Buttressing the staple line in lung volume reduction surgery: a randomized three-center study

Safety and efficacy of new staple-line reinforcement in lung resection: a prospective study of 48 patients

PURPOSE

To evaluate the safety and efficacy of new staple-line reinforcement (SLR) in pulmonary resection through a prospective study and to compare the results of this study with historical control data in an exploratory study.

METHODS

The subjects of this study were 48 patients who underwent thoracoscopic lobectomy. The primary endpoint was air leakage from the staple line. The secondary endpoints were the location of air leakage, duration of air leakage, and postoperative pulmonary complications.

RESULTS

The incidence of intraoperative air leakage from the staple line was 6.3%. Three patients had prolonged air leakage as a postoperative pulmonary complication. No malfunction was found in patients who underwent SLR with the stapling device. When compared with the historical group, the SLR group had a significantly lower incidence of air leakage from the staple line (6.3% vs. 28.5%, P < 0.001) and significantly shorter indwelling chest drainage time (P = 0.049) and length of hospital stay (P < 0.001).

CONCLUSIONS

The use of SLR in pulmonary resection was safe and effective. When compared with conventional products, SLR could control intraoperative air leakage from the staple line and shorten time needed for indwelling chest drainage and the length of hospital stay.

Predictors of reoperation after lung volume reduction surgery

OBJECTIVES

Lung volume reduction surgery (LVRS) has proven an effective treatment for emphysema, by decreasing hyperinflation and improving lung function, activity level and reducing dyspnoea. However, postoperative air leak is an important complication, often leading to reoperation. Our aim was to analyse reoperations after LVRS and identify potential predictors.

METHODS

Consecutive single-centre unilateral VATS LVRS performed from 2017 to 2022 were included. Typically, 3-5 minor resections were made using vascular magazines without buttressing. Data were obtained from an institutional database and analysed. Multivariable logistic regression was used to identify predictors of reoperation. Number and location of injuries were registered.

RESULTS

In total, 191 patients were included, 25 were reoperated (13%). In 21 patients, the indication for reoperation was substantial air leak, 3 patients bleeding and 1 patient empyema. Length of stay (LOS) was 21 (11-33) vs. 5 days (3-11), respectively. Only 3 injuries were in the stapler line, 13 within < 2cm and 15 injuries were in another site. Multivariable logistic regression analysis showed that decreasing DLCO increased risk of reoperation, OR 1.1 (1.03, 1.18, P = 0.005). Resections in only one lobe, compared to resections in multiple lobes, were also a risk factor OR 3.10 (1.17, 9.32, P = 0.03). Patients undergoing reoperation had significantly increased 30-day mortality, OR 5.52 (1.03, 26.69, P = 0.02).

CONCLUSIONS

Our incidence of reoperation after LVRS was 13% leading to prolonged LOS and increased 30-day mortality. Low DLCO and resections in a single lobe were significant predictors of reoperation. The air leak was usually not localized in the stapler line.

Technical Aspects of Lung Volume Reduction Surgery Including Anesthetic Management and Surgical Approaches

As palliative treatment, lung volume reduction surgery can be offered to a selected subset of chronic obstructive pulmonary disease patients. Careful adherence to established inclusion and exclusion criteria is critical to achieve good outcomes. The evolution of surgical techniques toward minimally invasive approaches has improved outcomes. The fully extrathoracic access combining a subxiphoid incision with subcostal port placement allowed a further decrease in perioperative pain, which favors spontaneous respiratory drive and early postoperative mobilization. Less aggressive resections and better match for size of the hemithorax have contributed to a short-term reduction in morbidity and continued improvements in cardiopulmonary function.

Efficiency and safety of TachoSil® in the treatment of postoperative air leakage following pulmonary surgery: a meta-analysis of randomized controlled trials

OBJECTIVE

There has been still no consensus whether to apply TachoSil® to reduce the incidence of air leakage after pulmonary surgery. We conducted this meta-analysis of randomized controlled trials (RCTs) to identify the efficiency and safety of TachoSil® applied in the prevention of postoperative air leakage following pulmonary surgery.

METHODS

We performed a systematic electronic search through EMABSE, PubMed and Web of Science up to March 2018. Summary risk ratio (RR) and weight mean difference (WMD) with corresponding 95% confidence intervals (CI) were calculated to analyze the outcomes. Fixed effect or random effect model was used to pool the estimates. Two independent reviewers assessed the quality of included studies using Cochrane risk-of-bias tool for RCTs.

RESULTS

We included six RCTs with a total of 921 patients. Compared with standard treatment (suturing, stapling techniques or electrocautery), TachoSil® was associated with the decreased air leak duration (WMD: -3.32 days; 95% CI: -5.34--1.31; P = 0.001), chest tube duration (WMD: -1.99 days; 95% CI: -3.14--0.84; P = 0.0007), hospital stay (WMD: -1.89 days; 95% CI: -2.42--1.35; P < 0.0001), and incidence of prolonged air leak (RR: 0.57; 95% CI: 0.35-0.92; P = 0.02). No significant difference was found between the two groups regarding the incidence of postoperative complications (RR: 0.86; 95% CI: 0.69-1.06; P = 0.16).

CONCLUSIONS

TachoSil® was safe, cost-effective and superior over standard treatment for patients who underwent pulmonary surgery in decreasing incidence of postoperative air leak, air leak duration, chest tube duration and the length of hospital stay.

Clinical outcomes of polymeric sealant use in pulmonary resection: a systematic review and meta-analysis of randomized controlled trials

Background

Prolonged alveolar air leak (PAL) is the most common adverse event following pulmonary resection. It carries morbidity for patients by increasing empyema risk, and for hospital administration with the cost of prolonged length of hospital stay (LOS). Intra-operative sealant technology is available to surgeons, and may decrease PAL. Our aim was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) on the effect of intraoperative polymeric sealant use on PAL, empyema, and LOS.

Methods

Standard PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analysis and methods) protocol was adhered to. For qualitative review the search strategy yielded 21 RCTs reporting polymeric sealant use in lung resection, 19 of which were included in meta-analyses. The control arm in the two excluded RCTs was not "standard care." Random-effects meta-analyses were conducted. Inter-trial heterogeneity was assessed with the I2 statistic. Publication bias was assessed with a funnel plot and Egger statistic for small study effects.

Results

Pooled analysis was derived from 2,537 randomized participants. They were allocated to the intervention arm of lung resection with intra-operative application of a polymeric sealant (n=1,292), or the control arm of standard care involving pulmonary resection with pneumostasis by sutures and/or stapler (n=1,245). Participants came from 10 different countries, with mean (SD) age of 62.5 (4.2) years, and 31.6% (95% CI: 30.0-33.5) female. Pooled estimates revealed polymeric sealant decreased odds of PAL (OR 0.55, 95% CI: 0.35-0.87), and decreased LOS by one day (mean difference -0.96, 95% CI: -1.74 to -0.18), without increasing odds of pleural sepsis (OR 1.134, 95% CI: 0.343-3.748). There was evidence of publication bias in the LOS meta-analysis.

Conclusions

Pooled analysis revealed decreased odds of PAL, and decreased LOS by one day with intraoperative use of polymeric sealants. There was no associated increase in odds of adverse events, including empyema.

Lung volume reduction followed by lung transplantation-considerations on selection criteria and outcome

Lung transplantation (LuTX) and lung volume reduction (LVR), either surgical (LVRS: lung volume reduction surgery) or endoscopic (ELVR: endoscopic lung volume reduction), are established therapies in the treatment of end-stage chronic obstructive pulmonary disease (COPD) patients. Careful patient selection is crucial for each intervention. If these techniques are sequentially applied there is a paucity of available data and individual center experiences vary depending on details in selection criteria and operative technique. This review aims to summarize the published data with a focus on LuTX after LVRS. This review covers patient selection for LuTX and LVR, technical considerations, limitations and outcomes. Published literature was identified by systematic search on Medline and appropriate papers were reviewed. Seven case reports/series, 7 comparative observational studies and one multicenter database analysis incorporating a total of 284 patients with LuTX and LVR were evaluated. Prior LVR can significantly affect intraoperative and postoperative risks after subsequent LuTX. Careful patient selection and timing and the choice of appropriate techniques such as minimal invasive LVRS and using ECMO as extracorporeal support during LuTX if required can minimize those risks, ultimately leading to very good postoperative outcomes in terms of lung function and survival. LVRS has the potential to delay listing and to bridge patients to LuTX by improving their physical condition while on the waiting list. After single lung transplantation (SLuTX) contralateral LVRS can counteract the deleterious effects of native lung hyperinflation (NLH). LVR and LuTX are adjunct therapies in the treatment of end-stage COPD. The combination of both can safely be considered in selected patients.

Surgical and endoscopic treatment for COPD: patients selection, techniques and results

Chronic obstructive pulmonary disease (COPD) is a very heterogeneous disease characterised by an obstructive lung pattern that constitutes worldwide a major cause of high morbidity and mortality. In the last decades, lung volume reduction surgery (LVRS) has demonstrated to be a potential good alternative to transplantation in patients affected by COPD. The trend toward minimally invasive techniques resulted not only in surgical procedures better tolerated by the patients but also in several endoscopic treatments modality that are rapidly gaining ground.

Postoperative complications and management after lung volume reduction surgery

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.

Enhanced recovery after surgery and video-assisted thoracic surgery lobectomy: the Italian VATS Group surgical protocol

Enhanced recovery after surgery (ERAS^®) is a strategy that seeks to reduce patients' perioperative stress response, thereby reducing potential complications, decreasing hospital length of stay and enabling patients to return more quickly to their baseline functional status. The concept was introduced in the late 1990s and was first adopted in patients undergoing open colorectal surgery. Since then, the concept of ERAS has been adopted by multiple surgical specialties. The diffusion of video-assisted thoracic surgery lobectomy (VATS-L) sets also the surgical treatment of lung cancer as a new area for ERAS development. In this paper, we present the Italian VATS Group (www.vatsgroup.org) surgical protocol as part of the ERAS clinical pathway belonging to the VATS-L national database.

In Vitro Evaluation for Potential Calcification of Biomaterials Used for Staple Line Reinforcement in Lung Surgery

Bovine pericardium (BPC) and polytetrafluoroethylene (PTFE) have been widely used to reinforce staple lines in lung resection. Since limited Information regarding the calcification of these biomaterials is available, we undertook an In vitro study to evaluate their calcification potential. Commercially available BPC and PTFE biomaterials were evaluated and compared with custom-prepared BPC tissue. In vitro calcification was performed via submersion in supersaturated solution In a double-walled glass reactor at 37.0°C ± 0.1°C, pH 7.4 ± 0.1, mimicking most ion concentrations of human blood plasma. In processing of calcification, the pH decrease of the solution simulated the addition of consumed H+, Ca2+, and PO43– ions from titrant solutions, the concentrations of which were based on the stolchiometry of octacalcium phosphate. The molar ion addition with time was recorded, and the initial slope of the curve was computed for each experiment. The rate of calcification developed (molar calcium phosphate ion addition rate per time and total surface area) (R) was computed after that with respect to the relative supersaturation (σ) used in each experiment. R for custom-prepared BPC tissues was found to be in the range of 0.19 ± 0.08 to 0.52 ± 0.19 (n = 17) in σ range of 0.72 to 1.42. Commercial BPC was found to be 0.016 to 0.052 (n = 4), and PTFE was 0.005 to 0.05 (n = 8) in the same σ range. Both clinically applied biomaterials, BPC and PTFE, seemed to be calcified with rates of at least one order of magnitude lower than the custom-prepared BPC tissue. This data suggested that BPC and PTFE biomaterials showed a similar, relatively very low tendency for calcification compared with custom-prepared BPC tissue. Although further studies are necessary, staple line reinforcement by these two biomaterials should be considered safe from the calcification point of view.

Lung volume reduction surgery for diffuse emphysema

BACKGROUND

Lung volume reduction surgery (LVRS) performed to treat patients with severe diffuse emphysema was reintroduced in the nineties. Lung volume reduction surgery aims to resect damaged emphysematous lung tissue, thereby increasing elastic properties of the lung. This treatment is hypothesised to improve long-term daily functioning and quality of life, although it may be costly and may be associated with risks of morbidity and mortality. Ten years have passed since the last version of this review was prepared, prompting us to perform an update.

OBJECTIVES

The objective of this review was to gather all available evidence from randomised controlled trials comparing the effectiveness of lung volume reduction surgery (LVRS) versus non-surgical standard therapy in improving health outcomes for patients with severe diffuse emphysema. Secondary objectives included determining which subgroup of patients benefit from LVRS and for which patients LVRS is contraindicated, to establish the postoperative complications of LVRS and its morbidity and mortality, to determine which surgical approaches for LVRS are most effective and to calculate the cost-effectiveness of LVRS.

SEARCH METHODS

We identified RCTs by using the Cochrane Airways Group Chronic Obstructive Pulmonary Disease (COPD) register, in addition to the online clinical trials registers. Searches are current to April 2016.

SELECTION CRITERIA

We included RCTs that studied the safety and efficacy of LVRS in participants with diffuse emphysema. We excluded studies that investigated giant or bullous emphysema.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed trials for inclusion and extracted data. When possible, we combined data from more than one study in a meta-analysis using RevMan 5 software.

MAIN RESULTS

We identified two new studies (89 participants) in this updated review. A total of 11 studies (1760 participants) met the entry criteria of the review, one of which accounted for 68% of recruited participants. The quality of evidence ranged from low to moderate owing to an unclear risk of bias across many studies, lack of blinding and low participant numbers for some outcomes. Eight of the studies compared LVRS versus standard medical care, one compared two closure techniques (stapling vs laser ablation), one looked at the effect of buttressing the staple line on the effectiveness of LVRS and one compared traditional 'resectional' LVRS with a non-resectional surgical approach. Participants completed a mandatory course of pulmonary rehabilitation/physical training before the procedure commenced. Short-term mortality was higher for LVRS (odds ratio (OR) 6.16, 95% confidence interval (CI) 3.22 to 11.79; 1489 participants; five studies; moderate-quality evidence) than for control, but long-term mortality favoured LVRS (OR 0.76, 95% CI 0.61 to 0.95; 1280 participants; two studies; moderate-quality evidence). Participants identified post hoc as being at high risk of death from surgery were those with particularly impaired lung function, poor diffusing capacity and/or homogenous emphysema. Participants with upper lobe-predominant emphysema and low baseline exercise capacity showed the most favourable outcomes related to mortality, as investigators reported no significant differences in early mortality between participants treated with LVRS and those in the control group (OR 0.87, 95% CI 0.23 to 3.29; 290 participants; one study), as well as significantly lower mortality at the end of follow-up for LVRS compared with control (OR 0.45, 95% CI 0.26 to 0.78; 290 participants; one study). Trials in this review furthermore provided evidence of low to moderate quality showing that improvements in lung function parameters other than forced expiratory volume in one second (FEV1), quality of life and exercise capacity were more likely with LVRS than with usual follow-up. Adverse events were more common with LVRS than with control, specifically the occurrence of (persistent) air leaks, pulmonary morbidity (e.g. pneumonia) and cardiovascular morbidity. Although LVRS leads to an increase in quality-adjusted life-years (QALYs), the procedure is relatively costly overall.

AUTHORS' CONCLUSIONS

Lung volume reduction surgery, an effective treatment for selected patients with severe emphysema, may lead to better health status and lung function outcomes, specifically for patients who have upper lobe-predominant emphysema with low exercise capacity, but the procedure is associated with risks of early mortality and adverse events.

Efficacy and safety of Innoseal for air leak after pulmonary resection: a case-control study

BACKGROUND

Prolonged air leak is one of the most common complications after lung surgery and the cause of prolonged hospital stay frequently associated with major postoperative morbidity and thus responsible for even higher hospital costs. This case-control study was designed to test the sealing efficacy and safety of Enable-Innoseal TP4 in patients undergoing pulmonary resection for lung cancer.

METHODS

This was a case-control trial enrolling patients with primary or single site metastatic lung cancer scheduled for elective anatomic or nonanatomic pulmonary resection presenting intraoperative grade 1 or 2 air leak at water submersion test; the study group population was then matched 1:1 according to surgical procedure, male/female ratio, preoperative FEV1, and age.

RESULTS

In the study population, 21 patients (70.0%) presented intraoperative grade 1 air leak and 9 patients grade 2 (30.0%) air leak; after comparison with the control group, we observed a significant shorter time for chest drain removal in the study population (P = 0.0050), whereas no difference was registered in terms of number of days needing for discharge (P = 0.0762).

CONCLUSIONS

Enable-Innoseal TP4 was effective in treating limited intraoperative air leaks after pulmonary resection and preventing prolonged postoperative air leaks in patients receiving either anatomic or nonanatomic lung resections. Further randomized double-arm studies are required to confirm the efficacy of Enable-Innoseal TP4 demonstrated by this pilot study.

Prevention of lung cancer recurrence using cisplatin-loaded superhydrophobic nanofiber meshes

For early stage lung cancer patients, local cancer recurrence after surgical resection is a significant concern and stems from microscopic disease left behind after surgery. Here we apply a local drug delivery strategy to combat local lung cancer recurrence after resection using non-woven, biodegradable nanofiber meshes loaded with cisplatin. The meshes are fabricated using a scalable electrospinning process from two biocompatible polymers--polycaprolactone and poly(glycerol monostearate-co-caprolactone)--to afford favorable mechanical properties for use in a dynamic tissue such as the lung. Owing to their rough nanostructure and hydrophobic polymer composition, these meshes exhibit superhydrophobicity, and it is this non-wetting nature that sustains the release of cisplatin in a linear fashion over ∼90 days, with anti-cancer efficacy demonstrated using an in vitro Lewis Lung carcinoma (LLC) cell assay. The in vivo evaluation of cisplatin-loaded superhydrophobic meshes in the prevention of local cancer recurrence in a murine model of LLC surgical resection demonstrated a statistically significant increase (p = 0.0006) in median recurrence-free survival to >23 days, compared to standard intraperitoneal cisplatin therapy of equivalent dose. These results emphasize the importance of supplementing cytoreductive surgery with local drug delivery strategies to improve prognosis for lung cancer patients undergoing tumor resection.

A comparison of a single center's experience with three staple line reinforcement techniques in 1,502 laparoscopic sleeve gastrectomy patients

OBJECTIVE

This study aimed to compare outcomes of laparoscopic sleeve gastrectomy (LSG) patients based on three types of staple line reinforcement (SLR): seromuscular suturing (imbrication), absorbable polymer membrane (APM), and bovine pericardial strips (BPS).

BACKGROUND

LSG represented 67.3 % of bariatric procedures performed in Michigan in 2013, and its prevalence continues to rise. Multiple studies suggest that SLR can potentially reduce the incidence of complications. However, the current literature is limited secondary to a small sample size and is not conclusive on which type of reinforcement technique is best in reducing the risk of complications.

METHODS

The charts of 1,526 consecutive patients who underwent an LSG from January 2005 to January 2013, by four experienced surgeons, were reviewed. Data include patient demographics, reinforcement technique utilized, length of hospitalization, complications, hospital readmission rates, and mortality.

RESULTS

Of 1,502 patients who underwent an LSG and met inclusion/exclusion criteria, 373 (24.8 %) were reinforced using imbrication, 269 (17.9 %) with BPS, and 860 (57.3 %) with APM. Patient demographics and complication rates were similar between groups. A statistically significant difference occurred in length of stay, readmission, and reoperation rates (p < 0.01). Length of stay was shortest in the BPS group, but readmission and reoperation rates were statistically higher, and there was a trend towards increased leaks (p = 0.08).

CONCLUSIONS

A comparison of imbrication, BPS, and APM demonstrated significantly increased readmission and reoperation rates with a trend towards increased leak rates with the use of BPS in LSG patients. Hemorrhage was not statistically different between the three reinforcement techniques.

Postlobectomy Early Complications

Immediate postoperative complications are common after lobectomy. The most effective management of postoperative crises is prevention, which starts with preoperative preparation and patient screening. There are many factors that can be controlled and improved by the patient. Equally important is patient selection, which is influenced by pulmonary function tests, cardiopulmonary reserve, and preexisting comorbidities. After the operation, the care team can also greatly improve outcomes with aggressive cardiopulmonary therapies, ambulation, vigilant monitoring, and frequent assessments of the patient. Prevention strategies can minimize risks; however, when they occur, a proactive approach may minimize the long-term sequelae.

Advanced therapies for COPD-What's on the horizon? Progress in lung volume reduction and lung transplantation

Advanced chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity. Treatment options beyond conventional medical therapies are limited to a minority of patients. Lung volume reduction surgery (LVRS) although effective in selected subgroups of patients is not commonly undertaken. Morbidity associated with the procedure has contributed to this low utilisation. In response to this, less invasive bronchoscopic lung volume techniques are being developed to attempt to mitigate some of the risks and costs associated with surgery. Of these, endobronchial valve therapy is the most comprehensively studied although the presence of collateral ventilation in a significant proportion of patients has compromised its widespread utility. Bronchial thermal vapour ablation and lung volume reduction (LVR) coils are not dependent on collateral ventilation. These techniques have shown promise in early clinical trials; ongoing work will establish whether they have a role in the management of advanced COPD. Lung transplantation, although effective in selected patients for palliation of symptoms and improving survival, is limited by donor organ availability and economic constraint. Reconditioning marginal organs previously declined for transplantation with ex vivo lung perfusion (EVLP) is one potential strategy in improving the utilisation of donor organs. By increasing the donor pool, it is hoped lung transplantation might be more accessible for patients with advanced COPD into the future.

The role of the emphysema multidisciplinary team in a successful lung volume reduction surgery programme†

OBJECTIVES

Lung volume reduction surgery (LVRS) for advanced emphysema is well established, with strong evidence from the National Emphysema Treatment Trial. However, there is still reluctance to offer the procedure, and many have looked for alternative, unproven treatments. The multidisciplinary approach has been well established in treatment of lung cancer and, more recently, in coronary artery surgery. We reviewed our practice to validate the role of our multidisciplinary team approach in our LVRS programme.

METHODS

Our multidisciplinary approach employs respiratory physicians, radiologists and surgeons involved in case selection, who meet on a regular basis. Cases are selected on the basis of clinical presentation, imaging (radionuclide lung perfusion and computerized tomography) and respiratory physiology. Retrospective analysis of prospectively collected data on 633 patients referred for lung volume reduction surgery between July 1995 and July 2013.

RESULTS

Six hundred and thirty-three patients (422 male) were referred for LVRS, of whom 253 [178 male; median age 61 years (range 37-79 years)] underwent 292 LVRS procedures.There were 268 video-assisted thoracoscopic surgical procedures, of which 13 were one-stage bilateral procedures and 37 required a staged second side. Overall median hospital stay was 13 (4-197) days, during which 11 patients died. Prolonged hospital stay was associated with increasing age and with duration of air leak, which in turn was associated with diffusion capacity and forced expiratory volume in 1 s.

CONCLUSIONS

The outcomes of a successful LVRS programme are not only dependent on good surgical technique and post-operative care. Case selection and work-up by a dedicated multidisciplinary approach for emphysema patients plays an invaluable and integral part in an LVRS programme.

[Lung volume reduction surgery for emphysema and bullous pulmonary emphysema]

The improvement of respiratory symptoms for emphysematous patients by surgery is a concept that has evolved over time. Initially used for giant bullae, this surgery was then applied to patients with diffuse microbullous emphysema. The physiological and pathological concepts underlying these surgical procedures are the same in both cases: improve respiratory performance by reducing the high intrapleural pressure. The functional benefit of lung volume reduction surgery (LVRS) in the severe diffuse emphysema has been validated by the National Emphysema Treatment Trial (NETT) and the later studies which allowed to identify prognostic factors. The quality of the clinical, morphological and functional data made it possible to develop recommendations now widely used in current practice. Surgery for giant bullae occurring on little or moderately emphysematous lung is often a simpler approach but also requires specialised support to optimize its results.

Efficacy of an absorbable polyglycolic acid patch in surgery for pneumothorax due to silicosis

Background

We conducted a retrospective study to evaluate the efficacy and safety of an absorbable polyglycolic acid (PGA) patch in surgery for refractory pneumothorax due to silicosis.

Methods

A retrospective analysis was performed of 56 patients who received thoracotomy or thoracoscopic surgery for refractory pneumothorax due to silicosis between 1995 and 2010. An absorbable PGA patch was used as a reinforcement or repair material after resection of the bulla in 24 operations and it was not used in another 32 operations. Clinical outcomes were compared between the two groups (with a PGA and without a PGA).

Results

We found that the duration of postoperative chest drainage (5.04 ± 1.12 days vs. 8.19 ± 1.60 days, p < 0.01) and hospital stay after the operation (8.33 ± 1.34 days vs. 11.56 ± 1.50 days, p < 0.01) were significantly shorter in patients who used an absorbable PGA patch in the operation compared with those who did not use a PGA patch. The incidence of initial air leakage (58.3% [14/24] vs. 93.8% [30/32], p < 0.05) and relapse rate of pneumothorax in 6 months (4% [1/24] vs. 25% [8/32], p < 0.05) were also significantly lower in patients who used an absorbable PGA patch in the operation compared with those who did not use a PGA patch. No related adverse effects of the absorbable PGA patch occurred after the operations.

Conclusions

Use of an absorbable PGA patch as a reinforcement or repair material in surgery for refractory pneumothorax due to silicosis can reduce postoperative air leakage and improve clinical outcome.

Bioabsorbable staple-line reinforcement for pancreatectomy in a porcine model: a preliminary study

BACKGROUND

We conducted an exploratory study to assess the use of FOREseal® bioabsorbable reinforcement sleeves in stapling of the pancreatic parenchyma.

METHODS

A left pancreatectomy was carried out with linear stapler on 12 pigs: in the FOREseal group (n = 6), the stapling was reinforced with FOREseal, while in the control group (n = 6), simple stapling was applied.

RESULTS

The mean operating time was not different between the two groups. No additional haemostasis of the stapling transection was necessary with FOREseal, while in the control group, four pigs required additional haemostasis (p = 0.03). The mean postoperative drainage volume and the mean duration of drainage were, respectively, in the FOREseal group versus the control group: 82 versus 204 ml (p = 0.2) and 3.2 versus 4.7 days (p = 0.3). No adverse event occurred in the FOREseal group. There was no anatomopathological difference between the two groups.

CONCLUSION

A good tolerance of FOREseal was observed when used on the pancreatic stump. In this study, it was demonstrated a better haemostatic control of the pancreatic stump with FOREseal which also tends to reduce the volume of postoperative drainage liquid.

Several clinical interests regarding lung volume reduction surgery for severe emphysema: meta-analysis and systematic review of randomized controlled trials

Objectives

We aim to address several clinical interests regarding lung volume reduction surgery (LVRS) for severe emphysema using meta-analysis and systematic review of randomized controlled trials (RCTs).

Methods

Eight RCTs published from 1999 to 2010 were identified and synthesized to compare the efficacy and safety of LVRS vs conservative medical therapy. One RCT was obtained regarding comparison of median sternotomy (MS) and video-assisted thoracoscopic surgery (VATS). And three RCTs were available evaluating clinical efficacy of using bovine pericardium for buttressing, autologous fibrin sealant and BioGlue, respectively.

Results

Odds ratio (95%CI), expressed as the mortality of group A (the group underwent LVRS) versus group B (conservative medical therapies), was 5.16(2.84, 9.35) in 3 months, 3(0.94, 9.57) in 6 months, 1.05(0.82, 1.33) in 12 months, respectively. On the 3^rd, 6^th and 12^th month, all lung function indices of group A were improved more significantly as compared with group B. PaO2 and PaCO2 on the 6^th and 12^th month showed the same trend. 6MWD of group A on the 6^th month and 12^th month were improved significantly than of group B, despite no difference on the 3^rd month. Quality of life (QOL) of group A was better than of group B in 6 and 12 months. VATS is preferred to MS, due to the earlier recovery and lower cost. And autologous fibrin sealant and BioGlue seems to be the efficacious methods to reduce air leak following LVRS.

Conclusions

LVRS offers the more benefits regarding survival, lung function, gas exchange, exercise capacity and QOL, despite the higher mortality in initial three postoperative months. LVRS, with the optimization of surgical approach and material for reinforcement of the staple lines, should be recommended to patients suffering from severe heterogeneous emphysema.

Laparoscopic reinforced sleeve gastrectomy: early results and complications

BACKGROUND

Sleeve gastrectomy (SG) was pioneered as a two-stage intervention for super and super-super obesity to minimize morbidity and mortality; it is employed increasingly as a primary procedure. Early outcomes and integrity of laparoscopic SG (LSG) against leak using a technique incorporating gastric transection-line reinforcement were studied.

METHODS

Between 2003 and 2009, 121 patients underwent LSG (16, two-stage; 105, primary). Of the patients, 66% were women, mean age 38.8 ± 10.9 (15.0-64.0), and body mass index (BMI, kg/m(2)) 48.7 ± 9.3 (33.7-74.8). Bovine pericardium (Peri-Strips Dry [PSD]) was used to reinforce the staple line. Parametric and nonparametric tests were used, as appropriate. The paired t test was used to assess change from baseline; bivariate analyses and logistic regression were used to identify preoperative patient characteristics predictive of suboptimal weight loss.

RESULTS

Mean operative time was 105 min (95-180), and mean hospitalization was 5.6 days (1-14). There was no mortality. There were 6 (5.0%) complications: 1 intraoperative leak, 1 stricture, 1 trocar-site bleed, 1 renal failure, and 2 wound infections. There were no postoperative staple-line leaks. Following 15 concomitant hiatal hernia operations, 3 (20%) recurred: 1 revised to RYGB and 2 in standby. Two post-LSG hiatal hernias of the two-stage series required revisions because of symptoms. BMI decreased 24.7% at 6 months (n = 55) to 37.5 ± 9.3 (22.2-58.1); %EWL was 48.1 ± 19.3 (15.5-98.9). Twelve-month BMI (n = 41) was 38.4 ± 10.5 (19.3-62.3); %EWL was 51.7 ± 25.0 (8.9-123.3). Forty-eight-month BMI (n = 13) was 35.6 ± 6.8 (24.9-47.5); %EWL was 61.1 ± 12.2 (43.9-82.1) (p < 0.001). Preoperative BMI was predictive of >70% of patients who experienced <50% EWL at 6 months. At 2 weeks, 100% of type 2 diabetes patients (n = 23) were off medication (mean HbA(1C), 5.9 ± 0.5%; glycemia, 90.0 ± 19.9 mg/dL (p < 0.01) at 3 months).

CONCLUSIONS

Laparoscopic PSD-reinforced LSG as a staged or definitive procedure is safe and effective in the short term and provides rapid type 2 diabetes mellitus reduction with a very low rate of complications.

Effect of Ankaferd Blood Stopper on air leakage in the lung and prevention of bleeding: an experimental study

BACKGROUND

Air leakage and hemorrhage are important causes of morbidity and mortality in operations and traumas of the lung. Ankaferd Blood Stopper is a herbal product used for stopping hemorrhage. In our study, we investigated the efficacy of Ankaferd Blood Stopper in the prevention of air leakage in the lung and bleeding.

METHODS

A total of twenty-one Wistar-Albino rats weighing 240 ± 20 grams were used in our study. An equal amount of injury was created in all groups by performing left thoracotomies. No interventions were made on tissue injury in the first group, and suturing was performed in the second group, and Ankaferd was applied in the third group. Air leakage and duration of bleeding were recorded in all groups.

RESULTS

A statistically significant difference was found between the three groups in terms of air leakage time (p = 0,0001) and bleeding time (p = 0,0001). While a significant effect of Ankaferd was detected in terms of air leakage compared to standard surgery (p = 0,017), no difference was found in terms of bleeding time.

CONCLUSIONS

Ankaferd Blood Stopper ceases the air leakage in the lung parenchyma significantly and effectively. No significant difference is seen compared to the standard surgery group, although it ceases bleeding significantly.

Evidence-based suggestions for management of air leaks

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.

Special situations: air leak after lung volume reduction surgery and in ventilated patients

Patients undergoing lung volume reduction surgery and those supported by mechanical ventilation are among our most vulnerable patients. Prolonged air leak in these fragile patients can have dire, even fatal, consequences. This article describes the incidence of prolonged air leak in these populations, the causes ascribed to their development, and strategies that may be applied to their prevention and treatment.

[Surgical management of COPD distension]

INTRODUCTION

The impressive results seen when giant and compressing lung bullae are resected has inspired pneumonologists and thoracic surgeons to consider the possibility of applying a similar approach to the treatment of respiratory failure due to chronic obstructive pulmonary disease (COPD).

STATE OF THE ART

The major problem with this surgical indication lies in our ability to understand fully the pathophysiology of lesions and thus identify which emphysematous patients will have a response most similar to that achieved in purely bullous disease.

PERSPECTIVES

At the present time consideration should be given as to whether surgery is the only means of reducing pulmonary distension. Indeed, as endoscopic alternatives develop could they reproduce its beneficial effects and what would be their place compared to the surgery?

CONCLUSIONS

While waiting the development of these innovations, if the selection of the candidates is correct, the surgical treatment of lung hyperinflation can temporarily improve the quality of life of these patients by decreasing their dyspnea and increasing their exercise tolerance.

Management of complications of minimally invasive thoracic surgery

Minimally invasive thoracic surgery (MITS) has become part of the modern thoracic surgeon's armamentarium. Its applications include diagnostic and therapeutic procedures, and over the past one and a half decades, the scope of MITS has undergone rapid evolution. The role of MITS is well established in the management of pleural and mediastinal conditions, and it is beginning to move beyond diagnostic procedures for lung parenchyma conditions, to gain acceptance as a viable option for primary lung cancer treatment. However MITS poses technical challenges that are quite different from the conventional open surgical procedures. After a brief review of the history of MITS, an overview of the scope of MITS is given. Important examples of diagnostic and therapeutic indications are then discussed, with special emphasis on the potential complications specific to MITS, and their prevention and management.

BioGlue and Peri-strips in lung volume reduction surgery: pilot randomised controlled trial

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.

Lung volume reduction surgery: technique, operative mortality, and morbidity

The objective of lung volume reduction surgery (LVRS) is the safe, effective, and durable palliation of dyspnea in appropriately selected patients with moderate to severe emphysema. Appropriate patient selection and preoperative preparation are prerequisites for successful LVRS. An effective LVRS program requires participation by and communication between experts from pulmonary medicine, thoracic surgery, thoracic anesthesiology, critical care medicine, rehabilitation medicine, respiratory therapy, chest radiology, and nursing. The critical analysis of perioperative outcomes has influenced details of the conduct of the procedure and has established a bilateral, stapled approach as the standard of care for LVRS. The National Emphysema Treatment Trial (NETT) remains the world's largest multi-center, randomized trial comparing LVRS to maximal medical therapy. NETT purposely enrolled a broad spectrum of anatomic patterns of emphysema. This, along with the prospective, audited collection of extensive demographic, physiologic, radiographic, surgical and quality-of-life data, has positioned NETT as the most robust repository of evidence to guide the refinement of patient selection criteria for LVRS, to assist surgeons in providing optimal intraoperative and postoperative care, and to establish benchmarks for survival, complication rates, return to independent living, and durability of response. This article reviews the evolution of current LVRS practice with a particular emphasis on technical aspects of the operation, including the predictors and consequences of its most common complications.

Autologous fibrin sealant reduces the incidence of prolonged air leak and duration of chest tube drainage after lung volume reduction surgery: a prospective randomized blinded study

OBJECTIVE

Prolonged air leak is reported in up to 50% of patients after lung volume reduction surgery. The effect of an autologous fibrin sealant on the intensity and duration of air leak and on the time to chest drain removal after lung volume reduction surgery was investigated in a randomized prospective clinical trial.

METHODS

Twenty-five patients underwent bilateral thoracoscopic lung volume reduction surgery. In each patient, an autologous fibrin sealant was applied along the staple lines on one side, whereas no additional measure was taken on the other side. Randomization of treatment was performed at the end of the resection on the first side. Air leak was assessed semiquantitatively by use of a severity score (0 = no leak; 4 = continuous severe leak) by two investigators blinded to the treatment.

RESULT

Mean value of the total severity scores for the first 48 hours postoperative was significantly lower in the treated group (4.7 +/- 7.7) than in the control group (16.0 +/- 10.1) (P < .001), independently of the length of the resection. Prolonged air leak and mean duration of drainage were also significantly reduced after application of the sealant (4.5% and 2.8 +/- 1.9 days versus 31.8% and 5.9 +/- 2.9 days) (P = .03 and P < .001).

CONCLUSIONS

Autologous fibrin sealant for reinforcement of the staple lines after lung volume reduction surgery significantly reduces prolonged air leak and duration of chest tube drainage.

Buttressing staples with cholecyst-derived extracellular matrix (CEM) reinforces staple lines in an ex vivo peristaltic inflation model

BACKGROUND

Staple line leakage and bleeding are the most common problems associated with the use of surgical staplers for gastrointestinal resection and anastomotic procedures. These complications can be reduced by reinforcing the staple lines with buttressing materials. The current study reports the potential use of cholecyst-derived extracellular matrix (CEM) in non-crosslinked (NCEM) and crosslinked (XCEM) forms, and compares their mechanical performance with clinically available buttress materials [small intestinal submucosa (SIS) and bovine pericardium (BP)] in an ex vivo small intestine model.

METHODS

Three crosslinked CEM variants (XCEM0005, XCEM001, and XCEM0033) with different degree of crosslinking were produced. An ex vivo peristaltic inflation model was established. Porcine small intestine segments were stapled on one end, using buttressed or non-buttressed surgical staplers. The opened, non-stapled ends were connected to a peristaltic pump and pressure transducer and sealed. The staple lines were then exposed to increased intraluminal pressure in a peristaltic manner. Both the leak and burst pressures of the test specimens were recorded.

RESULTS

The leak pressures observed for non-crosslinked NCEM (137.8 +/- 22.3 mmHg), crosslinked XCEM0005 (109.1 +/- 14.1 mmHg), XCEM001 (150.1 +/- 16.0 mmHg), XCEM0033 (98.8 +/- 10.5 mmHg) reinforced staple lines were significantly higher when compared to non-buttressed control (28.3 +/- 10.8 mmHg) and SIS (one and four layers) (62.6 +/- 11.8 and 57.6 +/- 12.3 mmHg, respectively) buttressed staple lines. NCEM and XCEM were comparable to that observed for BP buttressed staple lines (138.8 +/- 3.6 mmHg). Only specimens with reinforced staple lines were able to achieve high intraluminal pressures (ruptured at the intestinal mesentery), indicating that buttress reinforcements were able to withstand pressure higher than that of natural tissue (physiological failure).

CONCLUSIONS

These findings suggest that the use of CEM and XCEM as buttressing materials is associated with reinforced staple lines and increased leak pressures when compared to non-buttressed staple lines. CEM and XCEM were found to perform comparably with clinically available buttress materials in this ex vivo model.

Complications in patients with severe emphysema

Thoracic surgeons frequently evaluate patients with severe emphysema and concomitant pathology requiring pulmonary resection. There are no absolute guidelines defining the suitability of a given patient for resection. In this review, we outline our approach to evaluating and treating patients with severe emphysema in need of resection. We describe the lessons learned from lung volume reduction surgery and apply that knowledge to the care of the patient with severe emphysema. Careful preoperative evaluation of the patient's lung anatomy, distribution of emphysematous changes in the lung, and overall health is essential to identifying the appropriate candidate for resection and avoiding postoperative complications.

Update in Surgical Therapy for Chronic Obstructive Pulmonary Disease

Bullectomy for giant bullae, lung volume reduction surgery, and lung transplantation are three surgical therapies that may benefit highly selected patients with advanced chronic obstructive pulmonary disease. In this article, each procedure is reviewed, with an emphasis on guidelines for patient selection and clinical outcomes for the practicing pulmonologist. Recent results from the National Emphysema Treatment Trial, updated International Society for Heart and Lung Transplantation Registry data, and revised guidelines for patient selection for lung transplantation are discussed.

Bovine pericardium buttress reinforces colorectal anastomoses in a canine model

PURPOSE

The consequences of an anastomotic leak or disruption can be devastating, particularly in the colorectal surgery population. The purpose of this study was to evaluate and compare colon anastomoses with or without a collagen matrix buttress derived from bovine pericardium.

METHODS

A circular stapler was used to create colon-colon anastomoses in a canine model. Twenty animals underwent two anastomoses each: one buttressed with bovine pericardium, and one without any reinforcement. Staple lines were evaluated at Days 0, 3, 7, 14, 42, and 84. Three animals were killed at each time interval, and evaluation included bursting pressure, bursting location, and histology.

RESULTS

Colon segments with nonbuttressed anastomoses were more likely to burst at the staple line (63 percent), whereas buttressed anastomoses were more likely to burst at the adjacent intestine (74 percent; P=0.048). The burst pressure of nonbuttressed staple lines tended to be consistently, although not significantly, higher than the burst pressure of buttressed staple lines (P=0.651). At histologic analysis, the bovine pericardium buttress demonstrated an ability to allow cellular ingrowth at Day 3 and neovascularization at Day 7. There was no evidence of stenosis or infection.

CONCLUSIONS

The use of a collagen matrix buttress in colorectal anastomoses was safe in a canine model. Our study indicates that true burst strength of the majority of buttressed anastomoses was greater than the adjacent intestine.

Lung volume reduction surgery for diffuse emphysema

BACKGROUND

Lung volume reduction surgery (LVRS) has been re-introduced for treating patients with severe diffuse emphysema. It is a procedure that aims to improve long-term daily functioning, although it is costly and may also be associated with a high risk of mortality.

OBJECTIVES

To assemble evidence from randomised controlled trials for the effectiveness of LVRS, and identify optimal surgical techniques.

SEARCH STRATEGY

Randomised controlled trials were identified using the Cochrane Airways Group Chronic Obstructive Pulmonary Disease (COPD) register. Searches are current to September 2005.

SELECTION CRITERIA

Randomised controlled trials that studied the safety and efficacy of LVRS in patients with diffuse emphysema were included. Studies were excluded if they investigated giant or bullous emphysema.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed trials for inclusion and extracted data. Where possible, data from more than one study were combined using RevMan 4.2 software.

MAIN RESULTS

Eight studies (1663 participants) met the entry criteria of the review. One study accounted for 73% of the participants recruited. Study quality was high, although blinding in studies was not possible. Ninety day mortality was significantly greater in all those who underwent LVRS (odds ratio 6.57 (95% CI 3.34 to 12.95), four studies, N = 1415). A subgroup analysis by risk status suggested that there was a subgroup of participants who were consistently at a significant risk of death, although this was only measured in one large study. The ninety day mortality data indicated that death was more likely with LVRS irrespective of risk status identified in one large study. Improvements in lung function, quality of life and exercise capacity were more likely with LVRS than with usual follow-up.

AUTHORS' CONCLUSIONS

The evidence summarised in this review is drawn from one large study, and several smaller trials. The findings from the large study indicated that in patients who survive up to three months post-surgery, there were significantly better health status and lung function outcomes in favour of surgery compared with usual medical care. Patients identified post hoc as being of high risk of death from surgery were those with particularly impaired lung function and poor diffusing capacity and/or homogenous emphysema. Further research should address the effect of this intervention on exacerbations and rate of decline in lung function and health status.

Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial

BACKGROUND

Although staple line buttressing is advocated to reduce air leak after lung volume reduction surgery (LVRS), its effectiveness is unknown. We sought to identify risk factors for air leak and its duration and to estimate its medical consequences for selecting optimal perioperative technique(s), such as buttressing technique, to preempt or treat post-LVRS air leak.

METHODS

Detailed air leak data were available for 552 of 580 patients receiving bilateral stapled LVRS in the National Emphysema Treatment Trial. Risk factors for prevalence and duration of air leak were identified by logistic and hazard function analyses. Medical consequences were estimated in propensity-matched pairs with and without air leak.

RESULTS

Within 30 days of LVRS, 90% of patients developed air leak (median duration = 7 days). Its occurrence was more common and duration prolonged in patients with lower diffusing capacity (p = 0.06), upper lobe disease (p = 0.04), and important pleural adhesions (p = 0.007). Duration was also protracted in Caucasians (p < 0.0001), patients using inhaled steroids (p = 0.004), and those with lower 1-second forced expiratory volume (p = 0.0003). Surgical approach, buttressing, stapler brand, and intraoperative adjunctive procedures were not associated with fewer or less prolonged air leaks (p >/= 0.2). Postoperative complications occurred more often in matched patients experiencing air leak (57% vs 30%, p = 0.0004), and postoperative stay was longer (11.8 +/- 6.5 days vs 7.6 +/- 4.4 days, p = 0.0005).

CONCLUSIONS

Air leak accompanies LVRS in 90% of patients, is often prolonged, and is associated with a more complicated and protracted hospital course. Its occurrence and duration are associated with characteristics of patients and their disease, not with a specific surgical technique.