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Ann Thorac Surg 1997;63:1573-1575
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Effect of Bovine Pericardial Strips on Air Leak After Stapled Pulmonary Resection

Divisions of Cardiothoracic Surgery and Pulmonary Medicine at Southern Illinois University, Springfield, Illinois, and St. Louis University, St. Louis, Missouri

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Surgical procedures for emphysema have been proposed and in many settings resulted in significant improvement in dyspnea and function. The most prevalent surgical problem in all series is prolonged postoperative air leak.

Methods. One hundred twenty-three patients undergoing stapled thoracoscopic unilateral lung volume reduction operation were prospectively randomized to receive either no buttressing of their staple lines or buttressing of all staple lines with bovine pericardial strips.

Results. The two groups were comparable in preoperative risks and in the severity of their emphysema. Postoperative complications were identical in the two groups with respect to pneumonia, empyema, and wound infection; however, there was a significant difference in the duration of postoperative air leaks. Those having the pericardial strips used to buttress their staple lines had chest tubes removed 2.5 days sooner and were discharged from the hospital 2.8 days sooner as a result. The cost data revealed that because of the cost of the pericardial sleeves, the overall hospital charges were almost identical for the two groups ($22,108 bovine, $22,060 no bovine) in spite of the shortened hospital stay.

Conclusions. The use of bovine pericardial sleeves to buttress the staple lines in thoracoscopic unilateral lung volume reduction operation results in a shorter duration of postoperative air leaks. Total hospital charges were comparable in the two groups as the 2.8 days saved in the hospital were offset by the cost of the pericardial sleeves.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 1575.

Surgical procedures for emphysema have created enthusiastic debate and resulted in numerous publications in the thoracic surgical literature. There has been a perceptible evolution in technique during the past 5 years from the initial laser techniques to the now more frequent stapled volume reduction procedures [1–6].

Although surgical techniques and patient selection have evolved, air leaks remain the most frequently seen complication in all reported series. Typical times for chest tubes to be required after operation are more than 7 days, often approaching 2 weeks. Prolonged air leaks after lung resections have always been an occasional postoperative management problem; however, the emphysematous lung is particularly unforgiving in this regard.

Understandably there have been attempts to decrease the duration of postoperative air leaks by using several techniques to buttress the areas of stapled resection. The most frequently used maneuver has been to use strips of bovine pericardium on the staple lines [7]. The use of heterologous pericardium could have an impact both on the incidence of postoperative infections and on total hospital costs. We performed a prospective trial to study the effect of heterologous pericardium on air leak duration.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
One hundred twenty-three consecutive patients undergoing lung volume reduction (LVR) were prospectively randomized to receive bovine pericardial strips on either all staple lines or none of them.

All patients enrolled met standardized criteria for inclusion in the LVR research protocol approved by the Investigational Review Board at both institutions. Inclusion in this study required disabling dyspnea at less than 50 yards with a forced expiratory volume in 1 second of less than 35% predicted. All patients had marked hyperinflation with residual volumes more than 175% predicted and all patients had pulmonary rehabilitation and could ambulate more than 350 yards preoperatively.

Preoperative parameters recorded included age, sex, spirometric valves, plethysmography results, diffusion capacity for carbon monoxide, and exercise testing by 6-minute walk distances. All surgical procedures were performed in an identical fashion with the exception of whether or not bovine pericardial strips were used. The technique was a unilateral thoracoscopic LVR in which the typical resection resulted in a disproportionate resection of the upper lobe to produce a 20% to 30% reduction in the volume of the lung. Areas of resection were guided by preoperative perfusion scans and computed tomographic scans as well as visual intraoperative findings.

Postoperatively chest tubes were removed 24 hours after the last detected air leak. This was determined by a team and patients were evaluated at least twice daily. Patients were followed up to determine the incidence of complications, duration of air leaks, length of intensive care unit and hospital stays, and total hospital charges. Parametric data were analyzed using ² and nonparametric data using the Wilcoxon rank sum test. Statistical significance required a p value of less than 0.05.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Of the 123 patients, 58 were randomized to receive the bovine pericardial sleeves and 65 did not. Table 1 demonstrates that there were no significant differences in any preoperative characteristic between the two groups. Table 2 depicts postoperative complications, which were comparable in the two groups with the notable exception of the duration of postoperative air leak. There were no patient deaths nor were there any patients in whom empyema developed or who were readmitted for pneumothorax. Seven patients were discharged with Heimlich valves, and the chest tube duration included the time the Heimlich valves were in postoperatively as an outpatient. Patients with Heimlich valves were evaluated daily as outpatients in an attempt to define accurately the duration of air leak. There was a statistically significant difference in both chest tube duration (7.9 versus 10.4 days) and hospital days (8.6 versus 11.4 days) favoring the group with the pericardium (Table 3).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The use of bovine pericardial strips has become prevalent in LVR operations despite a lack of objective data demonstrating efficacy. Early series on LVR operations have consistently reported prolonged air leaks (>7 days) in approximately 30% of patients and mean hospital stays of 11 to 18 days whether or not buttressing strips were used [2–6]. These figures combined with the relatively high cost of bovine pericardial sleeves caused us to question their routine use.

Our study population demonstrated no preoperative clinical differences in the two randomized groups. The surgical technique was identical with the exception of the use of the bovine pericardial sleeves. Our results demonstrated that the pericardial sleeve group had a shorter duration of air leaks by 2.5 days and hence a shorter total hospital stay by 2.8 days. This degree of difference in air leak and hospital stay is both clinically and statistically significant. All surgeons who deal with this population of patients recognize their propensity for postoperative complications and would agree that earlier mobilization and discharge are clearly desirable goals. Unfortunately even those patients in the bovine pericardial group had a mean hospital stay of 8.6 days, which is still longer than we would prefer and suggests that further work in this area is required.

Apart from air leak, there were no other differences in the two groups with regard to postoperative complications. Specifically, the infectious complications were not apparently increased in the bovine pericardial group. No empyema developed in any patient in this study. There were no deaths in this study, probably related to both careful patient selection and a large prior experience with this operation.

In our present era no study is complete without cost information. As mentioned, the cost of bovine pericardial strips is significant, averaging $925 (hospital charges) for a package that allows five endoscopic firings. The hospital costs are for the endoscopic 45-mm sleeves that are prepackaged as sleeves. The cost for other staple sizes are the same and hence a longer staple line may be less costly. The mean reduction in hospital stay of 2.8 days helps to offset this financial cost. The average hospital charge in the nonbovine patients for their last 3 days in the hospital was $2,099 (range, $1,454 to $2,988) and the mean hospital charge per patient for the bovine pericardial sleeves was $2,677 (range, $925 to $4,200). This would suggest that the bovine pericardial sleeve group still incurred an increase in hospital charge of $578 per patient in spite of an almost 3-day reduction in total hospital stay. Comparison of the actual hospital charges demonstrated that the mean total charge for the bovine pericardial group was $22,108 (range, $15,817 to $32,856) compared with $22,060 (range, $11,777 to $43,789) for the group not receiving any pericardial buttress strips.

This study was a prospective analysis addressing the impact of pericardial sleeves when LVR operation is undertaken in a "closed" or thoracoscopic fashion. Although it is likely that these results are also indicative of results when LVR is performed in an "open" fashion, it is possible that there are unique factors involved in the thoracoscopic technique that would alter these results. Trauma attributable to tissue handling may differ between the open and closed procedures and there are some minor differences in the types of stapling devices used.

In conclusion, the use of bovine pericardial sleeves is effective in reducing the duration of postoperative air leaks after thoracoscopic unilateral LVR operation. In spite of the reduction in hospital stay the total hospital charges were comparable. The mean hospital stay even with these buttressing sleeves was 8.6 days, clearly leaving room for future improvement. We would currently recommend the routine use of bovine pericardial sleeves in LVR operation because of the marked improvement in air leak duration and hospital stay.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-third Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 7–9, 1996.

Address reprint requests to Dr Hazelrigg, SIU School of Medicine, 800 N Rutledge, PO Box 19230, Springfield, IL 62794-9230.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Wakabayashi A, Brenner M, Kayaleh RA, et al. Thoracascopic carbon dioxide laser treatment of bullous emphysema. Lancet 1991;337:881–3.[Medline]
2. Hazelrigg S, Boley T, Henkle J, et al. Thoracoscopic laser bullectomy: a prospective study with three-month results. J Thorac Cardiovasc Surg 1996;112:319–27.[Abstract/Free Full Text]
3. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106–19.[Abstract/Free Full Text]
4. Keenan RJ, Landreneau RJ, Sciurba FC, et al.. Unilateral thoracoscopic surgical approach for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:308–16.[Abstract/Free Full Text]
5. McKenna RJ Jr., Brenner M, Gelb AF, et al. A randomized prospective trial of stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:317–22.[Abstract/Free Full Text]
6. Naunheim KS, Keller CA, Krucylak PC, Ruppm G, Singh A, Osterloh J. Unilateral video assisted thoracoscopic surgery lung reduction. Ann Thorac Surg 1996;61:1092–8.[Abstract/Free Full Text]
7. Cooper J. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038–9.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stephen R. Hazelrigg Keith S. Naunheim Mitchell J. Magee Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hazelrigg, S. R. Articles by Keller, C. N. Search for Related Content PubMed PubMed Citation Articles by Hazelrigg, S. R. Articles by Keller, C. N.