A clinical study of efficacy of polyglycolic acid sleeve after video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax

Efficacy of mesh coverage in surgical bullectomy for primary spontaneous pneumothorax: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Thoracic surgeons are now adopting a new method of using a mesh covering to reduce recurrence in surgical pleurodesis for pneumothorax. We aimed to review the literature and compare the outcomes of using mesh covering as an additional procedure during surgical pleurodesis.

METHODS

A comprehensive search was performed from inception to October 2022 on PubMed, Embase, Cochrane and Scopus. Randomised controlled trials (RCTs) and observational cohort studies (OCSs) comparing the use of mesh coverage, and different materials were included. Data were extracted to compare recurrence and other outcomes using a random effect model.

RESULTS

23 studies consisting of 2 RCTs and 21 OCSs totalling 5092 patients were included. Patients with a mesh had a significantly lower recurrence (OR = 0.22, 95% CI 0.12-0.42, p < 0.0001) and a shorter duration of chest tube drainage (SMD = -0.74 days, 95% CI -0.28 to -1.20, p < 0.0001) but no significant difference in the length of operation. The use of polyglycolic acid (PGA) and vicryl mesh was associated with a significantly shorter duration of chest tube drainage [(PGA, SMD = 0.83 days, 95% CI 0.14-1.52, p < 0.0001), (vicryl, SMD = 1.06 days, 95% CI 0.71-2.82, p = 0.0005)]. They also had a shorter post-operative length of stay than oxidized regenerative cellulose (ORC) but this was not statistically significant.

CONCLUSION

The use of a mesh material reduced the incidence of post-operative air leaks in the short term and the recurrence rate in the long term. Some mesh materials such as PGA and vicryl performed better than other materials.

Effectiveness of the polyglycolic acid patch in preventing prolonged air leakage after pulmonary decortication

AIM

This study aimed to investigate the effectiveness of an absorbable polyglycolic acid patch (PGA) in the early prevention of alveolar air leaks after pulmonary decortication operations.

METHODS

Between January 2016 and December 2019, files of 185 patients with pleural effusion, empyema, or hemothorax were examined retrospectively. Thirty-five patients who underwent decortication surgery were included in the study. Two-way posteroanterior (PA) chest x-ray, computed tomography (CT), pulmonary function tests (PFT), arterial blood gas, hemogram, and biochemical tests were performed for all patients before the operation. The patients were divided into two groups. Group 1 was composed of 16 patients (45.7%) with standard decortication, and Group 2 was formed with 19 patients (54.3%) with standard decortication + PGA patch.

RESULTS

The median age was 55 years (minimum = 25, maximum = 75) and the vast majority (82.9%; n = 29) of patients were males. There was no significant difference between groups in age, aetiology, or sex. The most common etiological cause in both Group 1 and Group 2 was nonspecific infection (56.3% and 73.7%, respectively). When Group 2 and Group 1 were compared regarding median times (day) of air leak cessation (Group 2 = 4; Group 1 = 8.5), chest drain removal (Group 2 = 5; Group 1 = 10), and hospital discharge times (Group 2 = 8; Group 1 = 13),the durations were statistically significantly shorter in Group 2 than in Group 1 (P < 0.001).

CONCLUSION

Use of the PGA patch in pulmonary decortication operations significantly reduced the duration of air leaks, drain removal, and discharge time from the hospital in the postoperative period.

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.

Polyglycolic acid sheet covering to prevent recurrence after surgery for spontaneous pneumothorax: a meta-analysis

The coverage technique using absorbable mesh was first described in a European guideline published in 2015 as a preventive method for the recurrence of spontaneous pneumothorax. We performed a meta-analysis based on a literature search of primary studies that compared the postoperative recurrence rate of primary spontaneous pneumothorax between the use and nonuse of polyglycolic acid sheet coverage. Two reviewers independently selected and evaluated the quality of the relevant studies. The risk ratio in each study was calculated in a random-effect meta-analysis. Statistical heterogeneity among the included studies was quantitatively evaluated using the I² index, and publication bias was assessed using a funnel plot. A total of 19 retrospective cohort studies were analyzed: 1524 patients who underwent wedge resection alone (the control group) and 1579 who received additional sheet coverage. Polyglycolic acid sheet coverage was associated with a lower recurrence rate than that in the control group (risk ratio: 0.27, 95% confidence interval 0.20–0.37, P < 0.001; I² 0%). The funnel plot suggested possible publication bias. The covering technique reduced the recurrence rate of pneumothorax after thoracoscopic surgery to one-fourth.

A clinical study of efficacy of polyglycolic acid patch in surgery for pneumothorax:a systematic review and meta-analysis

Objectives

A polyglycolic acid (PGA) patch is often used in pulmonary bullae resection, but consensus has not been reached on its effect on patient recovery. The aim of the study is to conduct a systematic review and meta-analysis of studies of polyglycolic acid for bullectomy.

Methods

A comprehensive literature search was performed using ScienceDirect, EMBASE, Ovid MEDLINE, PubMed, The Cochrane Library, Scopus, and Google Scholar. Clinical trials that compared PGA versus non-PGA for bullectomy were selected. The clinical endpoints included postoperative recurrence, average postoperative air leakage, prolonged air leaks, drainage tube removal time, and postoperative hospital stay.

Results

A total of eight articles (1095 patients) were included. Compared to the non-PGA approach, the PGA approach was associated with lower rates of postoperative recurrence (95% confidence interval [CI]: 0.16 to 0.39, p < 0.00001),) and of prolonged air leaks (95% CI: 0.29 to 0.72, p = 0.0007); a shorter time of drainage tube removal (95% CI: − 1.36 to − 0.13, p = 0.02); The time of average postoperative air leakage, postoperative hospital stay and operative time did not show a significant difference between the two groups.

Conclusions

These results suggest that the use of PGA patch might can prevent the postoperative recurrence of spontaneous pneumothorax and decrease the rates of prolonged air leaks. More large-scale, high-quality randomized controlled trials are required to confirm our finding.

Tubeless single-port thoracoscopic sublobar resection: indication and safety

Background

The tubeless technique, defined as non-intubated general anesthesia with omission of chest drainage after video-assisted thoracoscopic surgery (VATS), is a new concept to further minimize surgical trauma. However, there has been little investigation into the associated feasibility and safety. Minimization of postoperative pneumothorax is challenging. We set up a "tubeless protocol" to select patients for tubeless single-port VATS with monitoring of a digital drainage system (DDS).

Methods

From November 2016 to September 2017, 50 consecutive non-intubated single-port VATS for pulmonary resection were performed. In our study, patients with small and peripheral pulmonary lesions indicated for sublobar resections, as diagnostic or curative intent, were included. After excluding patients having tumors >2 cm, or intrapleural adhesions noted during operation, or forced expiratory volume in the 1 second <1.5 L, 36 patients were selected for tubeless protocol. The clinical characteristics and perioperative outcomes of these patients are presented.

Results

Among 36 cases, 5 patients had minor air leaks detected using the DDS and required intercostal drainage after wound closure. Among the remaining 31 patients in whom the DDS showed no air leak, the chest drainage was removed immediately after wound closure. A postoperative chest roentgenogram on the surgery day showed full expansion in all patients without pneumothorax. Only 7 (19.4%) patients developed minor subclinical pneumothorax on the first postoperative day without the need for chest drainage. All patients were discharged uneventfully without the need for intervention.

Conclusions

Our tubeless protocol utilizes DDS to select patients who can have intercostal drainage omitted after non-intubated single-port VATS for pulmonary resection. Using objective DDS parameters, we believe that this is an effective way to reduce the rate of pneumothorax after tubeless single-port VATS in selected patients.