The sealing effect of fibrin glue against alveolar air leakage evaluated up to 48h; comparison between different methods of application

Useful combination of Gehanno method, polyglycolic acid sheet and fibrin glue for prevention of postoperative dysfunction after soft palate resection with TORS

Oropharyngeal cancer requiring combined resection of the soft palate is relatively out of indication for transoral robotic surgery (TORS) due to postoperative functional problems. We report the case of a patient with oropharyngeal cancer in which half of the soft palate was resected, and good function was maintained using the Gehanno method, polyglycolic acid (PGA) sheet and fibrin glue. The patient was a woman in her 50 s with oropharyngeal squamous cell carcinoma (p16-positive, T2N1M0 stage I). TORS and right neck dissection were performed the same day. About half of the soft palate was resected cranially. After closing the right nasopharynx with the Gehanno method, the sutured part was reinforced by covering with a PGA sheet of about 10 mm on a side and fibrin glue. Oral feeding was started on postoperative day 4, but no nasal reflux was observed. Three weeks postoperatively, no nasal reflux was evident, normal food intake was possible, and nasal breathing was maintained. This technique may be effective after TORS surgery that requires soft palate resection.

Risk factors for late postoperative bleeding after partial glossectomy for tongue cancer

BACKGROUND

Partial glossectomy is the most common procedure for early-stage tongue cancer. Although late postoperative bleeding occasionally occurs, the associated risk factors have not been adequately identified.

AIMS/OBJECTIVES

We aimed to investigate the rate and risk factors for late postoperative bleeding after transoral partial glossectomy with or without neck dissection for tongue cancer at our institution.

MATERIAL AND METHODS

We analysed 211 patients who had undergone transoral partial glossectomy between January 2016 and January 2023. The potential risk factors associated with late postoperative bleeding were investigated using univariate and multivariate logistic regression analyses.

RESULTS

Of the 211 patients, 40 (19%) showed late postoperative bleeding, with 19 (9%) classified as grade IIIa (Clavien-Dindo classification). Regarding all grades, late postoperative bleeding was significantly higher in patients aged <70 years and in those with polyglycolic acid (PGA) sheets (p = .046 and .030, respectively). For grade ≥ IIIa, late postoperative bleeding was significantly higher in patients with a history of anticoagulant/platelet administration, a mucosal defect covered with fibrin glue and a PGA sheet (p = .045 and .026, respectively).

CONCLUSIONS AND SIGNIFICANCE

The findings of this study suggest that primary closure decreases the frequency of late postoperative bleeding.

Factors affecting polyglycolic acid sheet engraftment success for covering mucosal defects from head and neck surgery

BACKGROUND

Polyglycolic acid (PGA) sheets have been used with fibrin glue to cover extensive mucosal defects in oral and pharyngeal surgery; however, the sheets can fall off before wound healing is completed. Hence, prolonged fasting is often recommended in such patients. However, there are few studies on the factors that shape PGA sheet engraftment. We studied sheet engraftment rates considering these factors.

METHODS

All consecutive cases of oral surgery in 2013-21 in which the defect was covered with fibrin glue and Neoveil® or Neoveil Nano® PGA sheets were identified. The loss of all sheets was defined as an engraftment failure. Multiple logistic regression analysis was conducted to identify whether the PGA-sheet type, application site, defect size and postoperative fasting duration predicted engraftment.

RESULTS

Overall, 137 patients were identified (mean age, 73 years; 57% male). The surgeries were conducted with Neoveil® in 66% of the patients; the most common site was the buccal mucosa (25%), and the mean defect size and fasting duration were 709 mm2 and 4 days, respectively. The engraftment rate was 76%. Neoveil Nano® PGA sheets were associated with a 2.8-fold better engraftment rate than Neoveil® (univariate: 87 vs. 70%, P = 0.032; multivariate: 95% confidence intervals = 1.067-7.410, P = 0.036). Other variables, including fasting duration, were not predictive of engraftment.

CONCLUSIONS

This is the largest case series of patients with head and neck cancer who underwent fibrin glue-PGA sheet defect coverage. The fasting duration did not influence engraftment. Therefore, early oral intake is not contraindicated in such patients.

Advances in biomaterials as a retinal patch for the repair of rhegmatogenous retinal detachment

Rhegmatogenous retinal detachment (RRD) is the most common retinological emergency that can cause blindness without surgical treatment. RRD occurs when liquefied vitreous accumulates between the neurosensory retina and the retinal pigment epithelium via retinal breaks, which are caused by the separation of the vitreous from the retina with aging. Currently, the main treatment option is pars plana vitrectomy, which involves surgical removal of the vitreous and laser photocoagulation around retinal breaks to generate firm chorioretinal adhesion, as well as subsequent filling of the vitreous cavity with long-lasting substitutes (expansile gas or silocone oil) to prevent the connection between the subretinal space and the vitreous cavity via the breaks before the chorioretinal adhesion firm enough. However, the postoperative face-down position and the not very satisfactory first retinal reattachment rate place a heavy burden on patients. With the development of technology and materials engineering, researchers have developed biomaterials that can be used as a retinal patch to seal retinal breaks and prevent the connection of subretinal space and vitreous cavity via breaks, thus replacing the long-lasting vitreous substitutes and eliminating the postoperative face-down position. Preclinical studies have demonstrated that biomaterial sealants have enough biocompatibility and efficacy in the in vitro and in vivo experiments. Some sealants have been used in clinical trials on a small scale, and the results indicate promising application prospects of the biomaterial sealants as retinal patches in the repair of RRD. Herein, we review the recent advances in biomaterials as retinal patches for the repair of RRD, focusing on the biomaterial categories, methods, and procedures for sealing retinal breaks, as well as their biocompatibility and efficacy, current limitations, and development perspectives.

Double stapling method for closure of intraoperative alveolar air leakage adjacent to the staple line: a randomized experimental study on ex vivo porcine lungs

Background

Alveolar air leakage from a pleural defect around the staple line is one of the complications after wedge resection of the lung. An intraoperative closure of the pleural defect by suturing can cause additional pleural rupture due to tension of the pleura adjacent to staple lines. Therefore, we have introduced a novel closure method for pleural defect adjacent to the staple line, named the double stapling method. This study compared the efficacy of two closure methods; the double stapling method and conventional suturing method with pledgets using ex vivo porcine lungs.

Methods

The double stapling method involves closing the pleural defect by suturing the two parallel staple lines at both sides of the pleural defect. This method was developed to distribute the pleural tension around the needle holes of suturing. As a model of pleural defect adjacent to the staple line after wedge resection, wedge resection of the caudal lobe of left porcine lungs was performed, and a superficial square pleural defect (10 mm × 10 mm) adjacent to the staple line was made by scalpel. The defect was closed using the following two methods: (I) suturing with pledgets (n=10); and (II) double stapling method (n=10). The lobe was inflated in water at an airway pressure of 20, 25, and 30 cmH₂O; closure success or failure was judged by the absence or presence of air leakage.

Results

The closure success was confirmed in 2 (20%) out of 10 cases in the suturing with pledgets group and 9 (90%) out of 10 in the double stapling method group (P=0.007). In 4 out of 10 cases in the suturing with pledgets group, new pleural clefts longer than 3 mm were created around the needle holes of suturing.

Conclusions

Ex vivo experiments have suggested the superiority of the double stapling method for the intraoperative closure of alveolar air leakage adjacent to the staple line after wedge resection, compared to conventional suturing with the pledget method.

Spin-coated freestanding films for biomedical applications

Spin-coating is a widely employed technique for the fabrication of thin-film coatings over large areas with smooth and homogeneous surfaces. In recent years, research has extended the scope of spin-coating by developing methods involving the interface of the substrate and the deposited solution to obtain self-supported films, also called freestanding films. Thereby, such structures have been developed for a wide range of areas. Biomedical applications of spin-coated freestanding films include wound dressings, drug delivery, and biosensing. This review will discuss the fundamental physical and chemical processes governing the conventional spin-coating as well as the techniques to obtain freestanding films. Furthermore, developments within this field with a primary focus on tissue engineering applications will be reviewed.

Wound healing effect of autologous fibrin glue and polyglycolic acid sheets in a rat back skin defect model

Fibrin glue from autologous plasma may prevent viral infection and allergic reaction. Moreover, this biomaterial contains growth factors such as TGF-β and VEGF that promote reconstruction of the mucous membrane by stimulating fibroblast proliferation and angiogenesis. Thus, autologous fibrin glue is predicted to improve healing better than commercial fibrin glue. Here, we evaluated the effects of autologous fibrin glue on the crucial early phase of wound healing. Epithelial defects were introduced in rats and covered with polyglycolic acid (PGA) sheets with or without commercial or autologous fibrin glue. Wound healing was assessed for six weeks by histology and immunohistochemistry. Our results demonstrate that wounds covered with PGA sheets and autologous fibrin glue achieved efficient wound healing without complications such as local infection or incomplete healing. The rate of recovery of the regenerating epithelium in this group was superior to that in wounds covered with PGA sheets and commercial fibrin glue. Immunohistochemistry of laminin, cytokeratin, and VEGF confirmed fine and rapid epithelial neogenesis. Collectively, our results indicate that covering surgical wounds with autologous fibrin glue promotes wound healing and epithelialization, improves safety, and reduces the risks of viral infection and allergic reaction associated with conventional techniques.

Comparison of Postoperative Bleeding between Application of Polyglycolic Acid Sheet and Primary Closure in Tongue Cancer Patients with Partial Glossectomy

The technique of covering a mucosal defect with fibrin glue and a polyglycolic acid sheet (MCFP) for the resection of mucosa is applied in oral cancers. The MCFP technique for partial glossectomy provides faster relief from postoperative pain and the prevention of scar contracture, unlike primary closure. However, it has a major complication of postoperative bleeding. This study sought to compare postoperative bleeding between the MCFP technique and primary closure. We designed a retrospective study with a cohort of 57 patients who underwent partial glossectomy with the MCFP technique or primary closure. Our primary predictor variable was the wound closure procedure (primary closure or the MCFP technique). The primary outcome variable was postoperative bleeding, and the other variables were patient characteristics, excision area and depth, tooth contact for the wound, and antithrombotic therapy. Statistical evaluation was performed with Pearson’s chi-squared test, Welch’s t-test, and multiple logistic regression. P < 0.05 was considered statistically significant. The MCFP technique was selected for cases with a large excision area (1433 vs. 963 mm², P = 0.029). Total postoperative bleeding occurred in 10 of 57 patients (MCFP technique: 7 of 37 cases; primary closure: 3 of 20 cases). There was no significant difference in bleeding between the two groups (P = 0.71). Postoperative bleeding was significant in patients with antithrombotic therapy (MCFP: 40% vs. primary closure: 2%, P = 0.0024). Postoperative bleeding timing was significantly different in the MCFP technique (6.4 days) from that of primary closure (1 day; P = 0.0076). Postoperative bleeding was not associated with the MCFP technique or primary closure. However, postoperative bleeding with the MCFP technique occurred later than that with primary closure. The MCFP technique is not recommended for patients on antithrombotic therapy.

Long-term effects of pleural defect repair using sheet materials in a canine model

OBJECTIVE

A sheet material is widely used to repair pleural defects due to its excellent pressure resistance. We examined the long-term effects of sheet materials using an animal pleural defect model.

METHODS

Beagles were used for this study. The 5-mm circular pleural defects were created at 2 sites on each of the anterior, medial, and posterior lobe and repaired using a 2 cm square sheet material. The frequency of adhesion of those sheets to the thoracic walls and histological changes was examined after 6 months. In this study, three types of sheet materials were examined: polyglycolic acid, nano-polyglycolic acid, and oxidized regenerated cellulose where each sheet was tested with or without coating with fibrin glue, for a total of 6 groups. Each group contained an equal number of defect sites and evaluation of 12 defect sites was conducted.

RESULTS

Adhesion was observed in 16 of 72 sites (22%). Presence or absence of adhesion was not affected by the repair method or by the type of sheet material used. However, the use of fibrin glue significantly reduced the occurrence of adhesion (p = 0.023). At the defected sites, the posterior lobe showed significantly less adhesion (p = 0.019). Histologically, the sheet materials caused a thickening of the pleural wall 6-10 times thicker than the normal pleural wall.

CONCLUSION

No statistically significant differences regarding the presence or absence of adhesion to the thoracic wall were found among the sheet materials. The use of fibrin glue significantly reduced the adhesion to the thoracic wall.

Management of air leaks post-surgical lung resection

Airleaks are one of the most common complications associated with elective lung resection. There have been many techniques and modern advancements in thoracic surgery, however airleaks persist. This review article will discuss several interventions ranging from conservative noninvasive to surgical management of the persistent airleak. These techniques include stopping of suction on the plueravac, fibrin patches, pleurodesis, use of endobronchial valves (EBVs), return to OR for operative intervention, and lastly to send patients home with mini pleuravacs.

A Novel Non-Gas Endospray for Applying Fibrin Glue in Laparoscopic Surgery

Purpose: Fibrin glue and polyglycolic acid felt are used for tissue repair in various surgical procedures. However, using a spray device to apply fibrin sealant during laparoscopic surgery can increase the intraperitoneal pressure, which can cause complications such as air embolism. We developed a novel non-gas endospray for use in laparoscopic surgery. This study aimed to evaluate the sealing effect of this non-gas endospray in comparison with a conventional gas-spray device and to evaluate the safety of its application in the clinical setting. Materials and Methods: An ex vivo pressure test model was used to assess the sealing effect of the non-gas endospray (method 1) versus conventional gas-spray (method 2). A bottle was sealed with a rabbit skin sample that had been pierced nine times by a 19G needle. Each skin sample was sealed using either method 1 or method 2 (n = 10 for each method). The non-gas endospray was then used in two patients undergoing laparoscopic splenectomy with CO₂ pneumoperitoneum. Intra-abdominal pressure was measured throughout the surgery. Results: Bursting pressures were similar in method 1 (246.9 ± 123.2 mmHg) and method 2 (265.5 ± 93.6 mmHg; P = 0.7082). During laparoscopic splenectomy, the non-gas endospray was successfully used to apply fibrin glue without any increase in intra-abdominal pressure. Conclusions: The novel non-gas endospray produced a strong sealing effect similar to that of a conventional gas-spray device and has thus far proved feasible in the clinical setting.

Clinical complications in the application of polyglycolic acid sheets with fibrin glue after resection of mucosal lesions in oral cavity

OBJECTIVES

Covering open wounds with a polyglycolic acid (PGA) sheet using fibrin glue after resection of oral mucosal lesions is reportedly useful. We focused on clinical complications of this procedure: development of marked granuloma-like neoplasm (GLN) and abnormal postoperative bleeding (APB) on the resected region.

STUDY DESIGN

The characteristics of 100 cases with PGA sheet application after the resection of oral mucosal lesion were examined retrospectively by the medical records and/or oral photographs at our department between 2010 and 2016.

RESULTS

Our retrospective analysis identified included 8 cases of GLN development and 7 cases of APB. There was a significantly higher risk of GLN development when the PGA sheet was applied to the raw surface of the tongue. There were no immediate APBs, but 4 APBs occurred several hours after surgery. All APB cases involved the tongue.

CONCLUSIONS

Both GLNs and APBs are minor complications. Although all cases of GLNs did not involve the recurrence of a tumor, follow-up with incisional or excisional biopsy should be performed. APB in the oral cavity induced by the PGA sheet peeling due to fluctuating adhesive force of the PGA sheets and fibrin glue can sometimes induce life-threatening events.

Efficacy of a sheet combined with fibrin glue in repair of pleural defect at the early phase after lung surgery in a canine model

OBJECTIVE

Polyglycolic acid and oxidized regenerated cellulose have been widely used as a sealant for repairing pulmonary air leakage during respiratory surgery. However, fundamental research of these materials has not been sufficiently conducted. Therefore, we conducted studies to assess the pressure resistance ability of these materials using a canine visceral pleural defect model at the early phase.

METHOD

The 6-mm circular defect and the 12-mm square defect were created on the visceral pleura of anesthetized beagles. These defects were then repaired using one of four methods: method A using polyglycolic acid and fibrin glue; method B using oxidized regenerated cellulose and fibrin glue; method C using oxidized regenerated cellulose; method D using fibrin glue. Airway pressure was measured as bursting pressure when air leakage from the repaired areas occurred at 5 min, 3 h, and 24 h after repair.

RESULTS

For the 6-mm circle defect, method A showed higher bursting pressures than the other methods at 5 min and 3 h (p < 0.05); method B showed higher than methods C and D at 5 min and 3 h (p < 0.05). For the 12-mm square defect, method A showed higher bursting pressures than the other methods at all time points (p < 0.05). Moreover, method B showed higher than method C at 24 h (p < 0.05).

CONCLUSION

Visceral pleural repairs using polyglycolic acid combined with fibrin glue showed the highest bursting pressure. Oxidized regenerated cellulose combined with fibrin glue showed sufficiently high bursting pressure in repair of small 6-mm circular defects.

Clinical evaluations of autologous fibrin glue and polyglycolic acid sheets as oral surgical wound coverings after partial glossectomy

Polyglycolic acid (PGA) sheets and commercial fibrin glue are commonly used to cover open wound surfaces in oral surgery. Compared to commercial fibrin glue composed of pooled allogeneic blood, autologous fibrin glue is less expensive and poses lower risks of viral infection and allergic reaction. Here, we evaluated postoperative pain, scar contracture, ingestion, tongue dyskinesia, and postoperative bleeding in 24 patients who underwent partial glossectomy plus the application of a PGA sheet and an autologous fibrin glue covering (autologous group) versus 11 patients in whom a PGA sheet and commercial fibrin glue were used (allogeneic group). The evaluated clinical measures were nearly identical in both groups. Remarkable wound surface granulation was recognized in two cases in the autologous group. No complications were observed in either group, including viral infection or allergic reaction. Abnormal postoperative bleeding in the wound region was observed in one case in the allogeneic group. Coagulation and adhesion of the autologous fibrin glue were equivalent to those of conventional therapy with a PGA sheet and commercial fibrin glue. Thus, our results show that covering wounds with autologous fibrin glue and PGA sheets may help avoid the risks of viral infection and allergic reaction in partial glossectomy cases.

TissuePatch™ as a novel synthetic sealant for repair of superficial lung defect: in vitro tests results

Background

Controversies surrounding the efficacy of surgical sealants against alveolar air leaks (AAL) in lung surgery abound in the literature. We sought to test the sealing efficacy of a novel synthetic sealant, TissuePatch™ in an in vitro lung model.

Methods

The lower lobe of freshly excised swine lung (n = 10) was intubated and ventilated. A superficial parenchymal defect (40 × 25 mm) was created, followed by AAL assessment. After sealant application, AAL was assessed again until burst failure occurred. The length of defect was recorded to evaluate the elasticity of the sealant.

Results

Superficial parenchymal defects resulted in AAL increasing disproportionally with ascending maximal inspiratory pressure (Pmax). Multiple linear regression analysis revealed strong correlation between AAL and Pmax, compliance, resistance. After sealant application, AAL was sealed in all ten tests at an inspired tidal volume (TVi) of 400 ml, in nine tests at TVi = 500 ml, in seven at TVi = 600 ml and in five at TVi = 700 ml. The mean burst pressure was 42 ± 9 mBar. Adhesive and cohesive sealant failures were found in six and three tests respectively. The length of defect before sealant failure was 8.9 ± 4.9% larger than that at TVi = 400 ml, demonstrating an adequate elasticity of this sealant film.

Conclusions

TissuePatch™ may be a reliable sealant for alternative or adjunctive treatment for repair of superficial parenchymal defects in lung surgery. The clinical benefits of this sealant should be confirmed by prospective, randomised controlled clinical trials.

Abstrakt

Methode

Der Unterlappen von frisch entnommenen Schweinlungen (n = 10) wurde intubiert und beatmet. Eine pleurale Läsion (40 × 25 mm) wurde erstellt und APL mit steigendem inspiratorischem Tidalvolumen (TVi) untersucht. Nach Applikation von TissuePatch™ wurde APL auf die gleiche Weise gemessen bis zur Auftritt von Kleberbruch. Zur Untersuchung der Elastizität des Klebers wurde die Länge der pleuralen Läsion gemessen.

Ergebnis

Pleurale Läsion führte bei aufsteigendem maximalem inspiratorischem Druck (Pmax) zu überproportionalem Anstieg von APL. Multiple lineare Regressionsanalyse ergab eine starke Korrelation zwischen APL und Pmax, Lungencompliance sowie Widerstand. Nach der Applikation von Klebstoff wurde APL bei TVi = 400 ml in allen zehn Testen versiegelt, bei TVi = 500 ml in neun Testen, bei TVi = 600 ml in sieben und bei TVi = 700 ml in fünf Testen. Der mittlere Pmax, der zu Kleberbruch führte, betrug 42 ± 9 mBar. Bei den Versuchen wurden adhäsiver und kohäsiver Kleberbruch in jeweils sechs und drei Testen gefunden. Die Länge der pleuralen Läsion vor dem Kleberbruch war 8,9 ± 4,9% größer als die bei TVi = 400 ml.

Schlussfolgerung

Unsere Versuche zeigten eine zuverlässige Versiegelung von TissuePatch™ unter mechanischer Ventilation. Die klinische Nützlichkeit vom Kleber als unterstützende Maßnahme zur Prävention von alveolo-pleuralem Luftleck in Lungenchirurgie sollte durch prospektive, randomisierte kontrollierte klinische Studien bestätigt werden.

TissuePatch™ as a novel synthetic sealant for repair of superficial lung defect: in vitro tests results

BACKGROUND

Controversies surrounding the efficacy of surgical sealants against alveolar air leaks (AAL) in lung surgery abound in the literature. We sought to test the sealing efficacy of a novel synthetic sealant, TissuePatch™ in an in vitro lung model.

METHODS

The lower lobe of freshly excised swine lung (n = 10) was intubated and ventilated. A superficial parenchymal defect (40 × 25 mm) was created, followed by AAL assessment. After sealant application, AAL was assessed again until burst failure occurred. The length of defect was recorded to evaluate the elasticity of the sealant.

RESULTS

Superficial parenchymal defects resulted in AAL increasing disproportionally with ascending maximal inspiratory pressure (Pmax). Multiple linear regression analysis revealed strong correlation between AAL and Pmax, compliance, resistance. After sealant application, AAL was sealed in all ten tests at an inspired tidal volume (TVi) of 400 ml, in nine tests at TVi = 500 ml, in seven at TVi = 600 ml and in five at TVi = 700 ml. The mean burst pressure was 42 ± 9 mBar. Adhesive and cohesive sealant failures were found in six and three tests respectively. The length of defect before sealant failure was 8.9 ± 4.9% larger than that at TVi = 400 ml, demonstrating an adequate elasticity of this sealant film.

CONCLUSIONS

TissuePatch™ may be a reliable sealant for alternative or adjunctive treatment for repair of superficial parenchymal defects in lung surgery. The clinical benefits of this sealant should be confirmed by prospective, randomised controlled clinical trials. ABSTRAKT:

HINTERGRUND

Die Wirksamkeit von chirurgischen Klebstoffen zur Prävention von alveolo-pleuralem Luftleck (APL) ist trotz zunehmenden klinischen Anwendungen in Lungenchirurgie immer noch kontrovers diskutiert. Wir evaluierten die Abdichtungswirksamkeit von einem neuartigen synthetischen Kleber, TissuePatch™ mittels eines in vitro Lungenmodels. METHODE: Der Unterlappen von frisch entnommenen Schweinlungen (n = 10) wurde intubiert und beatmet. Eine pleurale Läsion (40 × 25 mm) wurde erstellt und APL mit steigendem inspiratorischem Tidalvolumen (TVi) untersucht. Nach Applikation von TissuePatch™ wurde APL auf die gleiche Weise gemessen bis zur Auftritt von Kleberbruch. Zur Untersuchung der Elastizität des Klebers wurde die Länge der pleuralen Läsion gemessen. ERGEBNIS: Pleurale Läsion führte bei aufsteigendem maximalem inspiratorischem Druck (Pmax) zu überproportionalem Anstieg von APL. Multiple lineare Regressionsanalyse ergab eine starke Korrelation zwischen APL und Pmax, Lungencompliance sowie Widerstand. Nach der Applikation von Klebstoff wurde APL bei TVi = 400 ml in allen zehn Testen versiegelt, bei TVi = 500 ml in neun Testen, bei TVi = 600 ml in sieben und bei TVi = 700 ml in fünf Testen. Der mittlere Pmax, der zu Kleberbruch führte, betrug 42 ± 9 mBar. Bei den Versuchen wurden adhäsiver und kohäsiver Kleberbruch in jeweils sechs und drei Testen gefunden. Die Länge der pleuralen Läsion vor dem Kleberbruch war 8,9 ± 4,9% größer als die bei TVi = 400 ml.

SCHLUSSFOLGERUNG

Unsere Versuche zeigten eine zuverlässige Versiegelung von TissuePatch™ unter mechanischer Ventilation. Die klinische Nützlichkeit vom Kleber als unterstützende Maßnahme zur Prävention von alveolo-pleuralem Luftleck in Lungenchirurgie sollte durch prospektive, randomisierte kontrollierte klinische Studien bestätigt werden.

Clinical evaluation of application of polyglycolic acid sheet and fibrin glue spray for partial glossectomy

PURPOSE

The aim of this study was to evaluate the usefulness of covering open wounds with a polyglycolic acid (PGA) sheet and a fibrin glue spray after partial glossectomy.

MATERIALS AND METHODS

We clinically evaluated postoperative pain and scar contracture in 44 patients who underwent partial glossectomy followed by covering with a PGA sheet and a fibrin glue spray (PGA sheet group), as compared with 29 patients who were closed primarily (primary closure group).

RESULTS

Duration of nonsteroidal anti-inflammatory drugs was almost the same between the PGA sheet group and the primary closure group. The degree of scar contracture was mild in many cases in both groups. In the case in which the excision area was wide and depth was shallow, there was a tendency for the scar contracture to be less in the PGA sheet group.

CONCLUSIONS

Our findings showed that the use of a PGA sheet and fibrin glue spray for open wounds resulting from partial glossectomy was useful in terms of rapid relief from postoperative pain and prevention of scar contracture.

The utility of BiClamp(®) for intraoperative air leakage control in video-assisted thoracic surgery for pulmonary lobectomy

We describe a simple technique of controlling air leakage from the lung parenchyma using BiClamp(®). The device creates appropriate protein coagulation at an air leakage point of the lung parenchyma. The leakage point and adjacent area are grasped with BiClamp(®) forceps and coagulated without tissue carbonization. After the procedure, no air leakage was recognized under airway pressure test of 15-20 cmH(2)O. This method is easy to handle, especially in video-assisted thoracic surgery lobectomy with an economical advantage as "Ecosurgery".

A unique method for repairing intraoperative pulmonary air leakage with both polyglycolic acid sheets and fibrin glue

BACKGROUND

In the present study we present a unique maneuver, using both fibrin glue and polyglycolic acid (PGA) sheets, for repairing intraoperative pulmonary air leakage, and report our clinical results.

METHODS

Based on the results from in vitro experiments, we retrospectively investigated the clinical effects of our method for repairing intraoperative pulmonary air leakage in 377 consecutive patients, who underwent a pulmonary resection for primary lung cancer or metastatic lung tumors from 2004 to 2009. From April 2004 through September 2007, repair of intraoperative pulmonary air leakage was performed in 204 patients using only fibrin glue. From October 2007 through December 2009, the repair was performed in 173 patients with a unique application of both fibrin glue and PGA sheets, i.e., (1) rubbing fibrin glue A solution, (2) applying a PGA sheet cut to an appropriate size, (3) rubbing fibrin glue B solution on the PGA sheet, and (4) reapplying fibrin glue A solution and rubbing.

RESULTS

The mean duration of postoperative pleural drainage was significantly shorter in the latter time period when both fibrin glue and PGA sheets were used than in the former period when fibrin glue was used alone. The incidence of prolonged air leakage longer than 1 week was also significantly lower in the latter era than in the former era.

CONCLUSION

Our unique application of both fibrin glue and PGA sheets for the intraoperative repair of pulmonary air leakage effectively resulted in a shortening of the duration of postoperative pleural drainage.

Safety and effectiveness of a new fibrin pleural air leak sealant: a multicenter, controlled, prospective, parallel-group, randomized clinical trial

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.

Pleural defect repair with an overlapping method using fibrin glue-coated collagen fleece

PURPOSE

Collagen fleece coated with fibrin glue (TachoComb; CSL Behring, Tokyo, Japan) is a tissue adhesive and sealant used to stop hemorrhage and air leakage. We assessed the efficacy of overlapping methods combined with the use of TachoComb to repair pleural defects.

METHODS

Using a beagle animal model, circular and square defects were created on the pulmonary pleura and then repaired with TachoComb patches of varying minimum overlap widths (MOW). The airway pressure at which air leakage from the repaired region occurred (bursting pressure) was measured in a water sealing test. The ability of TachoComb to withstand temporal changes was assessed by repairing a 6-mm circular defect. The bursting pressure was measured at 5 min, 10 min, 3 h, and 24 h after the repair.

RESULTS

TachoComb patches with an MOW ≥ 6 mm withstood significantly higher pressures than patches with an MOW ≤ 3 mm for both circular and square defects. The bursting pressure was found to increase over time for up to 3 h after being applied, indicating that adhesion of the TachoComb patch to the pleural tissue improved during the 3-h period.

CONCLUSION

Pleural defects repaired using an overlapping method with an MOW of 6 mm were able to withstand airway pressures ≥ 40 cmH(2)O.

Withstand pressure of a simple fibrin glue sealant: experimental study of mimicked sellar reconstruction in extended transsphenoidal surgery

BACKGROUND

To examine the strength and tolerance of the fibrin glue sealant in a situation of extended transsphenoidal surgery. The withstand pressure of fibrin glue sealant was measured using a simple sellar reconstruction model.

METHODS

A 15-mm diameter hole at the bottom of a 51-cm high cylinder was covered with a Gore-Tex (Gore-Tex, Tokyo, Japan) sheet. A small plate was placed on the center for a brief fixation, and 3 mL of fibrin glue was applied over the entire bottom. Then water was gradually filled in five cylinders, and the water level at leakage was measured as withstand pressures at 10 minutes and 24 hours after sealant application. The stability of the sealant under pressures of 20 and 30 cm H(2)O for 12 hours was also examined.

RESULTS

The median initial withstand pressure at 10 minutes was 32 cm H(2)O (n = 5), and was significantly increased to 47.5 cm H(2)O after 24 hours (n = 4). In four of five cylinders, fibrin glue sealants were stable against a pressure of 20 cm H(2)O for 12 hours and 30 cm H(2)O for the next 12 hours.

CONCLUSIONS

The withstand pressure of simple fibrin glue sealant without other biological reactions could be estimated to be more than 20 cm H(2)O after application, and increased to more than 40 cm H(2)O after 24 hours. These data are practical for neurosurgeons to comprehend the strength and limit of fibrin glue sealant and suggests the importance to control the intracranial pressure to less than 20 cm H(2)O, especially for the first 12 to 24 hours.

Improvement of the tissue-adhesive and sealing effect of fibrin sealant using polyglycolic acid felt

Although fibrin sealant (FS) has an advantage of high biocompatibility, its adhesive force and sealing effect have been generally considered to be inadequate. In the present study, a high adhesive force and sealing effect were obtained by first rubbing fibrinogen solution into the target tissue, attaching polyglycolic acid (PGA) felt to the treated area, and finally spraying it with FS. This method was compared with three conventional FS application methods and a method using fibrin glue-coated collagen fleece. The adhesive force resulting from the present method was 12 times higher than that for the sequential application method, 4.5 times higher than the spray method, 2.5 times higher than the rubbing and spray method, and 2.2 times higher than the use of fibrin glue-coated collagen fleece. The high adhesive force of FS with PGA felt seemed to be due the high fibrin content of the fibrin gel (FG). Light and electron microscopic observations suggested that the formation of FG in closer contact with the muscle fibers was a factor contributing to this superior adhesive force. Comparison of the sealing effect of the present method with other methods using various biomaterials in combination with FS showed that the sealing effect of FS with PGA felt was 1.4 times higher that of polyglactin 910, 1.8 times that of polytetrafluoroethylene, and 6.7 times that of oxidized regenerated cellulose.

Mesh-based pneumostasis contributes to preserving gas exchange capacity and promoting rehabilitation after lung resection

BACKGROUND

We recently introduced a technique of sutureless, mesh-based pneumostasis for preventing alveolar air leaks after lung resection. To verify the clinical usefulness of this technique, we examined if it can contribute to preserving gas exchange capacity and promoting postoperative rehabilitation.

METHODS

We prospectively collected perioperative data, including arterial oxygen saturation on postoperative day (POD) 1 and the length of postoperative rehabilitation in 100 patients undergoing elective, video-assisted major lung resection for cancer. Before April, 2006, intraoperative air leaks were sealed with the conventional method (control group), and thereafter, with bioabsorbable mesh and glue, without suturing, (treated group). To reduce the bias in comparison of the nonrandomized control group, we paired the treated group with the control group using the nearest available matching method on the estimated propensity score.

RESULTS

Thirty-five patients in the control group were matched to 35 patients in the treated group based on the estimated propensity score. The length of both chest tube drainage and postoperative rehabilitation were significantly shorter in the treated group than in the control group (median, 1 versus 1 d, P = 0.03; 2 versus 3 d, P = 0.01, respectively). The arterial oxygen saturation on POD 1 was significantly higher in the treated group than in the control group (median, 94.0 versus 92.5 %, P = 0.03).

CONCLUSION

Mesh-based pneumostasis during video-assisted major lung resection enabled early chest tube removal, preserved postoperative oxygenation capacity, and promoted postoperative rehabilitation, which may facilitate fast-track surgery for patients undergoing video-assisted major lung resection for cancer.

An apical symphysial technique using a wide absorbable mesh placed on the apex for primary spontaneous pneumothorax

BACKGROUND

The outcome of thoracoscopic bullectomy for primary spontaneous pneumothorax (PSP) is not satisfactory. To reduce postoperative pneumothorax recurrence after thoracoscopic bullectomy, an effective and easy surgical method is required. We tried a new method using an absorbable mesh that covered the whole apical visceral pleura.

METHODS

A total of 157 sides of 143 patients who underwent stapled bullectomy under thoracoscopy for PSP were reviewed retrospectively. In the apical covering group (group A), a 15 x 15-cm(2) absorbable mesh sheet was placed on the apical visceral pleura with fibrin glue. Patients in group B underwent bullectomy alone. Cumulative postoperative recurrence was compared between the groups. Recurrent cases in group A were examined clinicopathologically.

RESULTS

Group A had 111 cases and group B had 46. There was no operative mortality. Postoperative recurrence occurred in 15 of 157 cases (9.6%): 4 in group A and 11 in group B. The cumulative postoperative 5-year recurrence rate was 3.6% in group A and 23.9% in group B (log-rank test, p = 0.013). In group A, local adhesion was seen at the apical pleurae, and inflammatory changes with foreign body giant cells were seen at the pleura covered with the mesh.

CONCLUSIONS

Placement of a wide absorbable mesh with fibrin glue at the apical visceral pleura significantly reduced postoperative recurrence after thoracoscopic bullectomy for PSP. The mesh was thought to act as a foreign body on the pleura and induce local inflammatory adhesion between the apical pleurae after bullectomy. This was an easy and effective symphysial procedure.

Development of new biodegradable hydrogel glue for preventing alveolar air leakage

OBJECTIVE

Air leakage is a frequent complication during lung surgery. A new hydrogel glue was created by mixing aldehyded dextran and epsilon-poly(l-lysine), and its feasibility as a surgical sealant was evaluated in comparison with that of conventional fibrin glue.

METHODS

Bursting pressure after application of each glue to 30 x 30-mm pleuroparenchymal defects was evaluated in two groups of 14 beagle dogs. Biodegradability and histotoxicity of the glues were evaluated in another 6 dogs with 15-mm circular pleuroparenchymal defects. Adhesions, infections, and histologic changes were observed on scheduled days for 6 months.

RESULTS

The mean bursting pressure after application was 38.4 +/- 4.6 cm H2O for the new glue and 32.1 +/- 4.5 cm H2O for fibrin glue (P = .02), the former providing more effective sealing of pulmonary air leakage than the latter. Macroscopically, no adhesions or infections were observed in areas of glue application. About 90% of the new glue degraded within 3 months, but complete disappearance was not observed by 6 months. On the other hand, the fibrin glue was replaced by white pleural tissue at 4 weeks. Histologically, the new glue was covered by one layer of mesothelial cells at 2 weeks and completely covered by thick fibrous tissue at 4 weeks. Inflammatory reaction was minimal around the residual glue after 3 months. Although the new glue degraded more slowly than did the fibrin glue, the biocompatibility of the new glue was sufficient for clinical use.

CONCLUSION

Our new hydrogel glue demonstrates a strong sealing effect, with good biocompatibility, and has potential usefulness as an adhesive in lung surgery.

Creation of a uniform pleural defect model for the study of lung sealants

OBJECTIVE

Animal models are indispensable for the development of new therapeutic methods for the closure of alveolar air leakage. However, it is difficult to create a uniform pleural defect model. The purpose of this study was to establish an appropriate animal model for assessing the efficacy and histotoxicity of synthetic sealants for lung surgery.

METHODS

Nine beagle dogs were used to evaluate the pleural defect model in comparison with conventional resection procedures. A donut-shaped silicon ring with an inner diameter of 15 mm was placed on the pleura, and 0.1 mL of cyanoacrylate was dropped into the ring. A pleural defect was created by sliding a microtome blade just beneath the polymerized cyanoacrylate. Hemostasis was performed by pressure with a sponge.

RESULTS

Morphologically, round areas of the pleura were uniformly resected with our procedure. The resected tissue consisted of pleura and thin underlying lung parenchyma. Among the results from 3 surgeons, there were no significant differences in the mean time required for hemostasis (P = .69), the mean thickness of the resected tissue (P = .13), and the mean amount of air leakage from the resected area (P = .19). No penetration of cyanoacrylate into the lung parenchyma was evidenced by immunofluorescence microscopy. Histologically, when the pleura was resected without using cyanoacrylate, a thick fibrocellular layer extended to the lung parenchyma. Furthermore, severe fibrosis was observed when electrocautery was used for hemostasis. However, when the pleura was resected using cyanoacrylate, the normal alveolar structure was preserved.

CONCLUSIONS

Our uniform pleural defect model using cyanoacrylate may be feasible for the evaluation of synthetic sealants for alveolar air leakage.