Covering the staple line with a polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax prevents postoperative recurrent pneumothorax

The effect of polyglycolic acid sheet in preventing postoperative recurrent pneumothorax: a prospective cohort study

BACKGROUND

Primary spontaneous pneumothorax occasionally relapses, even after bullectomy; therefore, coverage of the bullectomy staple line for pleural reinforcement is common in Japan. However, the appropriate covering materials have not yet been determined.

METHODS

This was a longitudinal prospective cohort study. Data were available for patients aged < 40 years with primary spontaneous pneumothorax who underwent their first thoracoscopic bullectomy between July 2015 and June 2021. We used oxidized regenerated cellulose (ORC) sheets from July 2015 to June 2018, and polyglycolic acid (PGA) sheets from July 2018 to June 2021. The postoperative recurrence-free survival rate was evaluated. The characteristics of the recurrent cases (radiographic, intraoperative, and pathological findings) were also evaluated. The extent of pleural adhesions was classified into the following three groups: none, medium, or extensive.

RESULTS

A total of 187 patients were included in the study. There were 92 and 95 participants in the ORC and PGA sheet groups, respectively. The postoperative recurrence-free survival rates were significantly higher in the PGA sheet group than in the ORC sheet group (ORC group vs. PGA group, 82.9% vs. 95.4%, p = 0.031). In recurrent cases, there was a significant difference in terms of pleural adhesion (0.0% [12 of 12, none] vs. 100.0% [four of four, extensive], p < 0.001).

CONCLUSIONS

Compared with ORC sheets, PGA sheets are an effective material for preventing early recurrence of primary spontaneous pneumothorax. Strong local pleural adhesions potentially contribute to decreasing recurrence.

Early Postoperative Pneumothorax Might Not Be 'True' Recurrence

Objectives: To date, there is no consensual definition of what constitutes a postoperative recurrence of primary spontaneous pneumothorax (PSP), despite there being many studies reporting a high incidence of recurrence. This study aims to describe the long-term recurrence rates of pneumothorax and to suggest a possible way to differentiate recurrence events based on temporal patterns. Methods: This single-center study retrospectively evaluated all postoperative recurrence of PSP from January 2007 to May 2019. Patients’ demographics, history of pneumothorax, radiologic data, surgical technique, and the time between operation and recurrence were analyzed. Univariate and multivariable analyses were conducted to find potential risk factors related to long-term recurrence. Results: Of the 77 postoperative recurrent cases of pneumothorax, 21 (27.2%) occurred within 30 days after surgery and, thus, were classified as early recurrences (ER), while the remaining cases were classified as late recurrences (LR). There was no difference in preoperative variables between the two groups. However, the rate of incidence of second recurrence (SR), which represented a long-term prognosis, was significantly higher in the LR group (28.6% vs. 4.8%, p = 0.030). On univariate and multivariable analyses, late recurrence was the only significant factor predicting later recurrence events. Conclusion: Postoperative recurrence (PoR) within 30 days had a lower SR rate. Therefore, it might not be a ‘true’ postoperative recurrence with a favorable prognosis. Further studies investigating postoperative recurrence based on temporal patterns would be warranted to improve the classification of PoR.

Efficacy of pleural coverage with polyglycolic acid sheet after bullectomy for postoperative recurrence of spontaneous pneumothorax in young patients: a multi-institutional cohort study

OBJECTIVE

Various surgical procedures have been performed to decrease the recurrence of primary spontaneous pneumothorax after video-assisted thoracic surgery. This study aimed to examine the efficiency of pleural coverage for the prevention of postoperative recurrence in relatively young patients.

METHODS

Between January 2008 and December 2012, a total of 357 cases of 345 patients (age 15-29 years) with primary spontaneous pneumothorax who underwent bullectomy at 13 institutions were enrolled in this multi-institutional retrospective cohort study. A concurrent bilateral operation was counted as two cases. Polyglycolic acid sheets were used in 238 cases, and oxidized regenerated cellulose sheets were used in 37 cases to cover the visceral pleura, with no pleural coverage in 82 cases. The average observation period was 4.2 ± 2.0 years.

RESULTS

Postoperative recurrence was observed in 50 cases (14.0%) after video-assisted thoracic surgery. Twenty-six cases (10.9%) in the polyglycolic acid group, eight (21.6%) in the oxidized regenerated cellulose group, and sixteen (19.5%) in the non-coverage group experienced postoperative recurrence. Kaplan-Meier analysis revealed that the rate of freedom from postoperative recurrence in the polyglycolic acid group was significantly higher than that in the non-coverage group. Multivariate analysis showed that age ≥ 20 years and coverage with polyglycolic acid sheets were associated with reduced risk factors for postoperative recurrence.

CONCLUSION

Pleural coverage with a polyglycolic acid sheet is suggested to be effective in preventing postoperative recurrence of pneumothorax compared with non-coverage in relatively young patients.

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.

Bio-artificial pleura using autologous dermal fibroblast sheets to mitigate air leaks during thoracoscopic lung resection

Lung air leaks (LALs) due to visceral pleura injury during surgery are a difficult-to-avoid complication in thoracic surgery (TS). Reliable LAL closure is an important patient management issue after TS. We demonstrated both safeties of transplantation of a cultured human autologous dermal fibroblast sheet (DFS) to LALs. From May 2016 to March 2018, five patients who underwent thoracoscopic lung resection met all the inclusion criteria. Skin biopsies were acquired from each patient to source autologous dermal cells for DFS fabrication. During the primary culture, fibroblasts migrated from the dermal tissue pieces and proliferated to form cell monolayers. These fibroblasts were subcultured to confluence. Transplantable DFSs were fabricated from these subcultured fibroblasts that were trypsinized and seeded onto temperature-responsive culture dishes. After 10 days of fabrication culture, intact patient-specific DFS were harvested. DFSs were analyzed for fibroblast cell content and tissue contaminants prior to application. For closing intraoperative LAL, mean number of transplanted autologous DFS per patient was 6 ± 2 sheets. Mean chest drainage duration was 5.0 ± 4.8 days. The two patients with major LAL had a drainage duration of more than 7 days. All patients currently have no LAL recurrence after discharge. DFSs effectively maintain LAL closure via remodeling of the deposited extracellular matrix. The use of autologous DFSs to permanently close air leaks using a patient-derived source is expected to reduce surgical complications during high-risk lung resections.

Polyglycolic acid mesh for preventing post-thoracoscopic bullectomy recurrence

PURPOSE

Thoracoscopic bullectomy is a common treatment modality for spontaneous pneumothorax but can result in a high frequency of postoperative recurrent pneumothorax in young patients. This retrospective study compared the recurrence rate of pneumothorax following conventional thoracoscopic bullectomy to that following bullectomy using a low-density polyglycolic acid mesh to cover the staple line.

METHODS

Group A comprised 237 patients who experienced 294 episodes of pneumothorax and underwent thoracoscopic bullectomy alone, and Group B comprised 130 patients who experienced 155 episodes of pneumothorax and underwent bullectomy with polyglycolic acid mesh used to cover the visceral pleura. To compare the postoperative inflammatory response between the two groups, we measured three inflammatory parameters: highest body temperature after surgery, C-reactive protein level on postoperative day 3, and change in eosinophil count from the day before the surgery to postoperative day 3.

RESULTS

The recurrence rate was significantly lower in Group B than in Group A (2.6% vs. 24.8%, P < 0.000001). All three inflammatory parameters were significantly higher in Group B than in Group A.

CONCLUSIONS

Using a polyglycolic acid mesh covering after thoracoscopic bullectomy resulted in acceptable long-term results (recurrence rate: 2.6%). This method was associated with a slightly elevated inflammatory response.

Risk factors of postoperative recurrence of primary spontaneous pneumothorax

Background

Spontaneous pneumothorax is common in relatively young, healthy patients. The risk factors for postoperative recurrence after correction are not fully understood.

Methods

We retrospectively reviewed the records of patients who underwent surgery for spontaneous pneumothorax between January 2006 and October 2017. We assessed the possible factors causing postoperative recurrence using univariate and multivariate analyses. We then used the inverse probability of treatment-weighted method to correct for confounding factors.

Results

Postoperative recurrence was observed in 41 of 233 patients (17.6%). A significant association with recurrence was noted for primary spontaneous pneumothorax (PSP), never smokers, thoracoscopic surgery, patients younger than 30 years, operative time less than 100 minutes, and surgery by a resident surgeon. Patients younger than 30 years of age had a 5-year recurrence-free probability of 46.3%. On multivariate analysis, patients younger than 30 years was an independent risk factor for recurrence. The confounding factors for recurrence of PSP included patients younger than 30 years, surgery by a resident surgeon, and thoracoscopic surgery. After adjusting for confounders, patients younger than 30 years was the only factor associated with recurrence (P=0.015). Patients who underwent bulla ligation with pleural reinforcement using an absorbable polyglycolic acid (PGA) sheet had a 4% recurrence rate and a 5-year recurrence-free probability of 90.0%.

Conclusions

Patients younger than 30 years of age is a significant factor for postoperative recurrence in patients with PSP. Surgeons may attempt to prevent postoperative recurrence by devising the operative method and pleural reinforcement methods.

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.

Optimal margin distance of bullectomy for primary spontaneous pneumothorax reduces postoperative recurrence

Background

For primary spontaneous pneumothorax, bullectomy using autosutures is the standard procedure. Despite performing various methods for preventing postoperative recurrence, it remains relatively high. Although considering the margin distance of bullectomy is important, no argument has been discussed for the optical margin distance until now. Hence, we evaluated the optimal margin distance for bullectomy of spontaneous pneumothorax, bullectomy to reduce postoperative recurrence.

Methods

Between March 2015 and May 2018, 91 eligible candidates from 142 cases, who underwent video-assisted thoracoscopic bullectomy for spontaneous pneumothorax, bullectomy, were evaluated. We analysed the factors preventing postoperative recurrence, including the margin distance using the inverse-probability of treatment weighted method by propensity score was used to adjust for heterogeneous patient backgrounds.

Results

The patients' median age was 20 years (range, 14-86 years). Postoperative recurrences occurred in 8 cases (8.8%). The margin distance was 9.1±5.0 mm. The cut-off point of the margin distance was defined as 5.0 mm. The inverse-probability of treatment weighted method indicated that a margin distance ≥5.0 mm significantly prevented postoperative recurrence (P=0.0076, hazard ratio =0.18).

Conclusions

This study suggests that a margin distance of ≥5.0 mm for bullectomy of PSP can reduce postoperative recurrence.

The clinical characteristics and surgical results of smoking-related young pneumothorax

OBJECTIVE

Primary spontaneous pneumothorax is a common disease that develops in relatively young healthy patients. Although smoking is generally believed to have a negative effect on the lungs, some authors reported that smokers with primary spontaneous pneumothorax had significantly lower postoperative recurrence rates than nonsmokers. This unexpected result suggests that primary spontaneous pneumothorax is classified into two categories: smoking-related young pneumothorax and residual primary spontaneous pneumothorax. We compared these two categories to determine their characteristics and corresponding surgical results.

METHODS

Between January 2009 and December 2018, we enrolled 267 consecutive cases that underwent first surgery for primary spontaneous pneumothorax in our hospital. A total of 252 eligible cases (211 residual primary spontaneous pneumothorax and 41 smoking-related young pneumothorax) underwent evaluation. Smoking-related young pneumothorax cases were defined as cases with characteristic HRCT findings and smoking habit.

RESULTS

The mean ages for the residual primary spontaneous pneumothorax and smoking-related young pneumothorax groups were 25.9 ± 13.1 and 30.5 ± 6.9 years, respectively. The groups included 186 (88.2%) and 41 (100.0%) men, and the mean body mass indices were 19.1 ± 2.2 and 20.0 ± 1.9, respectively. Fifty-nine (28.0%) and 41 (100.0%) subjects were smokers, and there were 43 (20.4%) and 1 (2.4%) cases of postoperative recurrence, respectively. These results were significantly different between the two groups.

CONCLUSIONS

Individuals with smoking-related young pneumothorax were older, predominantly men, and had higher body mass index and significantly lower postoperative recurrence rates than those with residual primary spontaneous pneumothorax.

Neo-generation of neogenetic bullae after surgery for spontaneous pneumothorax in young adults: a prospective study

Background

To investigate the development of neogenetic bullae or blebs on 1-year postoperative chest computed tomography after video-assisted thoracic surgery (VATS) in young patients with primary spontaneous pneumothorax (PSP).

Methods

In this prospective study, 10- to 20-year-old patients with PSP were treated via VATS with additional procedures (bullectomy, cold coagulation, coverage, pleural abrasion, or chemical pleurodesis). All patients underwent the additional procedures and computed tomography of the chest 1 year postoperatively for the assessment of neogenetic bullae. Postoperative PSP recurrence was monitored, and recurrence-free survival was evaluated using Kaplan-Meier analysis.

Results

Fifty-seven patients (66 cases) aged 17 ± 2 years underwent VATS for PSP and were followed up for 938 ± 496 days. Of the 36 cases at 1-year follow-up, 23 (63.9%) showed neogenetic bullae, which were adjacent to the staple lines in 16 cases (69.6%). The 1- and 2-year recurrence-free survival rates were 88.9 and 85.1%, respectively. Nine of the 66 cases (13.6%) showed recurrence after 869 ± 542 days. A history of contralateral PSP was significantly associated with recurrence.

Conclusions

VATS, combined with additional procedures, provides acceptable long-term results in young patients with PSP. Additional procedures reduce the recurrence rate of PSP but do not prevent the occurrence of neogenetic bullae. A history of contralateral PSP is a potential risk factor for post-VATS recurrence in young patients.

Pneumothorax in teenagers: reducing recurrence through resection of superior segment of lower lobe

Background

Spontaneous pneumothorax in young patients is characterized by a high recurrence rate. We retrospectively investigated causes of recurrence and effective surgical methods to improve this statistic, in particular through resection of the superior segment of the lower lung lobe (S6a).

Methods

From April 2011 to September 2017, we performed 146 operations for 126 lateral side pneumothoraces in patients 20 years of age or younger (105 males and 7 females, mean age 17.2 years) at our institution. Two groups-one with patients who underwent both apical bullectomy and S6a resection (the S6a group), and the other with patients who underwent only apical bullectomy with apical reinforcement using an absorbable mesh sheet (the AB group)-were statistically compared in terms of recurrence rate.

Results

A significant difference was found between the S6a group and the AB group in terms of the number of S6a recurrences (0 vs. 8 cases, respectively; P=0.025), although there was no significant difference between the two groups in terms of the total recurrence rate (16.1% vs.18.6%, respectively). Pathological examination revealed that 55 of the 56 (98.2%) S6a specimens already contained asymptomatic, non-ruptured bullae or microscopic bullous lesions at the time of the initial operation.

Conclusions

In addition to the apex, the S6a often involves lesions responsible for pneumothorax recurrence. To reduce this recurrence in teenage patients, we suggest that S6a resection be concomitantly performed in the initial operation-even if there are no macroscopically visible blebs on the S6a.

Postoperative chest tube placement after thoracoscopic wedge resection of lung for primary spontaneous pneumothorax: is it mandatory?

Background

The goal of present study is to assess the efficiency and feasibility of postoperative care without positioning of chest tube after video-assisted thoracoscopic surgery (VATS) in patients with primary spontaneous pneumothorax (PSP).

Methods

We conducted a prospective randomized trial of patients who have undergone video-assisted thoracoscopic wedge resection surgery for PSP. During the period of April 2015 until December 2016, 119 eligible patients undergoing VATS for PSP were consecutively included. We divided the patients into two groups at random: (I) avoiding chest tube (ACT) group, comprising 58 patients in whom chest tube was not placed intra or postoperatively, and (II) indwelling chest tube (ICT) group, comprising 61 patients in whom chest tube was placed conventionally. Primary end point was to evaluate and analyze the postoperative clinical data and relevant morbidities between two groups.

Results

The mean postoperative length of hospital stay (3.57±0.79 vs. 5.39±0.97 days) and postoperative pain (1.37±0.78 vs. 2.53±0.63) in ACT group were significantly lower than in the ICT group (P<0.05). However, there were no statistical differences between two groups regarding other clinical data and postoperative morbidities. There were no patients who experienced significant adverse events postoperatively.

Conclusions

Postoperative management without chest tube placement is safe and feasible approach for patients undergoing thoracoscopic wedge resection for PSP.

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

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a common disease in thoracic surgery, and a prolonged postoperative air leakage is the most frequent and troublesome early complication after video-assisted thoracoscopic (VATS) bullectomy. This study aimed to explore the efficacy of polyglycolic acid (PGA) sleeve in preventing postoperative air leakage after a VATS bullectomy for PSP.

METHODS

This study was a prospectively randomised clinical study. The patients who underwent a VATS bullectomy were continuously enrolled from January 2015 to June 2016 in the Beijing Chaoyang Hospital and were randomly assigned to the experimental and control groups. The experimental group applied a PGA sleeve combined with an automatic stapler in the bullectomy, while in the control group, the bullae were resected using an automatic stapler alone during the operation. In addition, the staple lines in both groups were covered with an absorbable polyglycolic acid sheet and both groups performed pleural abrasion after the resection. Useful clinical data were recorded, including the number of cases there was no air leakage immediately after the operation and air leakage lasted more than 3 days, the average postoperative air leakage, the drainage tube removal time, the postoperative hospital stay, the postoperative complications, and the postoperative recurrence.

RESULTS

A total of 134 patients were enrolled in this study. The experimental group consisted of 60 subjects, and there were 74 in the control group. No operative related mortality was observed in either group. In the experimental group, 44 of the 60 patients did not have an air leakage immediately after the operation, which was significantly higher than the control group (73.33% vs. 54.05%, P=0.031). Compared with the control group, the average postoperative air leakage (0.57±1.11 days), the chest tube removal time (3.03±0.92 days), and the postoperative hospital stay (3.98±0.92 days) were all significantly shorter in the experimental group (P=0.048, P=0.012, and P=0.010, respectively). Moreover, the rate of postoperative complications in the experimental group was lower than the control group (3.33% vs. 16.22%, P=0.021). No postoperative recurrence was observed in either group during the follow-up period that ranged from 8 to 25 months.

CONCLUSIONS

The use of PGA sleeve during surgery for PSP might effectively prevent early postoperative air leakage, as well as reduce the postoperative drainage tube removal time and the postoperative hospital stay.

Association between postoperative bulla neogenesis at the staple line and resected lung weight for primary spontaneous pneumothorax: a retrospective study using the inverse-probability of treatment weighted method in patients grouped according to age

BACKGROUND

Bullectomy using autosutures is the standard procedure in patients with primary spontaneous pneumothorax (PSP). However, postoperative bulla neogenesis (POBN) along the staple line is relatively common and promotes PSP recurrence. We have previously reported the relationship between POBN and resected lung weight (LW). However, recently published data indicate that young patients with PSP have a high postoperative recurrence rate. Therefore, we evaluated the relationship between POBN and LW in PSP patients, subdivided according to age.

METHODS

Between February 2011 and April 2016, 96 lung-resection sites in 67 patients who underwent bullectomy were evaluated. Patients were subdivided into two groups by age: Y group (<25 years, 56 sites) and O group (≥25 years, 40 sites). We used the inverse-probability of treatment weighted (IPTW) method to adjust for the heterogeneity in their backgrounds. POBN was diagnosed by computed tomography.

RESULTS

Cox regression analysis for the O group indicated that LW ≥3.0 g was a significant risk factor for POBN (P=0.049). For the Y group, no association between lung weight and POBN was observed.

CONCLUSIONS

A LW ≥3.0 g is a significant risk factor for POBN in individuals aged ≥25 years.