Covering the staple line with polyglycolic acid sheet versus oxidized regenerated cellulose mesh after thoracoscopic bullectomy for primary spontaneous pneumothorax

Postoperative pneumothorax occurrence in patients with Marfan syndrome

OBJECTIVES

Marfan syndrome is a congenital connective tissue disorder frequently complicated by pneumothorax. However, the long-term efficacy of surgical intervention in these cases remains underreported. This study aimed to assess the surgical outcomes of pneumothorax associated with Marfan syndrome.

METHODS

A retrospective review was conducted at a single center, including patients diagnosed with secondary pneumothorax associated with Marfan syndrome who underwent surgery between 2004 and 2019. Postoperative pneumothorax recurrence rates and potential predictors of postoperative recurrence were assessed. The incidence of ipsilateral pneumothorax after surgery was analyzed and compared with that before surgery.

RESULTS

Overall, 20 patients (60% male, 40% female) with a median age of 18.5 years (range 13-40 years) were included in the analysis. Seventeen patients underwent bullectomy, while the remainder received pulmorrhaphy. The cumulative incidence of postoperative pneumothorax at 5 and 10 years was 25% and 44%, respectively. Notably, patients with pectus excavatum had a 5-year cumulative recurrence rate of 25%, and those with a flat chest had a rate of 60%, compared with 9.1% for patients without chest deformities (P = 0.017). Chest deformity emerged as a significant predictor of postoperative pneumothorax recurrence (hazard ratio 7.63; 95% confidence interval 1.29-45.1; P = 0.025). The frequency of ipsilateral pneumothorax significantly decreased postoperatively, from 1.09 ± 0.66 episodes/year (mean ± SD) pre-surgery to 0.04 ± 0.10 episodes/year post-surgery (P < 0.001).

CONCLUSIONS

Surgical intervention is an effective treatment for pneumothorax in patients with Marfan syndrome. Chest deformity may serve as a predictor of postoperative pneumothorax recurrence in this patient population.

Post-surgery spontaneous pneumothorax: Long-term recurrence rates and follow-up challenges revealed by a written survey

BACKGROUND

Spontaneous pneumothorax (SP) is a frequently encountered respiratory condition. Despite advancements in treatment techniques, there is currently no standardized treatment protocol. The aim of this study was to standardize the management of SP by collecting long-term postoperative data through written surveys.

METHODS

Our study included 673 surgeries performed for SP at our institution between January 2011 and December 2019. We administered written surveys via mail to gather data on post-surgery recurrence rates and other related factors. The survey addressed key symptoms, medical consultations, and specific diagnoses of SP after surgery.

RESULTS

The effective response rate was 70.7%, with significant differences observed across age groups. Among teenagers, the recurrence rate peaked three years postoperatively, with an ipsilateral recurrence rate of 4.8% and a contralateral incidence rate of 11.8%, both of which were significantly higher than those in other age groups. Additionally, age, sex, postoperative contralateral pneumothorax, and the period before the survey were identified as factors influencing the survey results.

CONCLUSION

This survey highlighted the need for long-term postoperative follow-up for teenagers. While written surveys have limitations, this study provided valuable data for understanding the outcomes of SP. Moving forward, it is advisable to conduct surveys using other effective tools or to continue follow-ups in outpatient clinics.

Efficacy of mesh coverage in surgical bullectomy for primary spontaneous pneumothorax: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Thoracic surgeons are now adopting a new method of using a mesh covering to reduce recurrence in surgical pleurodesis for pneumothorax. We aimed to review the literature and compare the outcomes of using mesh covering as an additional procedure during surgical pleurodesis.

METHODS

A comprehensive search was performed from inception to October 2022 on PubMed, Embase, Cochrane and Scopus. Randomised controlled trials (RCTs) and observational cohort studies (OCSs) comparing the use of mesh coverage, and different materials were included. Data were extracted to compare recurrence and other outcomes using a random effect model.

RESULTS

23 studies consisting of 2 RCTs and 21 OCSs totalling 5092 patients were included. Patients with a mesh had a significantly lower recurrence (OR = 0.22, 95% CI 0.12-0.42, p < 0.0001) and a shorter duration of chest tube drainage (SMD = -0.74 days, 95% CI -0.28 to -1.20, p < 0.0001) but no significant difference in the length of operation. The use of polyglycolic acid (PGA) and vicryl mesh was associated with a significantly shorter duration of chest tube drainage [(PGA, SMD = 0.83 days, 95% CI 0.14-1.52, p < 0.0001), (vicryl, SMD = 1.06 days, 95% CI 0.71-2.82, p = 0.0005)]. They also had a shorter post-operative length of stay than oxidized regenerative cellulose (ORC) but this was not statistically significant.

CONCLUSION

The use of a mesh material reduced the incidence of post-operative air leaks in the short term and the recurrence rate in the long term. Some mesh materials such as PGA and vicryl performed better than other materials.

Oxidized Regenerated Cellulose versus Polyglycolic Acid for Pleural Coverage in Pneumothorax Surgery

Objectives: Although surgical intervention for spontaneous pneumothorax (SP) reduces the recurrence rate, thoracoscopic surgery is associated with greater postoperative recurrence rates than open thoracotomy. A polyglycolic acid (PGA) sheet or oxidized regenerated cellulose (ORC) mesh can therefore be used for additional coverage after thoracoscopic surgery, and this study compared the clinical impacts of these two materials. Methods: From 2018 to 2020, 262 thoracoscopic surgeries for primary SP were performed, of which 125 patients were enrolled in this study, and 48 and 77 patients received ORC and PGA coverage, respectively. The clinical characteristics and surgical procedures were reviewed, and the recurrence rates were compared. To obtain more comprehensive evidence, we performed a literature review and meta-analysis comparing ORC and PGA coverage. Results: There were no significant differences in patient characteristics between the two groups. Operating time was slightly shorter in the ORC group than in the PGA group (p = 0.008). The pneumothorax recurrence rate was similar in both groups (PGA: 10.4%, ORC: 6.2%, p = 0.529), but the recurrence-free interval was significantly longer (p = 0.036) in the ORC (262 days) than in the PGA (48.5 days) group. The literature review identified three relevant studies, and the meta-analysis revealed no difference in pneumothorax recurrence rate between the two coverage materials. Conclusions: The two visceral pleural coverage materials, PGA and ORC, did not show significant differences in postoperative pneumothorax recurrence. Therefore, if applied appropriately, the choice of material between ORC and PGA for thoracoscopic pneumothorax surgery does not have a significant impact on the clinical outcome.

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.

Bullectomy used to treat a patient with pulmonary vesicles related to COVID-19: A case report

BACKGROUND

The corona virus disease 2019 (COVID-19) has been a pandemic for more than one year and estimated to affect the whole world in the near future.

CASE SUMMARY

Here we reported that one COVID-19 patient with vesicles was treated by bullectomy. The patient’s perioperative laboratory tests were analyzed. The pathological findings of bullectomy were described and compared with those of common bulla cases.

CONCLUSION

This patient with vesicles underwent bullectomy and had a poor prognosis. He showed diffuse alveolar damage and extensive necrosis in bullectomy specimen. We hope our report will be of interest for clinicians who will treat COVID-19 patients in the future.

Significance of very-low-voltage coagulation plus coverage with polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax

BACKGROUND

The purpose of this study was to clarify the efficacy of the combination of low-voltage coagulation plus staple line coverage with a polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax to prevent a postoperative recurrence.

METHODS

A total of 143 patients who underwent bullectomy for primary spontaneous pneumothorax between January 2014 and December 2019 were enrolled in this study. We classified the patients into two groups based on additional procedures after bullectomy, namely, low-voltage coagulation for the margin of the staple line plus coverage with a polyglycolic acid sheet (Group A) and staple line coverage with a polyglycolic acid sheet alone (Group B). We evaluated perioperative factors and recurrence-free survival after surgery in the two groups.

RESULTS

Nine patients in Group B developed postoperative recurrences. In contrast, there was no postoperative recurrence in Group A. According to the Kaplan-Meier curves, the 2-year recurrence-free survival rates of the patients were 100% and 90.3%, in Group A and Group B, respectively. The log-rank test showed a significant difference between the two groups (p = 0.031).

CONCLUSION

Low-voltage coagulation for the margin of a staple line plus coverage with a polyglycolic acid sheet is a useful option as an additional technique after bullectomy for primary spontaneous pneumothorax to prevent a postoperative recurrence.

Multicentre, prospective, observational study investigating the most appropriate surgical option that can prevent the recurrence of primary spontaneous pneumothorax after surgery: the PATCH study, protocol

INTRODUCTION

Thoracoscopic surgery is performed for refractory or recurrent primary spontaneous pneumothorax (PSP). To reduce postoperative recurrence, additional treatment is occasionally adopted during surgery after bulla resection. However, the most effective method has not been fully elucidated. Furthermore, the preference for additional treatment varies among countries, and its efficacy in preventing recurrence must be evaluated based on settings tailored for the conditions of a specific country. The number of registries collecting detailed data about PSP surgery is limited. Therefore, to address this issue, a prospective multicentre observational study was performed.

METHODS AND ANALYSIS

This multicentre, prospective, observational study will enrol 450 participants aged between 16 and 40 years who initially underwent PSP surgery. Data about demographic characteristics, disease and family history, surgical details, and CT scan findings will be collected. Follow-up must be conducted until 3 years after surgery or in the event of recurrence, whichever came first. Patients without recurrence will undergo annual follow-up until 3 years after surgery. The primary outcome is the rate of recurrence within 2 years after surgery. A multivariate analysis will be performed to compare the efficacy of different surgical options. Then, adverse outcomes correlated with various treatments and the feasibility of treatment methods will be compared.

ETHICS AND DISSEMINATION

This study was approved by the local ethics committee of all participating centres. The findings will be available in 2025, and they can be used as a basis for clinical decision-making regarding appropriate options for the initial PSP surgery.

TRIAL REGISTRATION NUMBER

NCT04758143.

Feasibility of application of an absorbable topical collagen hemostat sheet (INTEGRAN®) for prevention of postoperative recurrence of pneumothorax in youths

Background

Staple-line coverage is an effective method for prevention of postoperative recurrence of pneumothorax. However, the recurrence rate in young patients is still unsatisfactory using this method. Moreover, there is no consensus about the optimal material for use in this technique. To explore new material for this technique, we conducted this study to evaluate the safety of an absorbable topical collagen hemostat (INTEGRAN^®) for staple-line coverage in pneumothorax surgery in young patients.

Methods

A single-arm prospective interventional study was performed in 25 patients (age <25 years old) with primary spontaneous pneumothorax (PSP) who underwent wedge resection with staple-line coverage with INTEGRAN^® between 2017 and 2020. The rate of material-related adverse events (defined as a body temperature ≥38 ℃ continuing for ≥2 days, postoperative WBC >18,000/mm³ and/or CRP >15 mg/dL, or acute empyema within 30 postoperative days) was defined as the primary endpoint. The 1-year postoperative rates of recurrence and of new bullae around the staple-line were also measured.

Results

The median age was 19 years old. None of the patients had a body temperature ≥38 ℃ continuing for ≥2 days, extra-abnormal examination data, and acute empyema findings. At 1-year postoperatively, the recurrence rate was 12.0%, and the rate of new bullae around the staple-line was 16.7%.

Conclusions

This study showed the safety of use of INTEGRAN^® for staple-line coverage in pneumothorax surgery in young adults. The short-term recurrence rate was acceptable given the high-risk cohort examined in the study. A prospective randomized controlled study is needed for evaluation of the efficacy of INTEGRAN^® for prevention of recurrence of PSP.

Trial Registration

UMIN000026530 at UMIN Clinical Trials Registry

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.

Successful Enucleation of a Large Pancreatic Head Schwannoma

A presumed benign cystic tumor in the pancreatic head had been pointed out to a 78-year-old man 4 years ago. In addition to no communication between the tumor and the main pancreatic duct, magnetic resonance imaging showed that the cystic fluid was serous. Gradual tumor enlargement from 2.1 to 4.0 cm urged us to resect the tumor. In order to safely enucleate the tumor, we preoperatively placed a pancreatic duct stent and covered the pancreatic parenchyma with a polyglycolic acid sheet, fibrin glue, and thrombin after tumor enucleation. The patient postoperatively developed grade B pancreatic fistula but recovered with antibiotics therapy. Postoperative computed tomography showed successful preservation of the main pancreatic duct. Pathological study showed a well-defined tumor mainly composed of loosely textured and S-100-positive spindle cells with abundant and hyalinized blood vessels in the cystic walls with palisading spindle cells, leading to the diagnosis of Antoni B schwannoma. The patient was discharged on the 11th day after operation. Both pancreatic duct stunting and covering the exposed pancreatic parenchyma with a polyglycolic acid sheet, fibrin glue, and thrombin are feasible measures to enucleate large benign tumors in the pancreatic head.

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.

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.

Arthroscopic Rotator Cuff Repair With Muscle Advancement and Artificial Biodegradable Sheet Reinforcement for Massive Rotator Cuff Tears

Background

Because high failure rates have frequently been reported after arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (mRCTs), we introduced the technique of ARCR with supraspinatus and infraspinatus muscle advancement (MA). However, for cases where the original footprint cannot be completely covered, additional surgery using an approved artificial biomaterial is performed.

Purpose

To investigate the postoperative clinical outcomes and failure rate after MA-ARCR, with and without our reinforcement technique.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 74 patients (mean ± SD age, 68.7 ± 7.7 years) diagnosed with mRCT with a minimum postoperative follow-up of 2 years were included in the current study. Of these patients, 47 underwent MA-ARCR with polyglycolic acid (PGA) sheet reinforcement (study group), and 27 patients underwent MA-ARCR alone (control group). PGA reinforcement was performed when full coverage of the footprint could not be achieved by MA alone, but where the latter was possible, reinforcement was not required. Thus, the study group had significantly worse muscle quality than the control group (P < .05). The pre- and postoperative range of motion (ROM), isometric muscle strength, acromiohumeral interval, and clinical outcomes were evaluated and compared between these 2 groups. Cuff integrity during the last follow-up period was assessed with magnetic resonance imaging, and the failure rate was calculated. In addition, the postoperative foreign body reaction was investigated in the study group.

Results

In both groups, significant postoperative improvements were seen in acromiohumeral interval, clinical scores, ROM in anterior flexion, and isometric muscle strength in abduction, external rotation, and internal rotation (P < .001 for all). The failure rate of the study group was 12.8% (6 patients) and that of the control group was 25.9% (7 patients). No significant differences were noted between the 2 groups on any of the data findings, even regarding the failure rate. Foreign body reactions in the early period were found in 3 patients, although these spontaneously disappeared within 3 months.

Conclusion

Patients who underwent PGA patch reinforcement for MA-ARCR when the footprint could not be completely covered had clinical results similar to isolated MA-ARCR when the footprint could be covered. Both procedures resulted in significant improvement in symptoms and function compared with preoperatively.

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.