchiarini scale: 91 received FS and 94 had standard lung closure. The primary outcomes were the length of postoperative AAL duration and the mean time to chest drain removal. Other end points included the percentage of patients without AAL, the development of serum antibodies against bovine aprotinin, and any adverse event related to FS. Chest drains were removed when fluid output was 100 mL/day or less, with no air leak. RESULTS The study groups were comparable with respect to demographic variables and surgical procedures. The FS group showed a statistically significant reduction in duration of postoperative AALs (9.52 vs 35.8 hours; p < 0.005) and in the percentage of patients with AALs at wound closure (81.11% vs 100%; p < 0.001); the difference in time to chest drain removal was not significant. Pleural empyema developed in 1 patient with FS treatment vs in 4 with standard treatment, and antibodies against bovine aprotinin were found in 34 of 91 FS-treated patients. CONCLUSIONS The present study showed that the new FS is safe and effective in preventing AALs after lung resections and in shortening the duration of postoperative AALs.
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De Leyn P, Muller MR, Oosterhuis JWA, Schmid T, Choong CK, Weder W, Sokolow Y. Prospective European multicenter randomized trial of PleuraSeal for control of air leaks after elective pulmonary resection. J Thorac Cardiovasc Surg 2011; 141:881-7. [DOI: 10.1016/j.jtcvs.2010.09.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Revised: 07/17/2010] [Accepted: 09/24/2010] [Indexed: 11/25/2022]
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Malapert G, Hanna HA, Pages PB, Bernard A. Surgical Sealant for the Prevention of Prolonged Air Leak After Lung Resection: Meta-Analysis. Ann Thorac Surg 2010; 90:1779-85. [DOI: 10.1016/j.athoracsur.2010.07.033] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Revised: 07/08/2010] [Accepted: 07/09/2010] [Indexed: 10/18/2022]
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Merritt RE, Singhal S, Shrager JB. Evidence-based suggestions for management of air leaks. Thorac Surg Clin 2010; 20:435-48. [PMID: 20619236 DOI: 10.1016/j.thorsurg.2010.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The management of postoperative alveolar air leaks (AALs) continues to challenge thoracic surgeons. AALs increase length of stay and health care costs, and likely lead to other postoperative complications. Staple line buttresses, topical sealants, pleural tents, pneumoperitoneum, and modifications of traditional chest tube management (ie, reduced suction) have all been proposed to help reduce AAL. However, the cost of some of the commercial products being marketed may outweigh their relative effectiveness, and some of these techniques and products have not been adequately studied to date. This article provides a review of the available evidence-based literature that addresses the efficacy of the options currently available to prevent and manage AALs. Management suggestions based on this literature are presented.
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Affiliation(s)
- Robert E Merritt
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford Medical Center, 2nd floor Falk Building, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Belcher E, Dusmet M, Jordan S, Ladas G, Lim E, Goldstraw P. A prospective, randomized trial comparing BioGlue and Vivostat for the control of alveolar air leak. J Thorac Cardiovasc Surg 2010; 140:32-8. [PMID: 20620377 DOI: 10.1016/j.jtcvs.2009.11.064] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 09/21/2009] [Accepted: 11/14/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE BioGlue (CryoLife, Europa Ltd, Surrey, UK) is effective in reducing alveolar air leak after pulmonary resection. However, concerns exist regarding the use of bovine-derived products. Vivostat (Vivostat A/S, Alleroed, Denmark) is an autologous fibrin sealant that confers certain advantages. It shows superior elastic properties, a faster absorption time, and the absence of risk of transmission of blood-borne diseases. METHODS We conducted a randomized, single blind controlled study to compare BioGlue and Vivostat in the control of postoperative air leak. Primary endpoints were duration of air leak, time to intercostal drain removal, and length of hospital stay. Secondary endpoints related to postoperative complications. RESULTS Between December 2005 and December 2007, 103 patients were randomized. The analysis included 102 patients; 67% were male. Median age was 56 +/- 19 years. Indications for surgery were primary lung cancer in 41 patients (40%), secondary malignancy in 48 patients (47%), carcinoid in 6 patients (6%), and 7 patients underwent surgery for benign disease (7%). Bilobectomy was performed in 2 patients (2%), lobectomy in 41 patients (40%), lobectomy with lesser resection in 3 patients (3%), segmentectomy in 16 patients (16%), precision excision in 34 patients (33%), and 6 patients underwent other resections (6%). Median duration of air leak was 3 (0-32) days versus 2 (0-33) days for patients who received BioGlue and Vivostat, respectively (P = .677). Time to intercostal drain removal was 5 (1-32) days in the BioGlue group compared with 5 (1-34) days for the Vivostat group (P = .473). Median hospital stay was 8 (3-22) days versus 7 (2-29) days for the BioGlue and Vivostat groups, respectively (P = .382). There was no significant difference in the incidence of complications between the 2 groups (20 patients receiving BioGlue versus 19 patients receiving Vivostat, P = .839). CONCLUSIONS There were no significant differences in the 3 clinical outcome measures of duration of air leak, time to intercostal drain removal, and length of hospital stay in those patients receiving BioGlue or Vivostat. Given the inherent advantages of our institutional preference is to use Vivostat in the control of postoperative air leaks after pulmonary resection.
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Affiliation(s)
- Elizabeth Belcher
- Department of Thoracic Surgery, Royal Brompton Hospital, London, United Kingdom.
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Initial experience with a synthetic sealant PleuraSeal after pulmonary resections: a prospective study with retrospective case matched controls. J Cardiothorac Surg 2010; 5:50. [PMID: 20553612 PMCID: PMC2898668 DOI: 10.1186/1749-8090-5-50] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 06/16/2010] [Indexed: 11/10/2022] Open
Abstract
The objective of this study was to evaluate postoperative outcome and efficacy of a hydrogel tissue sealant for prevention of alveolar leakage after open lung resections. 20 consecutive patients were enrolled in the PleuraSeal sealant group (PSG) and case matched with 20 retrospective controls (CG) with standard treatment. Assessment of postoperative air leakage was performed until chest tube removal. Patients were followed until 30 days after discharge. At end of surgery, 100% in the PSG and 0% in the CG were air leak free (p < 0.001). Duration of postoperative chest tube suction was shorter in PSG (p < 0.001), and air leak chest tube was removed earlier (p = 0.03). Limitation for chest tube removal due to a pulmonary leak was 35% in CG and 5% in PSG (p = 0.04). Patients remaining air leak free thru discharge was 95% and 15% for PSG and CG (p < 0.001). The study demonstrated a superior efficacy of PleuraSeal sealant compared with standard surgical treatment for sustained sealing of postoperative air leakage and causes shorter air leak chest tube duration.
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Bertolaccini L, Lybéris P, Manno E. Lung sealant and morbidity after pleural decortication: a prospective randomized, blinded study. J Cardiothorac Surg 2010; 5:45. [PMID: 20509919 PMCID: PMC2907570 DOI: 10.1186/1749-8090-5-45] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 05/28/2010] [Indexed: 11/10/2022] Open
Abstract
Objectives Prolonged postoperative air leaks (AL) are a major cause of morbidity. Aim of this work was evaluating use of a Lung Sealant System (Pleuraseal™, Covidien, Mansfield, MA, U.S.A.) in pleural decortications for empyema thoracis. Methods From January 2008 to December 2008, 46 consecutive patients received pleural decortications for empyema thoracis. Post-procedural and malignancy-related empyemas were excluded. After hydro-pneumatic test and surgical correction of AL (until satisfaction), patients were assigned (23 per group) to Control or Sealant group. Control group underwent no additional interventions. In Sealant group, lung sealant was applied over AL areas. Following variables were measured daily: patients with AL; time to chest drainage (CD) removal; CD drainage volume at removal, postoperative length of hospital stay, postoperative C-reactive protein (CRP), and leukocyte counts. Personnel recording parameters were blinded to intervention. Two-tailed t-tests (normally distributed data) or Mann - Whitney U-test (not-normally distributed data) were used for evaluating significance of differences between group means or medians. Significance of any proportional differences in attributes were evaluated using Fisher's Exact Test. Statistical analysis was carried out using R-software (version 2.8.1). Results Groups were similar regarding demographic and baseline characteristics. No patients were withdrawn from study; no adverse effects were recorded. There were no significative differences on CRP and leukocyte levels between two groups. Compared with the Control group, in Sealant group significantly fewer patients had AL (30 versus 78%, p = 0.012), and drains were inserted for a shorter time (medians, 3 versus 5 days, p = 0.05). Postoperative hospitalization time was shorter in Sealant group than in control group, but difference was not significant (0.7 days, p = 0.121). Conclusions Pleuraseal™ Lung Sealant System significantly reduces AL following pleural decortications for empyema and, despite of not-increased infectious indexes, is suitable for routinely use, even in procedures with contaminated pleura.
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Ng T, Ryder BA, Machan JT, Cioffi WG. Decreasing the incidence of prolonged air leak after right upper lobectomy with the anterior fissureless technique. J Thorac Cardiovasc Surg 2010; 139:1007-11. [DOI: 10.1016/j.jtcvs.2009.07.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 06/07/2009] [Accepted: 07/08/2009] [Indexed: 10/20/2022]
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Belda‐Sanchís J, Serra‐Mitjans M, Iglesias Sentis M, Rami R. Surgical sealant for preventing air leaks after pulmonary resections in patients with lung cancer. Cochrane Database Syst Rev 2010; 2010:CD003051. [PMID: 20091536 PMCID: PMC7138070 DOI: 10.1002/14651858.cd003051.pub3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Postoperative air leak is a frequent complication after pulmonary resection for lung cancer. It may cause serious complications, such as empyema, or prolong the need for chest tube and hospitalization. Different types of surgical sealants have been developed to prevent or to reduce postoperative air leaks. A systematic review was therefore undertaken to evaluate the evidence on their effectiveness. OBJECTIVES To evaluate the effectiveness of surgical sealants in preventing or reducing postoperative air leaks after pulmonary resection for lung cancer. SEARCH STRATEGY We searched the electronic databases MEDLINE (1966 to September 2008), EMBASE (1974 to September 2008), and the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library, Issue 3, 2008) and listed references. We hand searched conference proceedings to identify published and unpublished trials. SELECTION CRITERIA We included randomized controlled clinical trials in which standard closure techniques plus a sealant were compared with the same intervention with no use of any sealant in patients undergoing elective pulmonary resection provided that a large proportion of the patients studied had undergone pulmonary resection for lung cancer. DATA COLLECTION AND ANALYSIS Four reviewers independently selected the trials to be included in the review, assessed methodological quality of each trial and extracted data using a standardized form. Because of several limitations, narrative synthesis was used at this stage. MAIN RESULTS Sixteen trials, with 1642 randomized patients in total were included. In thirteen trials there were differences between treatment and control patients in reducing postoperative air leaks. This reduction proved to be significant in six trials. Three trials showed a significant reduction in time to chest drain removal in the treatment group. In two trials, the percentage of patients with persistent air leak was significantly smaller in the treatment group. Finally, three trials including 352 patients showed a statistically significant reduction in length of hospital stay. AUTHORS' CONCLUSIONS Surgical sealants reduce postoperative air leaks and time to chest drain removal but this reduction is not always associated with a reduction in length of postoperative hospital stay. Therefore, systematic use of surgical sealants with the objective of reducing hospital stay cannot be recommended at the moment. More and larger randomized controlled clinical trials are needed.
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Affiliation(s)
- José Belda‐Sanchís
- Hospital Universitario Mutua de TerrassaCirugia TorácicaPlaza Dr. Robert, 5Terrassa (Barcelona)Spain08221
| | - Mireia Serra‐Mitjans
- Hospital Universitario Mutua de TerrassaCirugia TorácicaPlaza Dr. Robert, 5Terrassa (Barcelona)Spain08221
| | - Manuela Iglesias Sentis
- Hospital Universitario Mutua de TerrassaCirugia TorácicaPlaza Dr. Robert, 5Terrassa (Barcelona)Spain08221
| | - Ramon Rami
- Hospital Universitario Mutua de TerrassaCirugia TorácicaPlaza Dr. Robert, 5Terrassa (Barcelona)Spain08221
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Rathinam S, Naidu BV, Nanjaiah P, Loubani M, Kalkat MS, Rajesh PB. BioGlue and Peri-strips in lung volume reduction surgery: pilot randomised controlled trial. J Cardiothorac Surg 2009; 4:37. [PMID: 19615062 PMCID: PMC2722608 DOI: 10.1186/1749-8090-4-37] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Accepted: 07/17/2009] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Both tissue sealants and buttressing have been advocated to reduce alveolar air leaks from staple lines following Lung Volume Reduction Surgery (LVRS). However, the long term detrimental effects of buttressing material are increasingly apparent. We performed a pilot prospective randomised self controlled trial in patients undergoing LVRS comparing BioGlue and Peri-strips as adjuncts in preventing alveolar air-leaks. METHODS A pilot prospective self controlled clinical trial was conducted in patients undergoing LVRS. Each patient was treated with BioGlue on one side and pericardial buttress on the other side as an adjunct to the staple line. The sides were randomised for adjuncts with each patient acting as his own control. Duration of air leak, intercostal drainage and time to chest drain removal were the study end points. RESULTS 10 patients undergoing the procedure were recruited between December 2005 and October 2007. There were 6 men and the mean age was 59.8 +/- 4.9 years. There was one mortality due to multi-organ failure. The BioGlue treated side had a shorter mean duration of air-leak (3.0 +/- 4.6 versus 6.5 +/- 6.9 days), lesser chest drainage volume (733 +/- 404 ml versus 1001 +/- 861) and shorter time to chest drain removal (9.7 +/- 10.6 versus 11.5 +/- 11.1 days) compared with Peri-strips. CONCLUSION This study demonstrates comparable efficacy of BioGlue and Peri-strips, however there is a trend favouring the BioGlue treated side in terms of reduction in air-leak, chest drainage volumes, duration of chest drainage and significant absence of complications. A larger sample size is needed to validate this result.
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Affiliation(s)
- Sridhar Rathinam
- Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK
| | - Babu V Naidu
- Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK
| | - Prakash Nanjaiah
- Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK
| | - Mahmoud Loubani
- Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK
| | - Maninder S Kalkat
- Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK
| | - Pala B Rajesh
- Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK
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Shrager JB, DeCamp MM, Murthy SC. Intraoperative and Postoperative Management of Air Leaks in Patients with Emphysema. Thorac Surg Clin 2009; 19:223-31, ix. [DOI: 10.1016/j.thorsurg.2009.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lim E, Goldstraw P. Surgical sealants for air leaks after pulmonary surgery. Eur J Cardiothorac Surg 2007; 32:552-3. [PMID: 17627834 DOI: 10.1016/j.ejcts.2007.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Revised: 02/22/2007] [Accepted: 06/04/2007] [Indexed: 10/23/2022] Open
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