Gelatin-Resorcinol–Formaldehyde-Glutaraldehyde Glue-Spread Stapler Prevents Air Leakage From the Lung

Background. To reinforce the staple line of the emphysematous lung and thereby prevent air leakage during thoracoscopic operations, we have developed a procedure of lung excision that uses a gelatin-resorcinol–formaldehyde-glutaraldehyde (GRFG) glue-spread stapler.Methods. Formaldehyde-glutaraldehyde (FG) jelly is prepared by mixing FG fluid with 2.5% sodium carboxymethyl cellulose. The FG jelly is placed in the stapler groove and staple holes, and a gelatin-resorcinol (GR) mixture is applied. The GRFG glue-spread stapler was applied to emphysematous lung cutting during thoracoscopic operations in 10 cases.Results. An adhesion-strength test showed no difference in glue adhesion between FG fluid and FG jelly. An experiment using swine lung showed that with this newly developed stapler, no resistance in firing occurred, and GRFG glue covered every staple hole. Clinical application in 10 cases with emphysematous lung demonstrated no air leakage from the staple line, even long after the operation.Conclusions. Emphysematous lung excision using the GRFG glue-spread stapler during thoracoscopic operations is useful in preventing air leakage from the staple line and is a simple, safe, and low-cost procedure.(Ann Thorac Surg 1997;63:352–5)     

An effective case of a new biological adhesive agent, gelatin-resorcinol formaldehyde-glutaralhyde glue (GRFG-glue) in treating refractory pulmonary fistula following lobectomy for pulmonary aspergilloma]

We report a successful case of thoracoscopic therapy using a new biological adhesive agent, Gelatin-Resorcinol Formaldehyde glue (GRFG glue) for refractory pulmonary fistula. A 69-year-old male underwent right upper lobectomy for lung aspergilloma. Air leakage began 11 days after lobectomy. Closing alveolar fistula was performed 28 days after first operation. Relapsing air leakage began 2 days after second operation. The insertion of fibrin glue through thoracoscope at two times was not effective for refractory pulmonary fistula. But the insertion of GRFG glue was effective to close the fistula completely.     

One hundred consecutive treatments with holmium: YAG laser for pulmonary bullae: especially in conjunction with gelatin-resorcinol formaldehyde-glutaraldehyde glue adhesion

BACKGROUND AND OBJECTIVE: We have widely used a Ho:YAG laser to treat bullae thoracoscopically. STUDY DESIGN/MATERIALS AND METHODS: Bullae with broad necks were treated with a Ho:YAG laser thoracoscopically. Because one patient relapsed after application of fibrin glue in the early period, a DEXON (polyglycolic acid) mesh patch soaked in fibrin glue was used through a 2-cm opening in the subsequent cases. Lastly, gelatin-resorcinol formaldehyde-glutaraldehyde (GRFG) glue was applied through a 5-mm opening instead of a DEXON mesh after coagulation. RESULTS: In the 38 patients patched with DEXON mesh soaked in fibrin glue and 56 patched with GRFG glue after coagulation, none relapsed. CONCLUSION: Combined uses of fibrin glue plus DEXON mesh or GRFG glue were effective when bullae were treated with the Ho:YAG laser. However, the wound was smaller and more cosmetic in the GRFG glue group than in the DEXON mesh plus fibrin glue group.     

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     

两种组织黏合剂封堵肺创面漏气的研究

目的 探讨纤维蛋白胶(FG)和化学胶封堵肺创而漏气的临床价值.方法 FG先行体外耐压试验.将54只新西兰兔随机分为3组:对照组、FG组和化学胶组,每组18只.离体实验每组9只兔,分别注射40、50、60 ml空气行肺顺应性测定.在体实验每组9只兔,建立兔肺漏气模型.对照组关胸,另两组行FG及化学胶封闭肺创面做加压试验,术后3、7、14 d开胸观察取肺组织行苏木素-伊红(HE)染色.结果体外耐压试验中,FG承受50 cm H2O压力后出现漏气.离体实验中,FG组顺应性(1.820±0.280、1.181±0.144、0.947±0.080)与对照组(2.075±0.377、1.289±0.243、0.951±0.087)比较差异无统计学意义(P>0.05),化学胶组顺应性(1.594±0.294、0.956±0.094、0.861±0.076)与对照组、FG组比较明显减小(P<0.05).在体实验中,对照组兔在术后1～4 h内死亡,FG组在肺内压平均达到27.2 cmH2O时出现漏气,而当气道压达34 cmH2O时化学胶亦未漏气.化学胶组术后出现肺不张及少量胸水,病理切片示坏死组织及炎性细胞明显多于FG组.结论 两胶均可有效封闭肺创面漏气.与化学胶比较,FG对肺顺应性干扰小,可促进创面愈合、减轻炎症及瘢痕形成.     

Mixing collagen with fibrin glue to strengthen the sealing effect for pulmonary air leakage

BACKGROUND: To strengthen the sealing effect of fibrin glue for pulmonary air leakage, atelocollagen was mixed with the glue and the mixing effect was examined. METHODS: A mixture of fibrinogen and thrombin with atelocollagen was used as a test sample. The concentrations of atelocollagen were adjusted to levels of 0%, 0.375%, 0.75%, 1.1%, and 1.5%. We next performed air leakage tests on a plastic cap with pin holes and swine lung and also measured the elasticity and the adhesion strength. RESULTS: The pressure required to rupture the sealant on a plastic cap with pin holes increased as the concentration of atelocollagen increased, and the bursting pressures were significantly higher in the glue with 0.75%, 1.1%, and 1.5% of atelocollagen than in the glue without atelocollagen (p < 0.01 and p < 0.001). The air leakage pressure on the swine lung was significantly higher in the glue with 0.375%, 0.75%, and 1.1% of atelocollagen than in the glue without atelocollagen (p < 0.05 and p < 0.01), and it was the highest with 0.75%. The elasticity of the glue significantly increased as the concentration of atelocollagen increased (p < 0.001). However, the adhesion strength of the glue significantly decreased as the concentration of atelocollagen increased (p < 0.05 to p < 0.001). CONCLUSIONS: The mixing of atelocollagen with fibrin glue more effectively sealed pulmonary air leakage due to an increased elasticity of the glue while its adhesion strength decreased. The optimal concentration of atelocollagen in the fibrin glue to obtain the best sealing effect was 0.75%.     

Staple-line reinforcement with a new type of polyglycolic acid felt

Although various materials have been used for reinforcement in lung-volume-reduction surgery to buttress pulmonary staple-line, absorbable materials are not available for use in thoracoscopic surgery. Moreover, even nonabsorbable types of reinforcements have been used only for lung volume reduction surgery. However, elderly patients with spontaneous pneumothorax secondary to emphysematous lung are well treated with staple-line reinforcement. The authors developed a new type of polyglycolic acid felt to buttress staple-line. This felt is absorbable, easier to cut with a stapler knife than is the conventional polyglycolic acid felt, and inexpensive enough to use for various types of thoracic surgeries for emphysematous lungs in Japan, and it can be attached to staplers with a small amount of fibrin glue. These strips were used to reinforce pulmonary staple lines for resection of emphysematous lungs in 14 patients: pulmonary emphysema (n = 1), bilateral giant bullae (n = 1), ipsilateral giant bullae (n = 6), spontaneous pneumothorax with multiple bullae in an emphysematous lung (n = 5), and lung cancer in a patient with pulmonary emphysema (n = 1). There were no air leaks during surgery. Air leaks were noted in three patients after surgery. In two patients, the air leaks stopped within 2 weeks. In one patient, the air leak was found to originate from an untouched lobe during reoperation. No infection or allergic reaction developed in a patient during a mean follow-up of 12 months (range, 1 to 24 months).     

Autologous fibrin glue--preparation and clinical use in thoracic surgery.

Autologous fibrin glue was used in 20 patients undergoing lung resection to reduce pulmonary air leaks and improve hemostasis. The fibrinogen in the glue was prepared by ethanol precipitation of plasma separated from 88 ml of the patient's blood. The mean volume of fibrinogen concentrate +/- SD was 4.9 +/- 0.5 ml with a fibrinogen concentration of 28 +/- 5 mg/ml. The yield obtained by the separation was 81% +/- 9%. One part of fibrinogen concentrate was converted to solid fibrin by means of 0.3 parts of thrombin solution. The outcome was 6.4 ml of two-component fibrin glue. The preparation was performed in a closed system to ensure sterility, and was completed within 90 min. Pulmonary air leak decreased following sealing of the resection lines with autologous fibrin glue and the hemostasis was effective. No adverse effects were observed, and all cultures from the glue were negative. Autologous fibrin glue has the obvious advantages of safety from transmission of viral diseases and from immunological reactions. In summary, we report a new technique for preparing autologous fibrin glue with a high concentration of fibrinogen making it a safe and effective sealant of pulmonary air leak and hemostatic agent in thoracic surgery.     

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.     

Prevention of parenchymal air leakage after lung resection; comparison of effectiveness in drug formation of fibrin adhesive

We investigated the comparative effectiveness of the seat and glue types of fibrin adhesive, to clarify which is more useful in preventing postoperative parenchymal air leaks after lung resection. One hundred sixteen patients received fibrin adhesive to prevent postoperative air leakage after lung resection carried out by the same surgeon. Ninety-two lobectomies and 24 partial resections were assessed. There were 29 patients with emphysematous lung. In the seat type group, an average of 2.6 postoperative days elapsed before chest drain removal. In the glue type, this average was 3.2 days, a significant difference. This difference was also evident in the lobectomy group. However, among emphysematous lung patients and the partial resection group, there was no apparent difference. Prolonged air leakage was seen in 2 patients with emphysematous lung, but no difference in terms of drug formation could be seen. The seated type of fibrin adhesive was more useful than the glue type in preventing postoperative air leaks, but in emphysematous lung patients, better surgical technique would seem to be the critical factor.     

The covering with forceps-assisted polymeric biodegradable sheet and endostapling method: a simplified technique for wide coverage and reinforcement of staple-line in video-assisted thoracoscopic bullectomy for spontaneous pneumothorax

Primary spontaneous pneumothorax is one of the most common diseases. To prevent recurrent pneumothorax after video-assisted thoracoscopic surgery, various methods of pleural covering with biodegradable polymers have been devised. In addition, using fibrin sealant should be avoided as far as possible because of its infectious aspect. Thus, we devised the covering with forceps-assisted polymeric biodegradable sheet and endostapling method in response to these demands. With this novel technique, we used non-woven polyglycolic acid (PGA) NEOVEIL? sheet (Gunze, Ayabe, Japan). A 5-mm cut was made in the center of the PGA sheet, which was then guided over the apical bulla with a lung forceps. The bulla was then pulled through the cut hole with the lung forceps, in a manner similar to the way a cape is worn through the head. To avoid stapling failure caused by wrinkling of the PGA sheet, we moistened the sheet with a few drops of saline before endostapling. The diseased lung tissue was resected by endostapling across the PGA sheet. After firing the endostapler, we could perform a sealing test by inflating the lung to detect persistent air leaks. This is a simple and reliable technique of staple-line reinforcement without fibrin glue.     

Acute empyema with intraoperative intractable air leaks in a child; report of a case

We report a case of acute empyema with intraoperative intractable air leaks in a child. A 4-year-old girl was admitted with parapneumonic empyema by Staphylococcus aureus. Conventional conservative therapies such as antibiotics, chest tube drainage were failed. Then we performed dissection and debridement with video-assisted thoracoscopic surgery in fibrinopurulent phase of acute empyema. Intraoperative findings showed that the parietal pleura was very weak by Staphylococcus aureus pneumonia. Air leaks occurred,but pleural defects could not be closed by sutures and ligations. We could seal intractable air leaks to use fibrin glue soaked bioabsorbable polyglycolic acid felt sheet. Lung expansion promptly recovered and the patient was discharged on the 34th postoperative day without complications.     

Experimental evaluation of photocrosslinkable chitosan as a biologic adhesive with surgical applications.

BACKGROUND: In various surgical cases, effective tissue adhesives are required for both hemostasis (eg, intraoperative bleeding) and air sealing (eg, thoracic surgery). We have designed a chitosan molecule (Az-CH-LA) that can be photocrosslinked by ultraviolet (UV) light irradiation, thereby forming a hydrogel. The purpose of this work was to evaluate the effectiveness and safety of the photocrosslinkable chitosan hydrogel as an adhesive with surgical applications. METHODS: The sealing ability of the chitosan hydrogel, determined as a bursting pressure, was assessed with removed thoracic aorta, trachea, and lung of farm pigs and in a rabbit model. The carotid artery and lung of rabbits were punctured with a needle, and the chitosan hydrogel was applied to, respectively, stop the bleeding and the air leakage. In vivo chitosan degradability and biologic responses were histologically assessed in animal models. RESULTS: The bursting pressure of chitosan hydrogel (30 mg/mL) and fibrin glue, respectively, was 225 +/- 25 mm Hg (mean +/- SD) and 80 +/- 20 mm Hg in the thoracic aorta; 77 +/- 29 mm Hg and 48 +/- 21 mm Hg in the trachea; and in the lung, 51 +/- 11 mm Hg (chitosan hydrogel), 62 +/- 4 mm Hg (fibrin glue, rubbing method), and 12 +/- 2 mm Hg (fibrin glue, layer method). The sealing ability of the chitosan hydrogel was stronger than that of fibrin glue. All rabbits with a carotid artery (n = 8) or lung (n = 8) that was punctured with a needle and then sealed with chitosan hydrogel survived the 1-month observation period without any bleeding or air leakage from the puncture sites. Histologic examinations demonstrated that 30 days after application, a fraction of the chitosan hydrogel was phagocytosed by macrophages, had partially degraded, and had induced the formation of fibrous tissues around the hydrogel. CONCLUSIONS: A newly developed photocrosslinkable chitosan has demonstrated strong sealing ability and a great potential for use as an adhesive in surgical operations.     

Sealing effect of rapidly curable gelatin-poly (L-glutamic acid) hydrogel glue on lung air leak.

BACKGROUND: Air leak is a problem commonly occurring in lung and thoracic operations. In this study, a rapidly curable hydrogel glue was prepared as the seal for lung air leak. METHODS: Mixing an aqueous solution of gelatin and poly(L-glutamic acid) with a water-soluble carbodiimide produced a hydrogel. The sealing effect on the air leak wound of rat lung was compared with that of conventional fibrin glue. RESULTS: The gelatin-poly(L-glutamic acid) hydrogel glue was solidified as rapidly as the fibrin glue, and was significantly more effective in sealing the lung air leak than the fibrin glue. Approximately 80% of the lungs treated with the hydrogel glue exhibited no air leak at the lung pressure of 50 cm H2O. Urea addition could prevent spontaneous gelatination of the mixed solution at room temperature and did not affect the hydrogel sealing effect. The bonding strength of the hydrogel glue both with and without urea to the lung tissue was significantly higher than that of the fibrin glue. CONCLUSIONS: We concluded that this strong lung adhesion of the gelatin-poly(L-glutamic acid) hydrogel glue resulted in its superior sealing effect.     

New surgical technique of pulmonary segmentectomy by ultrasonic scalpel and absorbable sealing materials

We developed new surgical technique of pulmonary segmentectomy by ultrasonic scalpel to sever intersegmental pulmonary tissue and absorbable sealing materials to cover the cut surface of lung. This method is expected to preserve more anatomical lung volume than the segmentectomy with surgical stapler. Two cases of post surgical recurrent lung cancer, 3 cases of pulmonary metastasis and 4 cases of primary lung cancer were applied this technique to preserve function. Among 3 materials examined, best result was obtained with polyglycolic acid felt (PGAF:Neoveil). PGAF is a very soft and thin (0.15 mm depth) new absorbable material that is able to closely adhere to irregular sections of the lung with fibrin glue and effectively seals air leakage. Mean chest drainage period after surgery in 6 cases with PGAF was 3.3 days. Excellent lung expansion was obtained immediately after the surgery and PGAF was disappeared completely on chest CT within 1 year. Although the possible superiority of this method is suggested in the present study, further comparative study is necessary to clarify the advantage of this new technique.     

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.     

Use of biological glue to control pulmonary air leaks.

Biological glue is a natural adhesive generated by the interaction between fibrinogen (pre-glue) and thrombin to produce fibrin. The pre-glue is prepared from a single donor (to avoid the problems of pooled plasma) and stored as cryoprecipitate. Before being used it is thawed, dissolved in saline, and activated into an adhesive by the addition of topical thrombin. Biological glue was used prophylactically to prevent air leaks from bronchial suture lines and raw lung surfaces after pulmonary resections in six patients. In addition two new methods of using biological glue have been developed for the control of persisting air leaks. In selective intrabronchial tamponade the glue is instilled into the bronchial tree through a flexible bronchoscope, and in therapeutic pleurodesis it is instilled into the pleural cavity through a chest drainage tube. The air leaks were resolved in all cases. Seven procedures using selective intrabronchial tamponade were carried out in six patients. Four were immediately successful but three were not and required further interventions. Therapeutic pleurodesis alone was successfully carried out in one patient and as an adjunct to selective intrabronchial tamponade on two occasions. A thoracotomy was eventually needed in one of the seven patients.     

Successful use of fibrin glue during 2 years of surgery at a university medical center

A method for producing concentrated fibrinogen, an essential component of fibrin glue, from individually stored, single-donor units of human plasma is reported. The plasma is screened for hepatitis B antigen and HIV-1 virus to reduce the risk of transmission of hepatitis and acquired immunodeficiency syndrome (AIDS). This material is routinely stocked in some operating rooms. It is thus readily available when requested by a surgeon for use in combination with topical bovine thrombin to produce fibrin glue. From April 1985 to March 1987 this material was used by surgeons from eight different surgical specialties on 413 patients with a 91 per cent success rate (376/413). Uses have included sealing vascular suture lines, reinforcing pulmonary and esophageal staple lines, closing dural cerebrospinal fluid leaks, fixing split-thickness skin grafts, reducing lymphatic leakage, and controlling bone bleeding. Additional uses include closure of bronchopleural fistulas by means of the flexible bronchoscope, reduction of perioperative hemorrhage by spraying fibrin glue on the anterior mediastinum during cardiac surgery, and reduction of bleeding during debridement of burn eschars. Careful monitoring and patient follow-up detected no cases of transmission of blood-borne diseases. Only one complication, a local wound infection, has been documented. This material has been an important adjunct for the surgical services and may be safely used at hospitals with local blood bank facilities.     

Ipsilateral recurrence frequency after video-assisted thoracoscopic surgery for primary spontaneous pneumothorax.

OBJECTIVE: We retrospectively evaluated the results of video-assisted thoracoscopic surgery for primary spontaneous pneumothorax and recurrence. METHODS: A series of 424 patients with primary spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery-289 with an ipsilateral recurrent episode, 88 with persistent air leakage for 7 days or longer, 34 with a contralateral episode, 9 with hemopneumothorax, and 4 with tension pneumothorax. The commonest management was stapling of an identified bleb, undertaken in 375 patients (88.4%). Pleural abrasion was conducted in 250 (59.0%), but the abraded area was one-third or less of the thoracic cavity in 187 (74.8%). RESULTS: No operative deaths occurred. Revisional thoracotomy was required in 1 patient with postoperative bleeding and another with incomplete postoperative lung reexpansion; 26 had prolonged air leakage, but none required revisional thoracotomy. During a mean follow-up of 31.4 months, ipsilateral pneumothorax recurred in 40 patients (9.4%), with 26 (65.0%) having recurrence within 1 year postoperatively. A video-assisted thoracoscopic surgery was conducted again in 8, and thoracotomy in 14. CONCLUSIONS: The ipsilateral recurrence of primary spontaneous pneumothorax after video-assisted thoracoscopic surgery was high at 9.4%. If video-assisted thoracoscopic surgery is to be considered as a treatment for spontaneous pneumothorax, we must therefore reduce postoperative ipsilateral recurrence by training practitioners not to overlook blebs during the procedure and/or consider widening the area of pleurodesis.     

Ablation of persistent air leaks after thoracic procedures with fibrin sealant

Prolonged air leak after thoracic procedures was successfully treated in 11 of 12 patients under local anesthesia using video thoracoscopic instillation of fibrin sealant over the site of the leak. No related complications occurred. This method should be considered an effective option for the treatment of persistent pulmonary air leaks.