Efficacy and safety of TachoSil versus standard treatment of air leakage after pulmonary lobectomy

Objectives: Alveolar air leakage remains a serious problem in lung surgery, being associated with increased postoperative morbidity, prolonged hospital stay and greater health-care costs. The aim of this study was to evaluate the sealing efficacy and safety of the surgical patch, TachoSil^®, in lung surgery. Methods: Patients undergoing elective pulmonary lobectomy who had grade 1 or 2 air leakage (evaluated by the water submersion test) after primary stapling and limited suturing were randomised at 12 European centres to open-label treatment with TachoSil^® or standard surgical treatment (resuturing, stapling or no further treatment at the surgeons’ discretion). Randomisation was performed during surgery using a centralised interactive voice response system. Duration of postoperative air leakage (primary end point), reduction of intra-operative air leakage intensity (secondary end point) and adverse events (AEs), including postoperative complications, were assessed. Results: A total of 486 patients were screened and 299 received trial treatment (intent-to-treat (ITT) population: TachoSil^®, n = 148; standard treatment, n = 151). TachoSil^® resulted in a reduction in the duration of postoperative air leakage (p = 0.030). Patients in the TachoSil^® group also experienced a greater reduction in intra-operative air leakage intensity (p = 0.042). Median time until chest drain removal was 4 days with TachoSil^® and 5 days in the standard group (p = 0.054). There was no difference between groups in hospital length of stay. AEs were generally similar in both groups, including postoperative complications. Conclusions: TachoSil^® was superior to standard surgical treatment in reducing both postoperative air leakage duration and intra-operative air leakage intensity in patients undergoing elective pulmonary lobectomy.     

Efficiency of fleece-bound sealing (TachoSil) of air leaks in lung surgery: a prospective randomised trial.

OBJECTIVE: Persistent air leakage following pulmonary resection is a major limiting factor for discharge from hospital. The aim of this study was to evaluate the sealing capacity of TachoSil for the closure of alveolar air leaks following parenchymal resections and to determine its effect on time to chest drain removal and duration of hospitalisation. Methods: A total of 173 patients undergoing lobectomy or segmentectomy were enrolled in a single-centre, randomised study to compare the efficacy of TachoSil with standard treatment. Alveolar air leaks were evaluated intraoperatively by submersion of the resection site in saline and were graded according to the Macchiarini scale as 0 (no bubbles), 1 (single bubbles), 2 (stream of bubbles), 3 (coalescent bubbles). Patients with grade 1 or 2 air leaks were randomised to TachoSil or standard treatment. Grade 3 patients received standard treatment until the air leak was downgraded to grade 1 or 2 at which point they were randomised. Patients with grade 0 leakage were excluded. The primary efficacy endpoints of the study were postoperative quantification of air leakage on postoperative days 1 and 2. Other efficacy measurements included mean time to chest drain removal and mean time to hospital discharge. Results: The mean intraoperative post-treatment air leakage was significantly lower in the TachoSil group (153.32ml/min, range: 10-450ml/min) compared with the standard treatment group (251.04ml/min, range: 15-970ml/min; P=0.009). The significant difference in air leakage volume observed intraoperatively post-treatment was maintained postoperatively. TachoSil showed a trend towards reduced incidence of postoperative leakage when measured >48h or >7 days after surgery (30.7% vs 38.96% and 24% vs 32.46%, respectively). The mean times to chest drain removal and to hospital discharge were significantly reduced following the use of TachoSil (5.1 days vs 6.3 days, P=0.022 and 6.2 days vs 7.7 days, P=0.01, respectively). Conclusions: The use of TachoSil following pulmonary resection resulted in a reduction in air leakage compared with standard techniques. This reduction in air leakage resulted in a significant reduction in both the time to chest drain removal and the period of hospitalisation.     

The sealing effect of fibrin glue against alveolar air leakage evaluated up to 48 h; comparison between different methods of application.

OBJECTIVE: There is little experimental evidence to show how much positive airway pressure fibrin sealants can actually withstand, and in particular, how this effect changes over time. In the present study, we experimentally evaluated the sealing effect of fibrin glue against alveolar air leakage up to 48 h after application. METHODS: Beagles were used (n = 48). Under thoracotomy, approximately 5 x 10 mm defects (2 mm depth) were made on the lung surface. Fibrin glue sealants were applied to this defect in three ways. In rubbing and spray method, fibrinogen was rubbed, followed by spraying of both fibrinogen and thrombin solutions. In double layer method, fibrinogen was dripped, followed by thrombin. Collagen fleece, coated with fibrinogen and thrombin (TachoComb) was also tested. The minimum positive airway pressure which produced air leakage was measured for each sealed defect (seal breaking pressure, cmH2O) at 0, 3, 6, 12, 24, and 48 h after application (n = 6 at each time point). RESULTS: The seal-breaking pressure increased over time in all of the application methods. At 6 h, differences between methods were not significant but three defects in RS reached 70 cmH2O, the maximum pressure tested, compared with none in other two methods. At 12h, the seal-breaking pressure was significantly higher in RS compared with the other two methods (rubbing and spray method vs TachoComb; 66+/-3 vs 47+/-17, P = 0.047, rubbing and spray method vs double layer method; 66+/-3 vs 42+/-18, P = 0.024). Beyond 24 h, sealing pressure reached close to 70 cmH2O in all the methods. CONCLUSIONS: The results show that the sealing effect of fibrin glue is relatively unstable up to 12h after its application. Rubbing and spray method may help the fibrin seal to reach its full strength faster compared with the other two methods.     

Prospective comparison between endosuturing and endostapling in treating primary spontaneous pneumothorax

OBJECTIVE: Direct management of ruptured pulmonary blebs remains the definitive treatment for spontaneous pneumothorax. We compared endosuturing and endostapling performed via thoracoscopy to determine if suture closure of the blebs without resection was sufficient to treat primary spontaneous pneumothorax. METHODS: Nine female and forty-nine male prospective patients were prospectively enrolled into two groups between July 1999 and May 2003. The patients in the suturing group were treated with an endoscopic suturing technique to close existing blebs. Patients in the stapling group underwent endoscopic stapling to excise the blebs. Only three ports were needed for each procedure. RESULTS: Neither group experienced mortality or any major morbidity. There were no significant clinical differences between the suturing and stapling groups. The intra-operative blood loss was not significantly different (32.9+/-53.9 and 13.6+/-21.8 mL, respectively, P = 0.079). The duration of pleural drainage was not statistically significant (2.7+/-1.2 and 2.3+/-2.0 days, respectively, P = 0.369). The length of postoperative hospital stay was also not statistically significant (4.2+/-1.5 and 3.8+/-2.4 days, respectively, P = 0.386). However, the operative time was significantly longer in the suturing group (135.0+/-53.8 and 89.0+/-35.6 minutes, respectively, P < 0.05). In each group, there were two cases of recurrence during the 21.5+/-12.1 month followup period, all of which recovered well after retreatment. CONCLUSIONS: We believe that this is the first prospective study on thoracoscopic suture closure of blebs. By imbricating and buttressing the blebs without resection, the endosuturing method represents an effective way to treat primary spontaneous pneumothorax.     

Clinical managements for intractable pneumothorax with interstitial pneumonia

Intractable pneumothorax with interstitial pneumonia (IP) is famous for the disease finally to lead to death in case of persistent air leakage. It is because severe infection, respiratory insufficiency and tissue healing insufficiency by treatments with steroid hormones and immune-suppressants on IP. Pleurodesis is generally performed although the effect of it is questionable. It is important to stop immune-suppressants and reduce steroid hormones before the treatments to succeed in thoracoscopic surgery and thoracographic fibrin glue sealing method (TGF) if possible. Less invasive interventional treatments like TGF are recommendable because intractable pneumothorax with IP is in the high risk group to need to avoid surgery. Hand suturing, looping, covering and putting TachoComb on the air leak point instead of end-stapling should be performed in order to stop air leakage when forced to choose thoracoscopic surgery.     

Discharge independence with minimally invasive lobectomy

BACKGROUND: The effects of video-assisted thoracic surgery (VATS) pulmonary lobectomy on after-hospital care are not well known. METHODS: In a retrospective case-control study, 20 consecutive VATS cases were matched to 38 standard thoracotomies (open cases). RESULTS: Ages were 73.8 +/- 7.8 years with no initial differences between the groups. No hospital deaths occurred. Excluding 2 VATS and 6 open outliers, VATS cases had fewer hospital days (4.6 +/- 1.9 vs. 6.4 +/- 2.2, P <0.01), chest tube days (3.0 +/- 1.1 vs. 4.2 +/- 1.7, P = 0.01), and prolonged pain complaints (28% vs. 56%, P = 0.05). Transfer to care facilities or home nursing support was needed for 63% of open patients and only 20% of VATS patients (P = 0.015). Less personal care (10% vs. 21%), wound/medical care (0% vs. 13%), occupational/physical therapy (5% vs. 13%), or other home support (5% vs. 18%) was needed for VATS patients. CONCLUSIONS: In older populations, more independence and fewer resources after discharge favor VATS lobectomy over standard thoracotomy.     

Effect of fibrin glue on air leak and length of hospital stay after pulmonary lobectomy

AIM: Air leaks are a common cause of morbidity and prolonged hospital stay after pulmonary lobectomy. We reviewed our experience with intraoperative fibrin glue to determine if it reduced air leak and improved patient outcomes. METHODS: Records of patients undergoing pulmonary lobectomy for benign or malignant disease over a 4-year period (1998-2001) were reviewed. Data was collected on age, sex, pulmonary function, pulmonary pathology, use of fibrin glue, duration of chest tube drainage, length of hospital stay, and postoperative complications. RESULTS: Three hundred and sixty patients underwent lobectomy. Fibrin glue was used intraoperatively to seal air leaks in 102 of the 360 patients (study group: 102;control group: 258). Fibrin glue was used at the discretion of the surgeon, with some surgeons using it routinely. The groups did not differ in age (p=0.29), sex (p=0.42), FEV1 (p=0.57), or pathology (p=0.08). There were no differences in outcomes such as operative mortality (study: 2 of 102, control 6 of 258, p=0.85), empyema (study: 0 of 102, control: 3 of 258, p=0.55), prolonged (>7 days) air leaks (study: 10 of 20; control: 20 of 258, p=0.71), or length of hospital stay (study: 6.3+/-2.5 days, control:7.7+/-7.2 days, p=0.83). The use of fibrin glue was associated with a reduction in the duration of chest tube intubation (study: 4.1+/-3.2 days, control: 5.5+/-3.8 days, p=0.001). CONCLUSION: Patients treated intraoperatively with fibrin glue had a significantly shorter duration of chest tube intubation after pulmonary lobectomy than those treated conventionally. However, the use of fibrin glue did not significantly influence more clinically relevant outcomes such as length of hospital stay and incidence of prolonged (>7 days) air leaks.     

The effect of autologous fibrin sealant (Vivostat) on morbidity after pulmonary lobectomy: a prospective randomised, blinded study

Objective: Postoperative air leakage is the most frequent complication after pulmonary surgery. The development of modern surgical techniques has been influenced strongly by the need to manage air leakage effectively during pulmonary resection. This study evaluated the effect of using an autologous fibrin sealant (Vivostat^®) during lobectomy on morbidity following surgery. Methods: This was a prospective, blinded, randomised clinical study. Patients undergoing lobectomy were enrolled into two groups (Vivostat or non-treatment control, 20 per group). Air leakage was measured over a 1-h period (using a mechanical suction pump) on the day of operation, and both air leakage and bleeding/exudation (drainage volume) were recorded every morning postoperatively until the chest tubes were removed. Personnel recording these parameters were blinded to the intervention received. Results: Compared with the control group, mean bleeding/exudate volumes were significantly reduced in the Vivostat group (day 1, 370 vs. 525 ml; total, 424 vs. 782 ml; both P<0.001), and drains were inserted for a shorter time (medians, 1 vs. 2 days, P=0.07). Significantly fewer patients had air leakage at any time in the Vivostat group (40 vs. 80%, P=0.02), and air leakage volumes were significantly lower compared with the control group (median differences: day of surgery: 0.6 l/min, P=0.01; total 0.8 l/min, P=0.03). Postoperative hospitalisation time was shorter in the Vivostat group than in the control group but the difference was not significant (0.5 days, P=0.12). Conclusions: Vivostat fibrin sealant significantly reduces post-surgical air leakage and drainage volumes following lobectomy in pulmonary surgery and is suitable for routine use in this procedure.     

Pleural defect repair with an overlapping method using fibrin glue-coated collagen fleece

Purpose  

Collagen fleece coated with fibrin glue (TachoComb; CSL Behring, Tokyo, Japan) is a tissue adhesive and sealant used to stop hemorrhage and air leakage. We assessed the efficacy of overlapping methods combined with the use of TachoComb to repair pleural defects.     

Harmonic Curved Shears System Prevent of Bile Leakage After Liver Resection in a Pig Model

We evaluated the efficacy of TachoComb (TC) collagen fleece and Harmonic Focus (HF) shears in a pig liver resection model. Pigs were divided into 3 groups of 7, in which vessels were tied with silk and TC was applied to the cut surfaces (Silk+TC group), sealed and sheared with HF and TC (HF+TC group), or sealed using HF alone (HF–TC group). After 1 month, we conducted a histologic evaluation and recorded the incidence of bile leakage with infected collections at the liver cut surface. Six pigs were evaluated in each group. In the Silk+TC group, 4 of the 6 pigs had infected collections at the cut surface. Histologically, the silk had remained under the fibrotic tissue, which contained remnants of TC fragments. In the HF+TC group, 5 of the 6 pigs also had infected collections, and histologically, TC had remained in the hard fibrotic tissues. In the HF–TC group, none of the 6 pigs had infected collections, and the histologic findings were normal. Use of the HF alone may be an effective method for preventing bile leakage in infected collections after liver resection.Key words: Shears system, Fibrinogen sheet, Liver resection, Pig, BilomaSome liver centers commonly use collagen fleece with fibrin glue [TachoComb (TC) or TachoSill (TS) (CSL Behring, Tokyo, Japan)] to prevent bleeding during and after hepatectomy.^1–3 However, it is still unclear whether TC is effective for preventing bile leakage from the cut surface of the liver. In recent years, the harmonic curved shears system has been widely used in laparoscopic surgery, and some reports have shown that it is effective for compressing small vessels and lymph ducts, thus preventing lymphorrhea after lymph node dissection.⁴ In liver surgery, clamp crushing or a Cavitron Ultrasonic Surgical Aspirator (CUSA, Tyco Healthcare, Mansfield, Massachusetts) is commonly used during liver transection, and small vessels are usually tied with silk or sealed with vessel clips to prevent bile leakage and small-scale bleeding. The harmonic curved shears system (Harmonic Focus Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) is a new technology for vessel sealing and has not been evaluated for liver parenchymal transection in terms long-term morbidity after surgery.We report the results of a study we conducted to assess the efficacy of TC and Harmonic Focus (HF) shears in a pig liver resection model.     

Pleural tenting following upper lobectomies or bilobectomies of the lung to prevent residual air space and prolonged air leak.

OBJECTIVE: Apical residual air space and prolonged air leak are not uncommon entities following resection of upper lobe of the lung. This study was carried out to observe the efficacy of pleural tenting in preventing these problems. METHODS: This is a prospective randomised study. Pleural tenting after upper or upper and middle lobectomies was performed in 20 patients. In another 20 patients who underwent upper lobectomy or bilobectomy, pleural tenting was not performed. Both groups were compared in respect to durations of postoperative chest tube drainage and hospital stay, amount of total pleural drainage, and the presence of need for any additional intervention for prolonged air leak. RESULTS: Age, sex, pathology and pulmonary function tests of two groups were similar. Duration of chest tube drainage was shorter in whom pleural tenting was performed when compared to whom pleural tenting was not performed (4.3+/-0.16 days versus 7.40+/-0.68 days, P<0.0001). Mean hospital stay was shorter in tented group (7.60+/-0.4 days versus 9.35+/-0.6 days, P=0.024). Although the mean amount of total pleural drainage was less in tented group (667.5+/-57.7 ml versus 802.5+/-83.3 ml, P=0.1911), the difference was not statistically significant. Three (15%) patients in non-tented group needed an apical chest tube insertion in postoperative period for prolonged air leak with an apical pleural space. Asymptomatic apical residual space was observed in 3 patients in tented group. There was no morbidity in patients in tented group. CONCLUSION: Pleural tenting following upper lobectomy or bilobectomy of the lung shortens the duration of chest tube drainage and hospital stay, and it prevents apical residual air spaces and related complications. Pleural tenting is safe and relatively simple procedure, which has no associated morbidity.     

Sealing of the mediastinum with a local hemostyptic agent reduces chest tube duration after complete mediastinal lymph node dissection for stage I and II non-small cell lung carcinoma

BACKGROUND: We assessed the impact of coverage of the mediastinum with a local hemostyptic agent as well as the impact of perioperative thromboembolic prophylaxis on cumulative chest drain volume and on the duration of chest tubes after surgical resection with complete mediastinal lymph node dissection for stage I or II non-small cell lung cancer. METHODS: In a prospective, randomized two-by-two factorial design, 80 patients with clinical stage I or II non-small cell lung cancer were allocated to one of two surgical therapy arms (TachoComb or conventional surgical hemostasis) and one of two anticoagulation arms (enoxaparin 4,000 IU or dalteparin 5,000 IU). Primary end point was cumulative chest drain volume; secondary end point was duration of chest tubes. Additionally clinical data were obtained. RESULTS: Comparison of the surgical arms revealed significantly lower cumulative chest drain volumes and thereby an earlier chest tube removal in the TachoComb group (p = 0.045). With regard to thromboembolic prophylaxis, a significantly earlier chest tube removal was found for patients treated with dalteparin (p = 0.039). Analysis of the interaction of surgical and anticoagulation treatment revealed the combined use of TachoComb and dalteparin was superior to other combinations (cumulative chest drain volumes 498 +/- 67 mL versus 1,000 +/- 88 mL, 924 +/- 87 mL, and 895 +/- 118 mL; p = 0.008; mean duration of chest tubes 1.78 +/- 0.15 days versus 2.96 +/- 0.21 days, 2.93 +/- 0.17 days, and 3.06 +/- 0.27 days; p = 0.019). CONCLUSIONS: The combined use of a local hemostyptic agent and dalteparin seems superior as compared with other regimens of hemostasis and thromboembolic prophylaxis in patients undergoing surgical resection and complete mediastinal lymph node dissection for stage I and II non-small cell lung cancer with regard to cumulative chest drain volume as well as duration of chest tubes.     

Improvement of pulmonary function after lobectomy for non-small cell lung cancer in emphysematous patients.

OBJECTIVE: Pulmonary emphysema is frequently associated with lung cancer and, because of the impaired pulmonary function involved, it may contraindicate surgical treatment. However, improvement of pulmonary function has been observed after surgical resection in patients with advanced emphysema. The aim of this study was to evaluate whether pulmonary emphysema, as assessed by pulmonary function tests and radiological evaluation, can influence postoperative respiratory function after lobectomy for non-small cell lung cancer (NSCLC). METHODS: Respiratory function was evaluated before and after lobectomy for NSCLC. Radiological evaluation of emphysema was performed on chest X-ray and CT scan. Patients that had undergone chemo- or radiotherapy or had segmental or lobar atelectasis were excluded from the study. RESULTS: Thirty-five patients entered the study. A decrease in static lung volumes was observed after surgery. Total lung capacity (TLC) decreased from 6.58+/-0.92 to 5.46+/-0.77 l; functional residual capacity (FRC) from 3.70+/-0.88 to 2.96+/-0.73 1 and residual volume (RV) from 2.93+/-0.78 to 2.2+/-0.53 l. However, in a subgroup of 10 patients (Group 1), dynamic volumes after surgery were unchanged or slightly increased (forced vital capacity (FVC) from 3.23+/-0.65 to 3.3+/-0.68 l; forced expiratory volume in 1 s (FEV1) from 2.14+/-0.51 to 2.25+/-0.54 l), and airway resistances (sRaw) decreased from 15.58+/-5.18 to 11.42+/-5.25 cm H2O/s. Preoperative data showed that these patients had a greater obstruction, with FEV1 changing from 69+/-12.42 to 72.70+/-13.72% of predicted, as compared with a change from 87+/-12.7 to 72.08+/-13.10% in the other group of 25 patients (Group 2). Correlation analysis reached statistical significance between FEV1% variation (deltaFEV1%) and preoperative FEV1 and FVC% (r = -0.49, P = 0.002 and r = -0.5, P = 0.001, respectively) and between delta (FEV1)% and radiological scores for 3-level CT (r = 0.39, P = 0.04) and the sum of chest X-ray, single and 3-level CT scores (r = 0.49, P = 0.01). CONCLUSIONS: Pulmonary function may remain unchanged or even increase after lobectomy in patients with a pronounced emphysematous component of airway obstruction. The identification of preoperative parameters that identify this group of patients could extend the indications for the treatment of lung cancer in patients with pulmonary emphysema.     

Pentoxifylline reverses oxidative mitochondrial defect in claudicating skeletal muscle.

OBJECTIVE: Previous morphologic studies and phosphorus nuclear magnetic resonance spectroscopy (31P MRS) have suggested a primary mitochondrial defect in claudicating skeletal muscle. We hypothesized that pentoxifylline may alleviate this defect. METHODS: The response of calf muscle bioenergetics to pentoxifylline was evaluated in 10 male, nondiabetic claudicants with 31P MRS and standard treadmill testing before and after 12 weeks of pentoxifylline therapy. Phosphocreatine (PCr) and adenosinodiphosphate (ADP) recovery rate constants, two very sensitive measures of oxidative mitochondrial function, were measured. RESULTS: Seven of the 10 subjects had abnormal baseline PCr (<0.015 s(-1)) and ADP (<0.024 s(-1)) recovery rate constants. These 7 had significant improvement in mitochondrial function with pentoxifylline; their PCr recovery rate constants increased from 0.009 +/- 0.002 to 0.013 +/- 0.002 s(-1) (P = 0.013) and their ADP recovery rate constants increased from 0.015 +/- 0.002 to 0.022 +/- 0.002 s(-1) (P = 0.004). The remaining 3 patients had normal baseline constants and demonstrated no improvement after pentoxifylline therapy. Baseline PCr and ADP recovery rate constants inversely correlated with their corresponding percentage of improvement after pentoxifylline (P < 0.05). In addition the percentage of improvement in the PCr and ADP recovery rate constants correlated with the percentage of improvement in initial claudication distance and maximum walking capacity (P < 0.05). CONCLUSIONS: Pentoxifylline improves the mitochondriopathy of claudicating muscle, producing the most improvement in limbs with the worse baseline mitochondrial function. These results point to a potential new mode of action for pentoxifylline in the treatment of claudication and identify a subgroup of patients with the best potential for improvement with treatment.     

The clinical application of a new method for sealing the cut surface of lung using the photopolymerized synthetic bioabsorbable hydrogel (Advaseal)

We report a case of 67-years-old male, who suffered right upper lobectomy for primary lung cancer. The upper-middle interlobar surface of right lung was incomplete interlobe. Many air leakages were noted in the cut surface of upper-middle interlobe during the sealing test. We sealed this cut surface of upper-middle interlobe by using the photopolymerized synthetic bioabsorbable hydrogel (Advaseal). Air leakage was not noted during the sealing test, and no leakage was not noted after operation. We have observed no biological toxicity (such as cytotoxicity, hemolytic toxicity, systemic toxicity or mutagenic toxicity) by using Advaseal. The new photopolymerized synthetic bioabsorbable hydrogel (Advaseal) is a effective sealant against pulmonary air leaks in the cut surface of the lung.     

Ruptured abdominal aortic aneurysms in community practice: age and operative variables predict survival

Our objective is to determine if the mortality and functional outcome of patients with ruptured abdominal aortic aneurysms treated at community hospitals is more a function of patient factors and comorbidities or hospital system and surgeon-controlled variables. We used a retrospective review of all patients with infrarenal ruptured abdominal aortic aneurysms treated at three large community hospitals in Chicago from 1996 to 2005. There was an overall 58 per cent mortality rate. There was a statistically significant difference in the age of those who lived (69 +/- 9.8) and those who died (78 +/- 7.9, P = 0.0005). Mortality was found to increase with each increasing decade of life. None of the patients from age 50 to 60 died, whereas 44 per cent of the patients from 61 to 70, 65 per cent of those 71 to 80, 64 per cent of those 81 to 90, and 100 per cent of those older than 90 died. There was an increased hazard ratio of 10.9 times the risk of mortality once a patient became older than age 70 (P = 0.02). Intra-operative variables did influence survival: duration of surgery (lived 230 +/- 78 minutes, died 324 +/- 130 minutes, P = 0.006), intra-operative blood loss (lived 1894 +/- 1014 mL, died 5692 +/- 3018 mL, P = 0.00003), and blood transfusion (lived 6.7 +/- 2.8 units, died 10.5 +/- 3.7 units, P = 0.0006). Age and intra-operative factors play a major role in the survival or mortality of patients with ruptured abdominal aortic aneurysms. Short operative time combined with minimizing blood loss and transfusion requirements improve survival, especially in the elderly.     

Effect of routine fibrin glue use on the duration of air leaks after lobectomy

The effectiveness of fibrin glue as a sealant to reduce postoperative air leaks after pulmonary lobectomy was evaluated in 28 consecutive patients between November 1988 and May 1989. A fibrin glue spray was used in 14 patients, and 14 patients served as controls. Assignment of either group was made before thoracotomy. Nine male and 5 female patients with a mean age of 63.8 years were in the fibrin glue experimental group, and 8 male and 6 female patients with a mean age of 59 years, in the control group. An equal number of complete and incomplete fissures were in each group. All fissures were handled in the same way (stapled). Two milliliters of fibrin glue was applied through a double-syringe delivery system and sprayed on the staple line and any cut surface of the inflated lung just before thoracotomy closure. The fibrin glue-treated group had a mean air leak duration of 2.3 +/- 3.7 days, chest tube drains for 6 +/- 4.1 days, and a postoperative hospitalization of 9.8 +/- 3.1 days. The control group had a mean air leak duration of 3.3 +/- 3.3 days (p = 0.94), chest tube drains for 5.9 +/- 3.9 days (p = 0.95), and a postoperative hospitalization of 11.5 +/- 3.9 days (p = 0.21). We conclude that the routine use of a fixed quantity of fibrin glue is not effective in reducing the duration of air leaks, chest tube drainage, or hospitalization after uncomplicated pulmonary lobectomy.     

Hypoglossal-facial nerve anastomosis in the rabbits using laser welding

The aim of this study is to compare laser nerve welding of hypoglossal-facial nerve to microsurgical suturing and a result of immediate and delayed repair, and to evaluate the effectiveness of laser nerve welding in reanimation of facial paralysis of the rabbit models. The first group of 5 rabbits underwent immediate hypoglossal-facial anastomosis (HFA) by microsurgical suturing and the second group of 5 rabbits by CO2 laser welding. The third group of 5 rabbits underwent delayed HFA by microsurgical suturing and the fourth group of 5 rabbits by laser nerve welding. The fifth group of 5 rabbits sustained intact hypoglossal and facial nerve as control. In all rabbits of the 4 different groups, cholera toxin subunit B (CTb) was injected in the epineurium distal to the anastomosis site on the postoperative sixth week and in normal hypoglossal nerve in the 5 rabbits of control group. Neurons labeled CTb of hypoglossal nuclei were positive immunohistochemically and the numbers were counted. In the immediate HFA groups, CTb positive neurons were 1416 +/- 118 in the laser welding group (n = 5) and 1429 +/- 90 in the microsurgical suturing group (n = 5). There was no significant difference (P = 0.75). In the delayed HFA groups, CTb positive neurons were 1503 +/- 66 in the laser welding group (n = 5) and 1207 +/- 68 in the microsurgical suturing group (n = 5). Difference was significant (P = 0.009). There was no significant difference between immediate and delayed anastomosis in the laser welding group (P = 0.208), but some significant difference was observed between immediate and delayed anastomosis in the microsurgical suturing group (P = 0.016). Injected CTb in intact hypoglossal neurons (n = 5) were labeled 1970 +/- 165. No dehiscence was seen on the laser welding site of nerve anastomosis in all the rabbits as re-exploration was done for injection of CTb. This study shows that regeneration of the anastomosed hypoglossal-facial nerve was affected similarly by either laser welding or microsurgical suturing in immediate repair; however, the welding was more effective especially in delayed repair.     

Pulmonary function after segmentectomy for small peripheral carcinoma of the lung.

OBJECTIVE: The aim of this study is to compare the pulmonary function after a segmentectomy with that after a lobectomy for small peripheral carcinoma of the lung. Patients And Methods: Between 1993 and 1996, segmentectomy and lobectomy were performed on 48 and 133 good-risk patients, respectively. Lymph node metastases were detected after the operation in 6 and 24 patients of the segmentectomy and lobectomy groups, respectively. For bias reduction in comparison with a nonrandomized control group, we paired 40 segmentectomy patients with 40 lobectomy patients using nearest available matching method on the estimated propensity score. RESULTS: Twelve months after the operation, the segmentectomy and lobectomy groups had forced vital capacities of 2.67 +/- 0.73 L (mean +/- standard deviation) and 2.57 +/- 0.59 L, which were calculated to be 94.9% +/- 10.6% and 91.0% +/- 13.2% of the preoperative values (P =.14), respectively. The segmentectomy and lobectomy groups had postoperative 1-second forced expiratory volumes of 1.99 +/- 0.63 L and 1.95 +/- 0.49 L, which were calculated to be 93.3% +/- 10.3% and 87.3% +/- 14.0% of the preoperative values, respectively (P =.03). The multiple linear regression analysis showed that the alternative of segmentectomy or lobectomy was not a determinant for postoperative forced vital capacity but did affect postoperative 1-second forced expiratory volume. CONCLUSION: Pulmonary function after a segmentectomy for a good-risk patient is slightly better than that after a lobectomy. However, segmentectomy should be still the surgical procedure for only poor-risk patients because of the difficulty in excluding patients with metastatic lymph nodes from the candidates for the procedure.     

A new minimized perfusion circuit provides highly effective ultrasound controlled deairing

Minimized perfusion circuits (MPCs) have been criticized for insufficient air elimination. The deairing capabilities of a new MPC, including an ultrasound controlled deairing unit, were compared to a standard extracorporeal circuit (ECC) in a laboratory setup. During blood flow of 4.0l/min, we injected 30-cc air over a period of 30 s into the venous line of both systems (n = 10 measurements/15-min intervals). Air was detected during the first 2 min post injection using a dual-channel ultrasound bubble counter. Venous air bubble measurements were made after the MPC bubble trap and the ECC hard-shell reservoir, respectively. Arterial air bubble data were obtained after the arterial filters (40 microm). Venous bubble count was significantly (P < 0.01) reduced in the MPC group (5-250 microm, 681 +/- 177; >40 microm, 288 +/- 92) compared with the ECC group (5-250 microm, 19 272 +/- 682; >40 microm, 7642 +/- 520). After the arterial filter, minimal numbers of air bubbles (5-250 microm, 172 +/- 59; >40 microm, 0) could be detected in the MPC group, but large amounts of air (5-250 microm, 16 194 +/- 1072; >40 microm, 3732 +/- 997) were measured in the ECC group. The air elimination of the modern MPC is superior to conventional ECC, which may result in a reduction of neurological complications.