Feasibility of using a vessel sealing system in a human pulmonary lobectomy: a retrospective comparison of this procedure with or without a vessel sealing system

Performance of the ENSEAL X1 Curved Jaw Tissue Sealer in thoracic procedures in a Japanese cohort: a case series report

BACKGROUND

Advanced vessel sealing electrosurgical systems have been widely adopted for grasping, cutting, and sealing vessels. Data remain sparse with regard to its use in thoracic procedures. Thus, a prospective case series, utilizing the ENSEAL X1 Curved Jaw Tissue Sealer (X1CJ) and its companion energy source, the Generator 11 (GEN11), in thoracic procedures was performed in a Japanese cohort.

METHODS

Subjects were recruited at two Japanese surgical sites. The primary endpoint of this post-market study was the achievement of hemostasis (≤ Grade 3) for each thoracic vessel transection. Performance endpoints included scores for tasks completed with X1CJ (adhesiolysis, lymphatics or tissue bundles divided, tissue grasping, tissue cutting, or tissue dissection); hemostasis grading vessel transected; additional products required to achieve hemostasis for Grade 4 vessel transections. Safety was evaluated by evaluating device-related adverse events. All endpoint data were summarized.

RESULTS

Forty subjects (50.0% female) of Asian ethnicity with a mean age of 67.6 ± 11.3 years underwent a lung resection. Estimated mean blood loss was 39.5 mL. Hemostasis was achieved in 97.5% of vessel transections. Thirty-seven vessel sealings resulted in a hemostatic Grade 1 (92.5%). All surgeons reported satisfaction/neutral in terms of tissue grasping (100.0%) while most reported satisfaction/neutral with tissue cutting (95.7%). One device-related serious adverse event was reported (2.5%), a chylothorax requiring an extension of hospitalization. There was no post-operative bleeding or deaths reported during the study period.

CONCLUSION

The X1CJ demonstrated safe and effective performance without any reports of significant intra-operative or post-operative hemorrhage in thoracic vessel sealing.

Energy devices versus electrocoagulation in video-assisted thoracoscopic lobectomy: a propensity-match cohort study

BACKGROUND

The aim of the study was to compare the effect on perioperative outcome of intraoperative use of different devices for tissue dissection (electrocoagulation [EC] or energy devices [ED]) in patients who underwent video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer.

METHODS

We retrospectively reviewed 191 consecutive patients who underwent VATS lobectomy, divided into two cohorts: ED (117 patients), and EC (74 patients); after propensity score matching, 148 patients were extracted, 74 for each cohort. The primary endpoints considered were complication rate and 30-day mortality rate. The secondary endpoints considered were length of stay (LOS) and the number of lymph nodes harvested.

RESULTS

The complication rate did not differ between the two cohorts (16.22% EC group, 19.66% ED group, P=0.549), before and after propensity matching (16.22% for both EC and ED group, P=1.000). The 30-day mortality rate was 1 in the overall population. Median LOS was 5 days for both groups, before and after propensity match, with the same interquartile range, (IQR: 4-8). ED group had a significantly higher median number of lymph nodes harvested (ED median: 18, IQR: 12-24; EC median: 10, IQR: 5-19; P=0.0002). The difference was confirmed after the propensity score matching (ED median: 17, IQR: 13-23; EC median: 10, IQR: 5-19; P=0.0008).

CONCLUSIONS

ED dissection during VATS lobectomy did not lead to different complication rates, mortality rates, and LOS compared to EC tissue dissection. ED use led to a significantly higher number of intraoperative lymph nodes harvested compared to EC use.

Thoracoscopic Lobectomy in Infants and Children

Indications for pulmonary lobectomy in infants and children include cystic pulmonary adenomatoid malformation, congenital lobar emphysema, chronic infection, and malignancy. These procedures can now all be done thoracoscopically avoiding the short- and long-term morbidity of an open thoracotomy. In this article we describe the technique of thoracoscopic lobectomy as well as the preoperative and postoperative care.

Heat production during pulmonary artery sealing with energy vessel-sealing devices in a swine model

OBJECTIVES

Energy vessel-sealing devices are being increasingly utilized to seal pulmonary artery (PA) branches during lobectomy. Heat from these devices can potentially injure surrounding tissues. We evaluated heat production from devices in a live animal model.

METHODS

PA branches were sealed in pigs with 4 energy vessel-sealing devices: 2 ultrasonic (US), 1 advanced bipolar or 1 mixed US and bipolar (mixed) device. Thermocouples were implanted in tissue surrounding the PA branch being sealed to measure tissue temperature. A thermal camera measured the sealing site and the temperatures of the instruments. Pathological analysis was performed on PA stumps to identify thermal damage.

RESULTS

A total of 37 PA branches were sealed in 4 pigs. Maximum tissue heat measured by the thermocouples for the 2 US, advanced bipolar and mixed devices was 42, 39, 42 and 46°C, respectively. The mean tissue temperatures at the site of the sealing measured with the thermal camera were 78, 75, 70 and 82°C (P = 0.834) and the mean instrument blade temperatures were 224, 195, 83 and 170°C (P = 0.000005) for the 2 US, advanced bipolar and mixed devices, respectively. The mean diameter of the region with tissue reaching 60°C or more measured with the thermal camera was between 4 and 6 mm for the 4 devices (P = 0.941). On pathological analysis, PA stumps had either thermal damage on the adventitia and external media (26/37) or transmural damage (11/37) at 1 mm from sealed site.

CONCLUSIONS

A 3-mm safety margin between the instrument blades and vital structures is recommended. Instrument blades can reach high temperatures that may cause tissue damage.

Energy devices safety and impact on video-assisted thoracoscopic lung lobectomy postoperative course: monopolar electrocautery versus ultrasonic dissector

Background

This study aims to compare safety and impact of monopolar electrocautery and ultrasonic dissector (Harmonic ACE Plus®) on postoperative short-term outcomes after video-assisted thoracoscopic (VATS) lobectomy and lymphadenectomy for lung cancer.

Methods

We analyzed the prospectively collected data of 140 consecutive patients [59% male; median age: 71(IQR:62–76) years] undergoing VATS lobectomy and lymphadenectomy in our institution between October 2016 and November 2019. Patients were divided in two groups based on device used: monopolar electric hook in 79 cases (Group A); ultrasonic dissector in 61(Group B). Energy instrument-related intraoperative accidents, hemothorax/chylothorax incidence, total pleural effusion volume at 48 postoperative hours and chest tube duration were compared between groups. Multivariable analysis was performed to test energy device as possible independent risk factor either for increased pleural effusion volume or for prolonged chest tube duration.

Results

No intraoperative accidents due to energy device occurred. No hemothorax was recorded. Postoperative chylothorax incidence was slightly higher in Group A (2.5% vs 0%; p-value = 0.21). Total pleural effusion volume at 48 h was significantly higher in Group B: 400 (285–500) vs 255 (150–459) ml (p-value = 0.005). Chest tube duration was similar in the two groups: 5 (3–9) vs 5 (3–8) days (p-value = 0.77). At multivariable analysis the energy device used was not associated with increased pleural effusion volume (p-value = 0.43) nor with prolonged chest tube duration (p-value = 0.28).

Conclusions

Monopolar electrocautery and Harmonic ACE Plus® were safe and had a similar impact on short-term outcomes after VATS lobectomy and lymphadenectomy, suggesting that energy devices choice could be left to surgeon’s preference.

Assessment of pleural air leakage using digital chest drainage system after surgical pulmonary resection: Comparison of visible alveolar air leakage with the digital value measured by a digital chest drainage system

Background

The sensitivity of postoperative pleural air leakage (PAL) after pulmonary resection is evaluated by a simple subjective grading method in clinical practice. A new electronic digital chest drainage evaluation system (DCS) recently became clinically available. This study was designed to evaluate the clinical application of the DCS in monitoring the airflow volume and managing postoperative PAL.

Methods

We prospectively enrolled 25 patients who underwent pulmonary resection. Postoperative PAL was evaluated using both conventional PAL grading based on the physician’s visual judgment (analog chest drainage evaluation system [ACS]: Level 0 = no leakage to 4 = continuous leakage) and the DCS. The DCS digital measurement was recorded as the flow volume (ml/min), which was taken once daily from postoperative day 1 to the day of chest drainage tube removal.

Results

In total, 45 measurements were performed on 25 patients during the evaluation period. Postoperative PAL was observed in five patients (20.0%) and judged as ACS Level >1. The mean DCS values corresponding to ACS Levels 0, 1, 2, and 3 were 2.42 (0.0–11.3), 48.6 (35.4–67.9), 95.6 (79.7–111.5), and 405.3 (150.3–715.6), respectively. The Spearman correlation test showed a significant positive correlation between the ACS PAL level and DCS flow volume (R = 0.8477, p < 0.001).

Conclusions

A relationship between the visual PAL level by the ACS and the digital value by the DCS was identified in this study. The numeric volume obtained by the DCS has been successful in information-sharing with all staff. The digital PAL value evaluated by the DCS is appropriate, and the use of the DCS is promising in the treatment of postoperative PAL after pulmonary resection.

Experimental study in pulmonary artery sealing with a vessel-sealing device

Background

The development of vessel-sealing devices will facilitate safety in video-assisted thoracoscopic surgery. Our objective was to evaluate the feasibility and safety of sealing pulmonary arteries with the Enseal tissue-sealing device.

Methods

Pulmonary arteries from beagle dogs (mean body weight 13.1 kg, range 10.5–15.4 kg) were divided into 3 groups according to the in-vivo sealing method used (Enseal, ligation, and proximal ligation plus distal Enseal) and extracted to evaluate the pressure tolerance up to 75 mm Hg at the sealed end. A left lower lobectomy was performed to evaluate chronic-phase durability of the sealed stumps in a survival model. Two or three branches of the pulmonary arteries in each dog were allocated to each of the 3 groups. After the scheduled survival period, the pulmonary arteries were sampled.

Results

Pressure tolerance at the sealed end was evaluated in 91 pulmonary artery sections. All sealed ends showed pressure tolerance >75 mm Hg. A left lower lobectomy was performed in 13 dogs in which 35 pulmonary artery sections had been allocated into the 3 groups. No sealing failure was found, and pathological findings showed healing and persistent hemostasis at all sealed ends of the pulmonary arteries after 2 and 4 weeks of the survival period.

Conclusions

Pulmonary arteries sealed in vivo with the Enseal device showed pressure tolerance >75 mm Hg in the acute phase, and persistent hemostasis after 2 or 4 weeks. Pulmonary artery sealing with the Enseal device is feasible and safe in thoracic surgery settings.

Energy-Based Ligation of Pulmonary Vessels: A Six-Year Experience With Ultrasonic Shears in Video-Assisted Thoracoscopic Lobectomy and Segmentectomy

BACKGROUND

Mechanical staplers are widely employed in minimally invasive anatomic lung resections, but have limitations when managing smaller pulmonary arterial and venous branches. Published data is lacking regarding the safety and efficacy of pulmonary vessel ligation using ultrasonic shears. We describe a single-surgeon experience employing ultrasonic shears for the ligation of pulmonary vasculature during lobectomy and segmentectomy, primarily in the setting of video-assisted thoracic surgery (VATS) resection.

METHODS

A retrospective chart review was conducted for all patients, who underwent anatomic resection, between 2008 and 2014. Charts were divided into 2 groups based on method of ligation (energy based or conventional). Dictated operative reports were reviewed and patient demographics, tumor characteristics, and complications were recorded.

RESULTS

Ultrasonic shears were used for pulmonary vessel ligation (5 to 6 mm) in 82 of 283 anatomic resections. A total of 118 vessels were ligated with ultrasonic shears. The majority of patients (83%) in the energy-based ligation group underwent VATS resection. There were fewer complications in the energy-based ligation group (26% vs 38%; p = 0.05); however, rates of intraoperative transfusion, prolonged air leak, empyema, and return to the operating room were similar across the 2 groups, and no statistically significant difference was found. There were no postoperative complications directly attributable to ultrasonic vessel ligation.

CONCLUSIONS

Energy-based ligation of small-diameter pulmonary vessels is a safe and useful adjunct in anatomic VATS resection and a viable alternative to mechanical stapling. Its narrow profile and thin blades make it ideal for ligation of pulmonary vasculature, particularly where the size and necessary clearance of mechanical staplers prohibit safe dissection.

Two decades of experience with thoracoscopic lobectomy in infants and children: standardizing techniques for advanced thoracoscopic surgery

OBJECTIVES

This study evaluates the safety and efficacy of thoracoscopic lobectomy in infants and children.

MATERIALS AND METHODS

From January 1994 to November 2013, 347 patients underwent video-assisted thoracoscopic lobe resection at two institutions. All procedures were performed by or under the direct guidance of a single surgeon. Patients' ages ranged from 1 day to 18 years, and weights ranged from 2.8 to 78 kg. Preoperative diagnosis included sequestration/congenital pulmonary airway malformation (n=306), severe bronchiectasis (n=24), congenital lobar emphysema (n=13), and malignancy (n=4).

RESULTS

Of the 347 procedures, 342 were completed thoracoscopically. Operative times ranged from 35 minutes to 240 minutes (average, 115 minutes). Average operative time when a trainee was the primary surgeon was 160 minutes. There were 81 upper, 25 middle, and 241 lower lobe resections. There were four intraoperative complications (1.1%) requiring conversion to an open thoracotomy. The postoperative complication rate was 3.3%, and 3 patients required re-exploration for a prolonged air leak. Hospital length of stay (LOS) ranged from 1 to 16 days (average). In patients <5 kg and <3 months of age, the average operative time was 90 minutes, and the LOS was 2.1 days.

CONCLUSIONS

Thoracoscopic lung resection is a safe and efficacious technique. With proper mentoring it is an exportable technique, which can be performed by pediatric surgical trainees. The procedures are safe and effective even when performed in the first 3 months of life. Early resection avoids the risk of later infection and malignancy.