Control of aerostasis in pulmonary metastasectomy by precision resection. Standard technique versus fibrin glue modification

The control of aerostasis after performing non-anatomical pulmonary resections constitutes a serious problem. The presence of an air leak in the postoperative period requires a prolonged thoracic drainage and consequently a longer hospital stay. The aim of our study was to evaluate the usefulness of fibrin glue and its effectiveness in the prevention of air leaks. At the Department of Thoracic Surgery of the National Cancer Institute of Milan, we conducted a case-control study in 90 patients submitted to metastasectomy for secondary lung cancer, removing multiple small nodules < or = 1.5 cm using the precision resection technique. We divided the patients into two groups, both of 45 subjects: group 1 treated with fibrin glue and group 2 submitted to cauterization of the pulmonary parenchyma. The patient characteristics were well matched for age, type of approach and operation, number of resections performed and type of pathology. The assessment parameters investigated were the duration of the air leak, expected complications, drainage time and length of hospital stay. In group 1 we performed fewer than 5 precision resections in 21 cases, from 5 to 10 in 16, and more than 10 in 8. In group 2 we executed fewer than precision resections in 21 cases, from 5 to 10 in 17, and more than 10 in 7. In group 1 the duration of the air leak was 2.93 +/- 1.91 days as against 6.95 +/- 7.01 days in group 2 (p = 0.000). In group 1 we had one complication (2%) (a long-term air leak lasting > 10 days), while in group 2 we had a long-term air leak in 11 cases (24%) (p = 0.000). Mean thoracic drainage time was 4.22 +/- 1.43 days in group 1, and 8.13 +/- 7.37 in group 2 (p = 0.000). The mean postoperative hospital stay was 6.22 +/- 1.43 days in group 1 compared to 10.13 +/- 7.37 days in group 2 (p = 0.000). In the group of patients treated with fibrin glue we obtained a significant reduction in drainage time, complications and postoperative hospital stay. The results of our experience show that the use of fibrin glue in non-anatomical resections with a high risk of developing air leakage is effective in reducing the expected complications, with a favourable impact also on the quality of life of patients with metasases.     

Clinical Evaluation of Fibrin Glue in the Prevention of Anastomotic Leak and Internal Hernia after Laparoscopic Gastric Bypass: Preliminary Results of a Prospective, Randomized Multicenter Trial

Background: Gastro-jejunal anastomotic leak and internal hernia can be life-threatening complications of laparoscopic Roux-en-Y gastric bypass (LRYGBP), ranging from 0.1-4.3% and from 0.8-4.5% respectively. The safety and efficacy of a fibrin glue (Tissucol^?) was assessed when placed around the anastomoses and over the mesenteric openings for prevention of anastomotic leaks and internal hernias after LRYGBP. Methods: A prospective, randomized, multicenter, clinical trial commenced in January 2004. Patients with BMI 40-59 kg/m², aged 21-60 years, undergoing LRYGBP, were randomized into: 1) study group (fibrin glue applied on the gastro-jejunal and jejuno-jejunal anastomoses and the mesenteric openings); 2) control group (no fibrin glue, but suture of the mesenteric openings). 322 patients, 161 for each arm, will be enrolled for an estimated period of 24 months. Sex, age, operative time, time to postoperative oral diet and hospital stay, early and late complications rates are evaluated. An interim evaluation was conducted after 15 months. Results: To April 2005, 204 patients were randomized: 111 in the control group (mean age 39.0±11.6 years, BMI 46.4±8.2) and 93 in the fibrin glue group (mean age 42.9±11.7 years, BMI 46.9±6.4). There was no mortality or conversion in both groups; no differences in operative time and postoperative hospital stay were recorded. Time to postoperative oral diet was shorter for the fibrin glue group (P=0.0044). Neither leaks nor internal hernias have occurred in the fibrin glue group. The incidence of leaks (2 cases, 1.8%) and the overall reoperation rate were higher in the control group (P=0.0165). Conclusion: The preliminary results suggest that Tissucol^? application has no adverse effects, is not time-consuming, and may be effective in preventing leaks and internal hernias in morbidly obese patients undergoing LRYGBP.     

Sealing effect of fibrin glue on the healing of gastrointestinal anastomoses: implications for the endoscopic treatment of leaks

Background The adoption of advanced laparoscopic techniques for complex surgical procedures has raised the concern that the leak rate might be higher than for open surgery, particularly in the surgeon's early experience or in difficult cases. In this study, the sealing effect of fibrin glue on leaking gastrointestinal anastomoses was evaluated in an experimental swine model. Methods A standardized gastrojejunostomy was performed on 20 female pigs (mean weight, 47.7 ± 5.7 kg). A leak was created on the anterior surface of the anastomosis. The animals were randomized to either fibrin glue or no treatment of the leak. Clinical conditions and vital signs, including body temperature, heart rate and, respiratory rate, were collected three times a day. Preoperative and postoperative complete and differential blood count and lactate dehydrogenase levels were determined. Postmortem analysis was performed when the animals were killed. Results Clinical signs of peritonitis developed in the control animals by the second or third postoperative day. Findings that confirmed the presence of an anastomotic leak at the postmortem examination were the presence of food or gastrojejunal juices in the abdominal cavity, a localized abscess, or a positive air leak test. Fibrin glue treatment prevented the development of peritonitis in all the animals. Complete sealing of the leak was observed on postoperative day 7 in all treated animals, except one in which an asymptomatic contained leak developed. The postoperative total white blood count was significantly increased in the untreated group (24.69 ± 5.5 vs 12.74 ± 3.7 10³/ul p < 0.001, paired t-test), as compared with the treated group (15. 55 ± 2.4 vs 14.89 ± 2.7 10³/ul; p = 0.24). Conclusion In this study, fibrin glue showed reproducible sealing effects on leaking gastrojejunal anastomoses. Fibrin glue application may be a valuable approach for the treatment of gastrointestinal anastomotic leaks. 2004 Oral Presentation at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Denver, CO, USA.     

Verification of Early Removal of the Chest Tube after Absorbable Mesh-based Pneumostasis Subsequent to Video-assisted Major Lung Resection for Cancer

Background

We previously reported that the combined use of absorbable mesh and fibrin glue is superior to the use of fibrin glue alone to stop intraoperative air leaks. However, concern remains about whether mesh-based pneumostasis can induce the recurrence of air leaks after chest tube removal.

Methods

We reviewed our prospective database of selected patients (n?=?206) who underwent video-assisted major lung resection for cancer. Exclusion criteria included simultaneous combined resection, induction radiotherapy, entire intrathoracic adhesion, or a history of prior ipsilateral thoracotomy. We sealed any intraoperative air leaks with absorbable mesh and fibrin glue and then carried out prophylactic chest-tube drainage for 1?day.

Results

Intraoperative air leaks were detected in 133 (65%) patients. Overall, air leaks were not detected postoperatively in 186 (91%) patients, allowing chest tube removal on the day after the operation. The mean length of time for chest tube drainage was 1.2?days. A prolonged air leak (>7?days) was observed in one (0.5%) patient, and this leak resolved by itself. After chest tube removal, an air leak recurred in six (2.9%) patients during the 30?day follow-up period, necessitating chest tube reinsertion. Although the recurrence was observed more frequently after segmentectomy than after lobectomy (p?=?0.04), the recurrence was not observed more frequently in patients who had an intraoperative air leak than in patients who did not (p?=?0.3).

Conclusion

Early removal of the chest tube after pneumostasis with absorbable mesh is verified in selected patients who underwent video-assisted major lung resection for cancer. However, further attempts should be made to prevent air leaks after anatomical segmentectomy.     

Efficacy of a Pedicled Pericardial Fat Pad Fixed with Fibrin Glue on Postoperative Alveolar Air Leakage

The purpose of this randomized trail was to investigate the effect of using a pedicled pericardial fat pad fixed with fibrin glue on postoperative alveolar air leakage. Thirty consecutive patients with lung cancer, who had moderate alveolar air leaks after pulmonary resection, were randomized into two groups: in group A fibrin glue was applied onto the surface of the leaking raw lung and in group B, after applying fibrin glue in the same manner as in group A, a pedicled pericardial fat pad was immediately fixed to the leaking lung surface with fibrin glue. The duration of the postoperative air leakage and chest tube drainage was recorded. In 6 of 15 patients in group B the air leakage ceased within the first 24 h after pulmonary resection, while in group A only 1 of 15 patients showed a cessation of the air leakage, and a significant difference was noticed between the two groups (P = 0.0309). The duration of the postoperative air leakage was 4.8 ± 4.6 days in group A and 3.6 ± 3.4 days in group B. The pedicled pericardial fat pad fixed onto the surface of the leaking raw lung using fibrin glue was found to reduce alveolar air leakage after pulmonary resection. Received: January 11, 2001 / Accepted: September 11, 2001     

Effect of fibrin glue on the prevention of persistent cerebral spinal fluid leakage after incidental durotomy during lumbar spinal surgery

Approximately one million spinal surgeries are performed in the United States each year. The risk of an incidental durotomy (ID) and resultant persistent cerebrospinal fluid (CSF) leakage is a significant concern for surgeons, as this complication has been associated with increased length of hospitalization, worse neurological outcome, and the development of CSF fistulae. Augmentation of standard dural suture repair with the application of fibrin glue has been suggested to reduce the frequency of these complications. This study examined unintended durotomies during lumbar spine surgery in a large surgical patient cohort and the impact of fibrin glue usage as part of the ID repair on the incidence of persistent CSF leakage. A retrospective analysis of 4,835 surgical procedures of the lumbar spine from a single institution over a 10-year period was performed to determine the rate of ID. The 90-day clinical course of these patients was evaluated. Clinical examination, B-2 transferrin assay, and radiographic imaging were utilized to determine the number of persistent CSF leaks after repair with or without fibrin glue. Five hundred forty-seven patients (11.3%) experienced a durotomy during surgery. Of this cohort, fibrin glue was used in the dural repair in 278 patients (50.8%). Logistic models evaluating age, sex, redo surgery, and the use of fibrin glue revealed that prior lumbar spinal surgery was the only univariate predictor of persistent CSF leak, conferring a 2.8-fold increase in risk. A persistent CSF leak, defined as continued drainage of CSF from the operative incision within 90 days of the surgery that required an intervention greater than simple bed rest or over-sewing of the wound, was noted in a total of 64 patients (11.7%). This persistent CSF leak rate was significantly higher (P < 0.001) in patients with prior lumbar surgery (21%) versus those undergoing their first spine surgery (9%). There was no statistical difference in persistent CSF leak between those cases in which fibrin glue was used at the time of surgery and those in which fibrin glue was not used. There were no complications associated with the use of fibrin glue. A history of prior surgery significantly increases the incidence of durotomy during elective lumbar spine surgery. In patients who experienced a durotomy during lumbar spine surgery, the use of fibrin glue for dural repair did not significantly decrease the incidence of a persistent CSF leak.     

Does Fibrin Glue Reduce Lymph Leakage (Pleural Effusion) after Extended Esophagectomy? Prospective Randomized Clinical Trial

Fibrin glue has been shown to be effective in improving postoperative chylothorax following various thoracic procedures and in reducing lymphorrhea after axillary dissection. It is unknown, however, whether fibrin glue is effective in reducing lymph leakage (pleural effusion) after esophagectomy. A series of 43 consecutive patients with thoracic esophageal cancer who underwent extended esophagectomy were prospectively randomized to two groups: group A (n = 21), in whom 3 ml of fibrin glue was applied to the dissected mediastinum; and group B (n = 22), in whom fibrin glue was not applied. The time of drain removal and the volume of the thoracic drainage were compared. All data were expressed as the mean ± standard deviation. There were no significant differences in the clinicopathologic characteristics between the two groups. None of the patients developed chylothorax or died during their hospital stay. The daily volume from the thoracic drain (457 ± 273 ml) was significantly (p < 0.05) larger on postoperative day (POD) 1 in group A than in group B (298 ± 158 ml) and tended to be larger (p < 0.10) on PODs 4 and 6 in group A than in group B. The cumulative drainage volume was significantly (p < 0.05) larger on PODs 4 to 6 and POD 9, and it tended to be larger (p < 0.10) on PODs 1, 3, 7, 8, 10, and 11 in group A than in group B, suggesting that the cumulative drainage volume in group A was consistently larger than that in group B. The cumulative numbers of patients with a drain remaining in place were not significantly different for the two groups (p = 0.4683). Three patients in group A, however, had prolonged insertion (> 20 days) of the chest tube. There were no significant differences in the incidence of postoperative chest-related complications. No patients in group A developed viral infectious disease during the long-term follow-up. Application of fibrin glue to the dissected mediastinum seems to induce postoperative lymph leakage and thus be responsible for prolonged chest tube insertion in some patients. Hence the use of fibrin glue cannot be recommended for reducing lymph leakage after esophagectomy.     

Normothermia is protective during infrarenal aortic surgery

Purpose: Mild hypothermia has been suggested to be protective against tissue ischemia during aortic operations. However, recent studies have documented detrimental cardiac effects of hypothermia during a variety of operative procedures. The influence of different warming methods and the impact of hypothermia during standard aortic procedures was assessed. Methods: One hundred patients who underwent repair of infrarenal aortic aneurysms or aortoiliac occlusive disease were prospectively randomized into 2 groups, receiving either a circulating water mattress or a forced air warming blanket. Adjuvant warming methods were standardized. The day before surgery, 48-hour Holter monitors were applied and interpreted by a cardiologist blinded to the treatment. Randomization resulted in equivalent groups with regard to patient history, indications for surgery, body mass index, length of surgery, and fluid requirements. Results: Core temperatures were significantly warmer during surgery (36.3°C ± 0.7°C vs 35.4 ± 0.8°C) and after surgery (36.4°C ± 0.7°C vs 35.6°C ± 0.9°C) in patients with forced air warming (P < .001). The circulating water mattress group had significantly more metabolic acidosis perioperatively (P = .03). Postoperative length of stay, cardiac complications, and death rates were not significantly different. Subgroup analysis of 83 aneurysm patients comparing normothermia with hypothermia (temperature less than 36°C) on arrival to the recovery room identified decreased cardiac output (P = .02), thrombocytopenia (P = .02), elevated prothrombin time (P = .04), and inferior Acute Physiology and Chronic Health Evaluation (APACHE) II scores (P < .001) in the hypothermic group. Holter analysis revealed more sinus tachycardia (ST) segment changes and ventricular tachycardia in hypothermic aneurysm patients (P = .05). Conclusion: Patients treated with forced air blankets had significantly less metabolic acidosis and were kept significantly warmer than those treated with circulating water mattresses. Patients with aneurysms that were kept normothermic had a significantly improved clinical profile, with fewer cardiac events on the Holter recordings. We therefore conclude that (1) normothermia is protective for infrarenal aortic surgical patients; and (2) forced air warming blankets provide improved temperature maintenance compared with circulating water mattresses. (J Vasc Surg 1998;28:984-94.)     

Fibrin glue and bioabsorbable felt patch for intraoperative intractable air leaks

Objective: We worked to devise a new way to prevent postoperative persistent air leaks in high-risk pulmonary surgery patients. Methods: From November 1993 to June 2002, 60 patients with difficult to control intraoperative pulmonary air leakage were treated using bioabsorbable polyglycolide felt patches soaked in fibrin glue to cover the leakage site. Results: After application, the felt patch adhered tightly to the lung surface without peeling off, enabling good leakage closure with only 2 ml of fibrin glue used. Air leakage was controlled successfully in 52 (86.7%) of the 60. Four of the 8 patients in whom this method failed to stop air leakage also developed mild pyothorax, with 2 requiring a second operation by video-assisted thoracic surgery. Leakage was eventually controlled in all patients, with no postoperative deaths relating to air leakage. Conclusions: Fibrin-glue-soaked bioabsorbable felt patches effectively seal intraoperative intractable air leaks. Felt patch use may increase the risk of postoperative infection. It should be considered for use on patients with fistulas that cannot be controlled by direct closure or otherwise intraoperatively and who may potentially develop uncontrollable air leakage postoperatively.     

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.     

Efficacy of Supraglottic Airway for Preventing Lung Injury Associated with Coughing at Extubation after Pulmonary Lobectomy

Background

The use of double-lumen endobronchial tubes (DLTs) is necessary for differential lung ventilation during pulmonary lobectomy. However, when used with conventional extubation procedures, coughing is more likely and is associated with an increased risk for parenchymal air leak along the staple line and possible subsequent lung injury. We examined the prevalence of coughing-associated air leaks at extubation and the efficacy of using supraglottic airways (SGAs) to prevent air leaks with post-lobectomy extubation.

Methods

This study included 150 patients with pulmonary emphysema diagnosed using preoperative computed tomography, who underwent pulmonary lobectomy between April 2010 and March 2015. The patients were chronologically enrolled in two groups: the DLT group (60 patients) from April 2010 to August 2012, and the SGA group (90 patients) from September 2012 to March 2015. (Note: the DLT group only included cases without air leak present just prior to extubation). Data were collected on specific patient characteristics and operative and postoperative factors.

Results

Coughing at extubation occurred in 15 (25.0 %) of 60 DLT patients, and parenchymal air leaks developed in 10 (66.7 %) of these 15. Comparison of groups revealed the SGA group was significantly lower for the following: patients with coughing at extubation (P < 0.001), coughing-associated air leaks at extubation (P < 0.001), air leaks >7 days (P = 0.006), reoperation due to air leaks (P = 0.013), and duration of chest tube drainage (P < 0.001).

Conclusions

The SGA is effective for preventing air leaks associated with coughing during conventional DLT extubation in post-lobectomy patients.

     

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.     

Intrapleural administration of a large amount of diluted fibrin glue for intractable pneumothorax

Objective: Pleurodesis using chemical agents has been applied to high-risk patients with pneumothorax. This treatment, however, is sometimes unsuccessful in patients with intractable pneumothorax. We have developed intrapleural administration of diluted fibrin glue as an effective treatment for such patients.Methods: Fibrin glue was diluted 4-fold with saline and/or contrast media. Pleurodesis with a large amount of the diluted fibrin glue was performed in 55 high risk patients (57 cases, bil.2 patients) with intractable pneumothorax.Results: The air leaks were stopped by administration of the glue in all except 2 patients. During the follow-up period, a recurrence rate of 10.5% was observed. These recurrent pneumothoraces were successfully treated using the same procedure with no further recurrence. Pyrexia (12.3%) and chest discomfort (8.8%) were observed as side effects, and there was no occurrence of severe chest pain or thoracic empyema.Conclusions: These results suggested that intrapleural administration of a large amount of diluted fibrin glue was an effective treatment for intractable pneumothoraces in high-risk patients.     

The effectiveness of fibrin glue sealant for reducing experimental pulmonary ari leak

The effectiveness of fibrin glue as a biological sealant for pulmonary air leaks was determined in 16 dogs. A standardized pleural defect was made in the left lower lobe, and the quantity of air passing through a chest tube was assessed with a Collins respirometer. For the 8 randomly assigned control animals, the air leak decreased over 90 minutes from a mean of 1.4 L/min to a mean of 1.1 L/min (mean decrease, 19.8%). In the 8 randomly assigned fibrin glue-treated animals, the air leak decreased from a mean of 2.1 L/min to a mean of 0.5 L/min (mean decrease, 80.8%) (p less than 0.0001). Postoperative evaluation of survivors disclosed no increased adhesions in the glue-treated animals and complete resorption of the glue at 3 months. We conclude that in this animal model, fibrin glue reduced the size of pulmonary air leaks in the early period after thoracotomy and did not lead to increased intrapleural adhesions.     

Anastomotic leaks: technique and timing of detection

Background

Despite the proven benefits of laparoscopic colorectal surgery, the rate of anastomotic leaks has not changed. This study looks at the time of presentation of anastomotic leaks between laparoscopic and open colectomies.

Methods

Retrospective chart review was performed between July 2008 and 2012. Two groups were created, laparoscopic and open. The time of presentation of significant leaks requiring reoperation were compared between the groups by index colectomies. Statistical analysis is presented as paired t test and chi-square test (P < .05).

Results

From 1,424 segmental colectomies, the anastomotic leak rate between the two groups was not statically significant (P = .69). No difference in the time of leak detection was evident (P = .67). Mortality rate was equal between the groups. The overall complication rate of the entire cohort was statically significant (P ≤ .001).

Conclusion

The timing of anastomotic leak detection does not differ between laparoscopy and open colorectal resections.     

Improvement of peripheral nerve regeneration in acellular nerve grafts with local release of nerve growth factor

Previous studies have demonstrated the potential of growth factors in peripheral nerve regeneration. A method was developed for sustained delivery of nerve growth factor (NGF) for nerve repair with acellular nerve grafts to augment peripheral nerve regeneration. NGF‐containing polymeric microspheres were fixed with fibrin glue around chemically extracted acellular nerve grafts for prolonged, site‐specific delivery of NGF. A total of 52 Wister rats were randomly divided into four groups for treatment: autografting, NGF‐treated acellular grafting, acellular grafting alone, and acellular grafting with fibrin glue. The model of a 10‐mm sciatic nerve with a 10‐mm gap was used to assess nerve regeneration. At the 2nd week after nerve repair, the length of axonal regeneration was longer with NGF‐treated acellular grafting than acellular grafting alone and acellular grafting with fibrin glue, but shorter than autografting (P < 0.05). Sixteen weeks after nerve repair, nerve regeneration was assessed functionally and histomorphometrically. The percentage tension of the triceps surae muscles in the autograft group was 85.33 ± 5.59%, significantly higher than that of NGF‐treated group, acellular graft group and fibrin‐glue group, at 69.79 ± 5.31%, 64.46 ± 8.48%, and 63.35 ± 6.40%, respectively (P < 0.05). The ratio of conserved muscle‐mass was greater in the NGF‐treated group (53.73 ± 4.56%) than in the acellular graft (46.37 ± 5.68%) and fibrin glue groups (45.78 ± 7.14%) but lower than in the autograft group (62.54 ± 8.25%) (P < 0.05). Image analysis on histological observation revealed axonal diameter, axon number, and myelin thickness better with NGF‐treated acellular grafting than with acellular grafting alone and acellular grafting with fibrin glue (P < 0.05). There were no significant differences between NGF‐treated acellular grafting and autografting. This method of sustained site‐specific delivery of NGF can enhance peripheral nerve regeneration across short nerve gaps repaired with acellular nerve grafts. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

In vitro and in vivo effects of photodynamic therapy on murine malignant melanoma

Background: The role of photodynamic therapy (PDT) in the treatment of malignant melanoma is not well defined, nor is it known whether the dark melanoma cells absorb the light used in PDT. Methods: In vitro studies: 2×10⁵ B16 murine melanoma cells were incubated with aluminum phthalocyanine (AlpcS₄, 2.5 mg/kg) and were then subjected to photoradiation (50, 100 or 200 J/cm²). Viability was then assessed.In vivo studies: Histology: C57/B1 mice received 2×10⁵ B16 cells subcutaneously and were randomized into study (PDT) and three control groups. AlpcS₄ 2.5 mg/kg was injected intraperitoneally and the mice were exposed to light (100 J/cm²). After 24 hours they were sacrificed and underwent autopsies. Survival: 40 mice were randomized into PDT (40 J/cm²) and control groups and were monitored for 50 days. Tumor growth: 40 mice were randomized into one control and three treatment groups (PDT on day 3, 6, or 12 after injection with B16 cells), and were monitored for 50 days. Temperature: Tumor temperatures before and at the end of PDT were recorded. Results: In vitro studies: PDT caused a decrease in cell viability to 15.5±0.7%, 11.5±2.1%, and 1.5±0.7% (at 50, 100, and 200 J/cm², respectively;P<.001). A significant reduction in thymidine incorporation was noted at all energy levels.In vivo studies: Histology: PDT caused massive tumor necrosis. Survival: PDT prolonged the survival of mice (41±13.4 days) compared to controls (15.8±3.8 days,P<.001). Tumor growth: 31 days after injection with B16 cells, the tumor size was 2.6±0.3 cm in the control group and 1.6±0.2, 0.9±0.3, and 1.0±0.4 cm in the PDT groups (days 3, 6 and 12, respectively;P<.01). Temperature: PDT increased skin temperature to 42.8°C±1.3°C, 45.3°C±3.5°C, and 51.7°C±2.7°C at 40, 60, and 100 J/cm², respectively (P<.01). Conclusions: Photodynamic therapy was found to have significant effects in experimental melanoma in mice. The role of PDT in human melanoma remains to be studied.Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, Illinois, March 20–23, 1997.     

Effect of 5-Fluorouracil plus Interferon on the Integrity of Colonic Anastomoses Covering with Fibrin Glue

Background It has been well established that the immediate postoperative intraperitoneal administration of chemotherapeutic agents such as 5-fluorouracil (5-FU) after curative colon resection for colon cancer destroys disseminated cancer cells and inhibits micrometastases but also inhibits anastomotic healing. On the other hand, the application of fibrin glue constitutes a physical barrier around the anastomosis and may prevent anastomotic leakage. The purpose of this experimental study was to determine the effect of 5-FU plus interferon (IFN)-α-2a on the integrity of colonic anastomoses covered with fibrin glue when injected intraperitoneally immediately after colon resection. Materials and Methods Sixty rats were randomized to one of four groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. Rats of the control and the fibrin glue groups were injected with 6 ml of 0.9% sodium chloride (NaCl) solution intraperitoneally. Rats in the 5-FU + IFN and the 5-FU + IFN + fibrin glue groups received 5-FU plus IFN intraperitoneally. The colonic anastomoses of the rats in the fibrin glue and in the 5-FU + IFN + fibrin glue groups were covered with fibrin glue. All rats were sacrificed on the 8th postoperative day, and the anastomoses were examined macroscopically. The bursting pressure measurements were recorded, and the anastomoses were graded histologically. Results Only the 5-FU + IFN group had anastomoses rupture, and the rupture rate (33%) in this group was significantly greater than in the other groups, where there were no ruptures (P = 0.015). The adhesion formations score was, on average, significantly higher in rats of the 5-FU + IFN group compared with the control group (P = 0.006) and the 5-FU + IFN + fibrin glue group (P = 0.010). Bursting pressures were significantly lower in the control group when compared to the fibrin glue and 5-FU + IFN + fibrin glue group (P < 0.001). Rats in the 5-FU + IFN + fibrin glue group developed significantly more marked neoangiogenesis than rats in the other groups. Inflammatory cell infiltration, collagen deposition, and fibroblast activity did not differ significantly among the four groups (P = 0.856, P = 0.192 and P = 0.243, respectively). Conclusion The immediate postoperative intraperitoneal administration of 5-FU plus IFN impairs colonic healing. However, when the colonic anastomoses were covered with fibrin glue, the injection of 5-FU plus IFN had no adverse effects on the integrity of the anastomoses.     

Management of air leak after pulmonary resection

Objective: We prospectively evaluated the efficacy of water seal in the management of air leak after pulmonary resection. Methods: Eighty-seven patients who underwent lobectomy were enrolled. Air leak was qualitatively described on each postoperative day using a six-grade scale. All chest tubes were continuously suctioned at a negative pressure of 12 cm H₂O until the morning of postoperative day (POD) 1. Switch was made to water seal if the air leak was graded as “minor at expiration” or lower. This procedure is referred to as “the water seal challenge”. Results: On POD 1, 58 patients had air leaks. The water seal challenge was attempted on POD 1.6±1.0. While 45 patients (78%) continued to receive the water seal, the remaining 13 patients were switched to suctioning at −5 cm H₂O followed by the successful second water seal challenge within 3 days from the first challenge. The air leak stopped 3.1±3.0 days after the application of the water seal in the 58 patients. None of the following correlated with the duration of air leak: preoperative pulmonary function tests, type of lobectomy, age, and gender. Only the leak grade on POD 0 correlated significantly with the duration of air leaks (p<0.0001). Conclusion: These results show that water seal is a safe and effective management option for air leak during the early postoperative period.     

A risk score to predict the incidence of prolonged air leak after video-assisted thoracoscopic lobectomy: An analysis from the European Society of Thoracic Surgeons database

Objective

The study objective was to develop an aggregate risk score for predicting the occurrence of prolonged air leak after video-assisted thoracoscopic lobectomy from patients registered in the European Society of Thoracic Surgeons database.