Ann Thorac Surg 2007;84:1858-1861. doi:10.1016/j.athoracsur.2007.06.080
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Sutureless Pneumostasis Using Polyglycolic Acid Mesh as Artificial Pleura During Video-Assisted Major Pulmonary Resection
Kazuhiro Ueda, MD*,
Toshiki Tanaka, MD,
Mitsutaka Jinbo, MD,
Takaharu Yagi, MD,
Tao-Sheng Li, MD,
Kimikazu Hamano, MD
Department of Surgery and Clinical Science, Division of Chest Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
Accepted for publication June 27, 2007.
* Address correspondence to Dr Ueda, Department of Surgery and Clinical Science, Division of Chest Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan (Email: kaueda{at}c-able.ne.jp).
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Abstract
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Background: Postoperative air leaks impede rehabilitation and prolong hospitalization after pulmonary resection. To promote rehabilitation after video-assisted major pulmonary resection, we attempted to control alveolar air leaks without suturing, using polyglycolic acid mesh as artificial pleura.
Methods: Forty-five patients undergoing video-assisted major pulmonary resection in our institute were enrolled in this study. Pneumostasis was done for intraoperative air leaks, by combining polyglycolic acid mesh with fibrin glue. We removed the chest tube the day after the air leaks stopped.
Results: Pneumostasis was done for intraoperative air leaks in 28 patients. The air leaks stopped immediately, allowing chest tube removal on postoperative day 1 in all but one patient whose air leak took 1 day longer to disappear. The time of chest tube drainage and the postoperative stay were similar in the patients with and those without intraoperative air leaks (mean 1.0 days vs 1.2 days and 6.8 days vs 7.1 days, respectively). The percentage of predicted forced expiratory volume in one second was significantly lower in patients with, than in those without, intraoperative air leaks (p < 0.05).
Conclusions: We achieved sutureless pneumostasis using bioabsorbable artificial pleura during video-assisted major pulmonary resection. This method may contribute to reducing hospitalization, especially in patients with poor pulmonary function.
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Introduction
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Video-assisted thoracic surgery (VATS) is reported to be associated with faster rehabilitation and reduced hospitalization, after major pulmonary resection, than standard thoracotomy [1, 2]. However, although it is less invasive, VATS may be inferior to standard thoracotomy in enabling the surgeon to search for and close alveolar air leaks. According to one retrospective study, the incidence of air leaks, which obviously prolong hospitalization, was higher after lobectomy by VATS than after lobectomy by standard thoracotomy [3]. To control postoperative alveolar air leaks without suturing, we used polyglycolic acid mesh as artificial pleura in patients undergoing major pulmonary resection by VATS.
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Patients and Methods
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Patients
Between April 2006 and March 2007, 45 patients scheduled to undergo major pulmonary resection by VATS at our institute were enrolled in this study. Patients who had undergone prior thoracotomy and those who underwent bronchoplasty were not entered in the study. This study was approved by the Institutional Review Board of the Yamaguchi University School of Medicine. Consent for the study was waived. Operability was determined according to the existing guidelines for pulmonary resection [4]. The criteria for resection included a partial pressure of arterial carbon dioxide 50 mm Hg or less, a mean pulmonary arterial pressure less than 30 mm Hg, and a calculated predicted postoperative forced expiratory volume in 1 second (FEV1) greater than 500 mL. Patient data obtained preoperatively included age, sex, smoking habits, site of resection, and spirometric variables; namely, vital capacity (VC), and % predicted FEV1. Smoking data included pack-years smoked (smoking index: average number of packages of cigarettes smoked per day multiplied by the number of years smoked). The patients’ characteristics are summarized in Table 1.
Two materials were used for the pneumostasis: polyglycolic acid mesh (Neoveil; Gunze, Osaka, Japan), a homopolymer nonwoven fabric with a molecular mass of 100,000; and fibrin glue (Bolheal; Chemo-Sero Therapeutic Institute, Kumamoto, Japan). The fibrin glue we used is composed of solutions A and B. Solution A contains 80 mg/mL human fibrinogen, 75 U/mL human plasma-derived coagulation factor XIII, and 1,000 kinetic isotope effects bovine aprotinin. Solution B contains 250 IU/mL human thrombin and 5.9 mg/mL calcium chloride. Mixing these two solutions forms a fibrin clot within 5 seconds.
Surgical Procedures and Chest Tube Management
A lateral minithoracotomy, 6- to 8-cm long, was made in the fourth or fifth intercostal space, without dissecting the latissimus dorsi muscle. Two or three additional 5- to 10-mm incisions were made in the anterior to posterior axillary line to allow the insertion of a thoracoscope and other instruments. During major pulmonary resection, an endoscopic stapler (Ethicon, Tokyo, Japan) was used to dissect the lung parenchyma, including incomplete fissures, and to excise the bronchus. After major pulmonary resection, a water-seal test was done to ensure pneumostasis. Pneumostasis was carried out without suturing, using fibrin glue and polyglycolic acid mesh, for any air leaks found during the water-seal test, in the following way.
Solution A was spread over the dissected lung parenchyma or stapling line by rubbing it on the surface so that the fibrinogens could penetrate the lung parenchyma. Then, solution B was spread onto the surface to create primary sealing. A piece of polyglycolic acid mesh, about 3 x 3 cm, soaked in solution A, was placed over the sealed lung parenchyma and adhered by dropping solution B onto it. This sealing technique was repeated until all of the dissected area was adhered by the mesh.
A 20F chest tube was placed within the hemithorax, and the wounds were closed. Postoperatively, chest tubes were placed on continuous suction at –10 cm H2O and we checked for any sign of air leak by observing the suction device. If an air leak was detected, the pressure was turned down in increments toward zero (water-seal). Chest tubes were removed the day after the air leak disappeared, regardless of pleural drainage. This management plan was verified in a previous study [5].
Statistical Analysis
The unpaired Student t test was used to test relationships between categoric variables and numeric variables, and the 
2 test was used to compare categoric variables. A p value of less than 0.05 was considered significant.
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Results
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All patients underwent major pulmonary resection by VATS. The operations performed were as follows: right upper lobectomy in 13 patients, right middle lobectomy in four, right lower lobectomy in nine, left upper lobectomy in five, left upper division segmentectomy in seven, left lingula segmentectomy in two, and left lower lobectomy in four. The water-seal test detected an air leak intraoperatively in 28 of the 45 patients. We performed pneumostasis using polyglycolic acid mesh and fibrin glue in all of these 28 patients. We applied 3 mL of fibrin glue, as solution A, and 20 to 100 cm3 polyglycolic acid mesh per patient. Air leaks disappeared immediately after pneumostasis, allowing chest tube removal on postoperative day (POD) 1, in all except one patient whose air leak eventually disappeared later on POD 1. A postoperative air leak was found in two of the 17 patients without any air leak detected intraoperatively. These air leaks disappeared on POD 1 in one patient and on POD 2 in the other patient. The days of chest tube drainage and the length of stay in hospital were similar in the patients with and those without intraoperative air leak (Table 2).
Figure 1
shows the number of days of chest tube drainage required in the patients with and those without an intraoperative air leak (Fig 1). The FEV1 was significantly lower in the patients with an intraoperative air leak than in those without an intraoperative air leak (p = 0.039; Table 2). During postoperative stay, one of the patients who had undergone pneumostasis was found to have subcutaneous emphysema on POD 3, although the chest X-ray showed only minimal pneumothorax. Although a small air leak was found after redrainage, the subcutaneous emphysema resolved and the patient was discharged from hospital on POD 10. Postoperative cardiopulmonary complications developed in two patients; as atrial fibrillation after right upper lobectomy in one and pulmonary embolism after left lower lobectomy in one. After discharge, late air leak occurred in one of the patients who had undergone pneumostasis; the air leak stopped the day after redrainage on POD 12. No other complications associated with sealants were found during the 30-day postoperative period.
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Fig 1. The number of days of chest tube drainage in patients with (n = 28) and those without intraoperative air leak (n = 17). The chest tube was removed on postoperative day 1 in 96% of the patients with an intraoperative air leak, and in 88% of the patients without an intraoperative air leak. This difference was not significant (p = 0.397).
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Comment
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We report on the utility of polyglycolic acid nonwoven fabric in combination with fibrin glue to achieve sutureless pneumostasis after pulmonary resection. However, this combination has been applied in other organ surgery with excellent results, and without any notable adverse reactions; for example, to prevent bile leak after hepatic resection [6], and to prevent cerebrospinal fluid leak after spinal surgery [7].
Although the current series included 19 (42%) patients with an FEV1 less than 70% and 30 (67%) patients with a smoking history, we still successfully controlled air leaks after major pulmonary resection. The method we described may be especially beneficial for patients undergoing VATS because it does not require identifying or suturing of the air leak points: the polyglycolic acid mesh, a stretchable, soft, thin (0.15 mm), and biocompatible material, can be firmly and widely adhered to the dissected lung parenchyma or the stapling line with fibrin glue.
Previously we reported that compromised pulmonary function is associated with prolonged air leak [8], rehabilitation, and hospitalization [9, 10] after major pulmonary resection. Accordingly, in the present study, limited pulmonary function was associated with intraoperative air leaks but it was not associated with prolonged air leak or prolonged hospitalization. This suggests that limited pulmonary function does not prolong hospitalization but postoperative air leaks do; thus, the prevention of postoperative air leaks may shorten hospitalization, especially in patients with limited pulmonary function.
Postoperative cardiopulmonary complications developed in two patients; as atrial fibrillation and pulmonary embolism in one each, respectively, which responded well to medical treatment. There were no major cardiopulmonary complications such as pneumonia or atelectasis, which may prolong hospitalization, in any of the patients in this series. Therefore, further investigation to clarify if the prevention of air leaks after VATS helps to prevent major cardiopulmonary complications is warranted.
We reported closing intraoperative alveolar air leaks using fibrin glue alone in a former prospective series of 62 patients who underwent major pulmonary resection [8]. The duration of chest tube drainage was significantly longer in that series than in the current series (median, 2 days vs 1 day; p < 0.01; Fig 2), although the FEV1 value in the former series was similar to that in the current series (mean, 74 ± 13% vs 72 ± 11%; p = 0.54). Thus, we believe that the addition of polyglycolic acid mesh to fibrin glue contributed greatly to the successful control of alveolar air leaks.
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Fig 2. Comparison of the number of days until chest tube removal in patients who underwent pneumostasis with fibrin glue alone (solid line, n = 62) and those who underwent pneumostasis with fibrin glue plus polyglycolic acid mesh (dotted line, n = 45). Two patients required postoperative intervention for pulmonary complications before chest tube removal (open circles). The median time until chest tube removal was two days in the fibrin glue alone group versus one day in the fibrin glue plus polyglycolic acid mesh group. There was a significant difference between the time until chest tube removal curves (log-rank test, p < 0.01).
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The optimal way to dissect pulmonary parenchyma and prevent postoperative air leak in every patient remains unclear. According to our experience, simple dissection using an electric scalpel followed by sealing with fibrin glue may be sufficient in patients with normal lung structure, whereas dissection using an endoscopic stapler followed by sealing with fibrin glue in combination with a mesh sheet may be advisable for patients with moderate to severe pulmonary emphysema. The strategy should be determined in accordance with the lung structural abnormality as evaluated by computed tomography. We reported previously that alveolar air leaks persist postoperatively in accordance with the extent of the low-attenuation area, determined by quantitative computed tomography, especially in patients with a smoking history [8].
In conclusion, we achieved sutureless pneumostasis successfully using bioabsorbable mesh in combination with fibrin glue during major pulmonary resection by VATS. This technique may contribute to shorter hospitalization, especially in patients with poor pulmonary function.
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References
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- Sugawara T, Itoh Y, Hirano Y, et al. Novel dural closure technique using polyglactin acid sheet prevents cerebrospinal fluid leakage after spinal surgery Neurosurgery 2005;57:290-294.[Medline]
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Abstract
Introduction
