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Ann Thorac Surg 1998;65:217-219
© 1998 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Bovine Pericardium Versus Bovine Collagen to Buttress Staples for Lung Reduction Operations

Chapman Lung Center, Chapman Medical Center, Orange, California, USA

Accepted for publication September 19, 1997.

Dr Fischel, Chapman Lung Center, Chapman Medical Center, 2601 East Chapman Ave, Orange, CA 92687.

	Abstract

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Air leaks after stapled lung volume reduction operations for emphysema remain the most common postoperative complication. Cooper developed the use of bovine pericardium buttress for the staple lines in an attempt to decrease the occurrence of prolonged postoperative air leaks. However, the materials cost for a bilateral procedure may add $3,000 to $4,000 to the cost of the operation. We undertook this study to evaluate the efficacy of a less expensive buttress.

Methods. Fifty-seven patients underwent a bilateral thoracoscopic stapled operation with bovine pericardium (Peri-Strips) on one side and bovine collagen (INSTAT) on the contralateral side to buttress the staples.

Results. The average time to chest tube removal was 8.6 ± 7.2 days for Peri-Strips and 10.7 ± 8.7 days for INSTAT (p = 0.16). No significant differences were seen when right-sided and left-sided application were considered separately (p = 0.12).

Conclusions. Peri-Strips or INSTAT for buttressing staple lines in thoracoscopic stapled bilateral lung volume reduction operations were equally effective. Materials cost savings of up to 80% per case can be realized by using the less expensive but equally effective INSTAT for buttressing staple lines.

	Introduction

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The initial results for the surgical treatment of certain patterns of emphysema appear very encouraging [1][2][3][4][5].

The most common complication after operations for emphysema is a prolonged air leak. After an initial experience with large air leaks on the staple line, Cooper developed the bovine pericardium patch to reduce the air leak [6]. The Peri-Strip patch adds $3,000 to $4,000 to the cost of a bilateral staple operation. This study was designed to compare the efficacy and handling characteristics of a less expensive product (INSTAT; bovine collagen) with Peri-Strips (bovine pericardium), related to this ability to decrease postoperative air leaks.

	Material and Methods

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Fifty-seven consecutive patients at a single institution underwent bilateral thoracoscopic stapled lung volume reduction procedures for heterogeneous bullous emphysema from January 17, 1995, to August 22, 1995. Thirty-six men and 21 women with a mean age of 67.7 ± 7.6 years were symptomatic despite maximal medical management. Chest radiographs showed hyperexpanded lungs with increased anteroposterior dimensions, flattened diaphragms, and apical thinning of pulmonary vessels. Chest computed tomographic scans showed heterogeneous disease with severe emphysematous changes in the upper lobes and relative sparing of middle and lower lobes. Quantitative lung perfusion scans also revealed heterogeneous disease with decreased perfusion to upper lobe areas. Plethysmography showed decreased forced expiratory volume in 1 second less than 35% (mean) and elevated total lung capacity greater than 120% and residual volume greater than 150%. The patient population, pulmonary function tests, and oxygen and steroid dependence profiles were similar to those of our overall population. Average forced expiratory volume in 1 second was 0.88 ± 0.45 L and residual volume was 192% of predicted. Twenty-six of the 57 patients were oxygen dependent preoperatively, and 25 of 57 were steroid dependent.

During a single period of anesthetia, all patients underwent bilateral thoracoscopy for resection of areas of severe emphysematous change. The ELC 60 Stapler (Ethicon, Cincinnati, OH) was used with either Peri-Strips (bovine pericardium; Biovascular, Minneapolis, MN) or INSTAT (collagen absorbable hemostat; Specialty Products Division, Ethicon, Inc, Somerville, NJ) as buttressing material. In each case, one side was completed with a single type of buttressing material whereas the contralateral side used only the other buttressing material. In this manner, each patient acted as his or her own control. The INSTAT was attached to the stapler with Steri-Strips (3M—Medical/Surgical Division, St. Paul, MN), which are easily removed thoracoscopically (Fig 1). The INSTAT is 2 mm thick so it significantly reduces the size of the opening of the endoscopic stapler. Therefore, after the INSTAT was attached to the stapler, it was closed to compress the collagen. This allowed more room to pull the lung tissue into the stapler. The collagen in the jaws was then wet slightly with water to facilitate advancing the lung tissue through the jaws of the stapler. After the stapler was fired, the Steri-Strips were wet with a suction-irrigator to loosen and remove them from the INSTAT (Fig 2). Peri-Strips were attached to the stapler using a paper sleeve preparation. The method of thoracoscopic application is outlined in detail elsewhere [7].

View larger version (1K): [in this window] [in a new window]   INSTAT loaded on ELC 60 Stapler. Notice tab formed on each end of the Steri-Strips to facilitate removal.

View larger version (1K): [in this window] [in a new window]   Endoscopic removal of Steri-Strip leaving INSTAT buttressing material in place.

Statistical analysis was performed using a standard Student’s t test for paired variables with statistical significance occuring at values of p less than 0.05. Test power was calculated with greater than 95% power to detect a 30% difference in the buttressing material.

	Results

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There were three deaths. One patient died of bilateral pneumonia and respiratory failure before removal of chest tubes and therefore was excluded from calculations. One patient died of refractory Clostridium difficile colitis and 1 of starvation after refusing to eat postoperatively. The length of hospital stay was 11.2 ± 7.7 days for the entire group. Twenty patients with Peri-Strips had air leaks lasting more than 7 days, whereas 25 patients with INSTAT had 7-day or greater air leaks. There were no complications in either group that could be attributed to the collagen or pericardium.

Table 1 shows the duration of chest tube drainage for the two materials, and Table 2 shows the cost per case related to the number of units of bovine pericardium or collagen used.

View larger version (1K): [in this window] [in a new window]   Histogram detailing the time to chest tube removal for the study group.

View larger version (16K): [in this window] [in a new window]   Box and whisker plot detailing the time to chest tube removal comparing pericardium and collagen buttressing.

	Comment

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

Initially, the collagen was more difficult to use than the pericardium because the former is thicker and lung tissue slides more easily across the pericardium than across dry collagen. This can be overcome if the stapler is closed after the collagen is in place before insertion of the stapler into the chest. This maneuver will compress the collagen so it does not take up so much of the limited space in the jaw of the stapler. Also, if the collagen is wet slightly with water, the lung slides easily over the materials.

In conclusion, the efficacy of bovine collagen appears to be similar to that of bovine pericardium when used as a buttress to reduce the air leak from a staple line on severely emphysematous lung. Although the physical properties of the pericardium are superior to those of the collagen, the cost is much greater.

In many cases air leaks occur on postoperative days after no air leak was present on leaving the operating room. Also, with direct inspection under thoracoscopic visualization many of the air leaks discovered at the time of the operation do not occur on the staple lines but at distant sites. Both of these occurrences suggest that many of the air leaks encountered in lung reduction operations are related to factors other than the buttress material used. Possible explanations include leaking due to tension placed on surrounding lung tissue, surgical technique, or the postoperative rupture of blebs in these severely emphysematous lungs. This may partially explain the lack of significant differences when using the two different buttressing materials. We have been able to significantly decrease the morbidity associated with prolonged air leaks and eliminate reoperation for air leak with the aggressive and outpatient use of Heimlich valves [8]. It should be noted that with the aggressive use of Heimlich valves to treat air leaks, the small differences seen between buttressing materials would most likely not result in an increased length of hospital stay for our patients.

	Acknowledgments

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Research supported in part by DOE grant DE-F603-91 ER61227, National Institutes of Health grant R01192, and the Heart and Lung Surgery Foundation.

	References

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

1. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106-119.[Abstract/Free Full Text]
2. McKenna RJ, Jr, Brenner M, Gelb A, et al. A randomized prospective trial of stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:317-322.[Abstract/Free Full Text]
3. McKenna RJ, Jr, Brenner M, Fischel R, Gelb A Should lung volume reduction surgery for emphysema be unilateral or bilateral?. J Thorac Cardiovasc Surg 1996;112:1331-1339.[Abstract/Free Full Text]
4. Sciurba FC, Rogers RM, Keenan RJ, et al. Improvement in pulmonary function and elastic recoil after volume reduction surgery for diffuse emphysema. N Engl J Med 1996;334:1095-1099.[Abstract/Free Full Text]
5. Brenner M, McKenna RJ, Jr, Gelb A, et al. Objective predictors of response for staple versus laser emphysematous lung reduction. Am J Respir Crit Care Med 1997;155:295-301.
6. Cooper JD Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038-1039.[Abstract]
7. Fischel RJ, McKenna RJ, Jr, Peters H Thoracoscopic stapled lung reduction surgery for emphysema. Surg Rounds 1996;19:272-278.
8. McKenna RJ, Jr, Fischel R, Brenner M, Gelb A Use of the Heimlich valve to shorten hospital stay after lung reduction surgery for emphysema. Ann Thorac Surg 1996;61:1115-1117.[Abstract/Free Full Text]

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