Efficacy of Polyglycolic Acid Sheet After Thoracoscopic Bullectomy for Spontaneous Pneumothorax

doi:10.1016/j.athoracsur.2013.03.011

The Annals of Thoracic Surgery

Volume 95, Issue 6, June 2013, Pages 1919-1923

https://doi.org/10.1016/j.athoracsur.2013.03.011 Get rights and content

Background

Various procedures have been performed to decrease the incidence of recurrent postoperative pneumothorax after thoracoscopic bullectomy. The purpose of this study was to determine the efficacy of a polyglycolic acid (PGA) sheet and pleural abrasion for prevention of recurrent postoperative pneumothorax.

Methods

From January 2009 to August 2011, 257 patients underwent thoracoscopic bullectomy for primary spontaneous pneumothorax. In group A, 128 patients underwent pleural abrasion. These patients were compared with 129 patients (group B) who underwent a procedure to cover stable lines with an absorbable PGA sheet in addition to pleural abrasion.

Results

There was no difference in preoperative demographics, although the age of patients in group A was statistically higher than that of patients in group B (23.67 ± 6.54 versus 21.69 ± 5.65; p = 0.010). In group A, prolonged postoperative air leaks (≥ 3 days) occurred more frequently (7.8% versus 2.3%; p = 0.045). A Kaplan-Meier curve showed that recurrence-free rates were higher in group B (p = 0.047).

Conclusions

Coverage with PGA sheet and pleural abrasion after thoracoscopic bullectomy is effective for preventing prolonged postoperative air leaks and reducing postoperative recurrence rates.

Section snippets

Patients and Methods

This study was approved by the Institutional Review Board of the Yonsei University College of Medicine (approval number 4-2010-0099). At preoperative workup, patients who agreed to the use of absorbable PGA sheet were assigned to group B, and those patients provided written informed consent.

Results

Patient age in group A was statistically higher than that in group B (23.67 ± 6.54 versus 21.69 ± 5.65 years; p = 0.010), whereas statistically significant differences in preoperative demographics that included sex, body mass index, smoking history, history of pulmonary tuberculosis, and pneumothorax site were not found (Table 1).

Number of wedge resections was not statistically different between groups (p = 0.971). There was no operative mortality or morbidity in either group. In this study,

Comment

PSP occurs in persons without underlying lung disease. It commonly occurs in thin or tall young male individuals between the ages of 10 and 30 years and rarely occurs in persons older than 40 years 1, 6, 7. In patients treated with conservative therapy for PSP (observation, needle aspiration, or chest tube drainage), the average recurrence rate is 30% (16%–52%) [8]. Therefore, surgical management is required to decrease the recurrence of PSP.

In the past, open bullectomy was the gold standard

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Cited by (35)

Efficacy of mesh coverage in surgical bullectomy for primary spontaneous pneumothorax: A systematic review and meta-analysis
2023, Surgeon
Thoracic surgeons are now adopting a new method of using a mesh covering to reduce recurrence in surgical pleurodesis for pneumothorax. We aimed to review the literature and compare the outcomes of using mesh covering as an additional procedure during surgical pleurodesis.
A comprehensive search was performed from inception to October 2022 on PubMed, Embase, Cochrane and Scopus. Randomised controlled trials (RCTs) and observational cohort studies (OCSs) comparing the use of mesh coverage, and different materials were included. Data were extracted to compare recurrence and other outcomes using a random effect model.
23 studies consisting of 2 RCTs and 21 OCSs totalling 5092 patients were included. Patients with a mesh had a significantly lower recurrence (OR = 0.22, 95% CI 0.12–0.42, p < 0.0001) and a shorter duration of chest tube drainage (SMD = −0.74 days, 95% CI −0.28 to −1.20, p < 0.0001) but no significant difference in the length of operation. The use of polyglycolic acid (PGA) and vicryl mesh was associated with a significantly shorter duration of chest tube drainage [(PGA, SMD = 0.83 days, 95% CI 0.14–1.52, p < 0.0001), (vicryl, SMD = 1.06 days, 95% CI 0.71–2.82, p = 0.0005)]. They also had a shorter post-operative length of stay than oxidized regenerative cellulose (ORC) but this was not statistically significant.
The use of a mesh material reduced the incidence of post-operative air leaks in the short term and the recurrence rate in the long term. Some mesh materials such as PGA and vicryl performed better than other materials.
Thickened parietal pleural covering in intractable pneumothorax: A case report
2022, Annals of Medicine and Surgery
Citation Excerpt :
The optimal choice of surgical treatment for intractable pneumothorax is complex. If air leaks are present, making resection unsuitable, and pleurodesis [1], fibrin glue injection [2], covering with artificial material [3], bronchial occlusion using Endobronchial Watanabe Spigot (silicone spigot, EWS®, Novatech, LaCiotat, France) [4], and the use of other bronchial valves must be considered. Treatment failure using these approaches necessitates the consideration of an autologous material for covering [5].
Choosing the optimal surgical approach for intractable pneumothorax can be challenging for surgeons.
A case describing the management of intractable pneumothorax has been presented.
Resection is not suitable in a stiff lung from repeated pleurodesis, and multiple air leakage points would make it more intricate.The ideal alternative is the use of another material to cover the entire lesion.
A thickened parietal pleura covering is an effective surgical approach for intractable pneumothorax.
Vicryl Mesh Coverage Reduced Recurrence After Bullectomy for Primary Spontaneous Pneumothorax
2021, Annals of Thoracic Surgery
Citation Excerpt :
One of the concerns about the pleural symphysial procedure is severe and extensive pleural adhesion, such as the talc effect,16 which may negatively affect future interventions in the pleural space if required.17 One cohort study reported that the use of a polyglycolic acid sheet fixed with a blood patch in addition to abrasion pleurodesis could prevent recurrence of pneumothorax.10 In their study, however, fibrin glue or a blood patch was used in addition to the mesh.
Although thoracoscopic stapled bullectomy is a standard procedure for primary spontaneous pneumothorax (PSP), the postoperative recurrence rate is high. We investigated whether using a Vicryl (Ethicon, Somerville, NJ) mesh to cover the staple line after bullectomy reduces the postoperative recurrence rate.
Our single-blind, parallel-group, prospective, randomized controlled trial at 2 medical centers in Taiwan studied patients with PSP who were aged 15 to 50 years and required thoracoscopic bullectomy. On the day of operation, patients were randomly assigned (1:1) to receive Vicryl mesh (mesh group) or not (control group) after thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion. Randomization was achieved using computer-generated random numbers in sealed envelopes. Our primary end point was the pneumothorax recurrence rate within 1 year after the operation (clinicaltrials.gov number, NCT01848860.)
Between June 2013 and March 2016, 102 patients were assigned to the mesh group and 102 to the control group. Within 1 year after operation, recurrent pneumothorax was diagnosed in 3 patients (2.9%) in the mesh group compared with 16 (15.7%) in the control group (P = .005). The short-term postoperative results and hospitalization duration were comparable between the groups.
For thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion, the use of a Vicryl mesh to cover the staple line is effective for reducing the postoperative recurrence of pneumothorax. Vicryl mesh coverage can be considered an optimal adjunct to the standard surgical procedure for PSP.
Evaluation of pleurodesis by poly-ε-caprolactone (PCL) gel in an animal model using New Zealand white rabbits
2019, Asian Journal of Surgery
Citation Excerpt :
More and more need for pleurodesis using some kind of biomaterial is noted in recent years when treating pleural diseases.1–3
Pleurodesis with biomaterial implant is an emerging treatment method for pleural diseases. However, the ideal biomaterial or the optimal form for the common diseases is still under investigation. In our previous study, Poly-ε-caprolactone (PCL) membrane produces significant pleurodesis in New Zealand White rabbit animal models.
We investigate the Poly-ε-caprolactone (PCL) gel pleurodesis by animal models using New Zealand White rabbits, which were sacrificed for examination after one month. Thirty-Six New Zealand White rabbits were randomized into three groups equally to undergo procedures. Gross pleurodesis scoring was evaluated. Additionally, inflammation and fibrosis scoring were done under microscopic evaluation, as well as Western blot analysis.
Gross evaluation of pleurodesis score revealed that lower concentrated PCL gel (10%) produced moderate pleural adhesion, while higher concentrated PCL gel (25%) showed significantly higher pleurodesis scores. (P < 0.05) Control group with thoracostomy alone produced almost no pleurodesis (P < 0.05). Western blot showed fibronectin expression was more evident in the 25% PCL gel than 10% one.
PCL gel induced significant degree of pleurodesis in the rabbits. The 25% PCL gel produces more intensive adhesion than 10% one. Fibronectin plays an important role in the process of pleurodesis. Further study is required for the clinical application of the promising biomaterial with gel form.
Study of poly-ɛ-caprolactone membranes for pleurodesis
2017, Journal of the Formosan Medical Association
Citation Excerpt :
A potential alternative to increase the intensity of pleural inflammation and thereby prevent pneumothorax recurrence is film pleurodesis. Only a few studies have been reported in which more than one film pleurodesis has been tried,12,13 and the mechanism of film pleurodesis remains unclear. Poly-ɛ-caprolactone (PCL) is a biomaterial approved by the US Food and Drug Administration, with a slow degradation time of ∼24 months when degraded by hydrolysis alone.14–18
Pleurodesis with biomaterial membrane is an emerging treatment method for pneumothorax. However, the ideal one for the common disease is still under debate.
We investigate the Poly-ε-caprolactone (PCL) membrane pleurodesis by using New Zealand White rabbits, which was sacrificed for examination one month later. Moreover, inflammation and fibrosis scoring were done under microscopic evaluation, as well as Western blot analysis in vitro and in vivo.
Gross evaluation of pleurodesis score revealed that dense PCL membrane produced moderate pleural adhesion, while porous PCL membrane exhibited significantly higher pleurodesis scores.
PCL membrane induced significant degree of adhesion, both within the abdomen and chest of the rabbits. The porous PCL membrane produces more intensive adhesion than dense one. Fibronectin plays an important role in the process of pleurodesis. Further study is required for the clinical application of the promising material.
Optimal surgical technique in spontaneous pneumothorax: a systematic review and meta-analysis
2017, Journal of Surgical Research
Citation Excerpt :
In the wedge resection + pleural abrasion + chemical pleurodesis group, two treatment arms used talc and two treatment arms used minocycline.11-18 Reinforcement of the staple line was preformed using polyglycolic acid sheets (three treatment arms), fibrinogen-based collagen fleece (one treatment arm), cellulose mesh (two treatment arms), Vicryl mesh (two treatment arms), and fibrin glue (one treatment arm).19-25 A total of 51 studies reported data for 65 treatment arms for the outcome recurrence rates.
Numerous thoracoscopic techniques have been used in the management of primary spontaneous pneumothorax (PSP), including wedge resection, pleurectomy, pleural abrasion, chemical pleurodesis, and staple line covering. The purpose of this systematic review was to compare outcomes for the most commonly reported techniques.
A systematic literature search looking at pneumothorax recurrence rate, length of stay, and chest tube duration after surgery was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database.
Fifty-one unique studies comprised of 6907 patients published between January 1988 and June 2015 were identified. Heterogeneity among effect sizes was significant for all outcomes. The lowest recurrence rates were observed in the wedge resection + chemical pleurodesis (1.7%; 95% confidence interval [CI], 1.0%-2.7%) and the wedge resection + pleural abrasion + chemical pleurodesis (2.8%; 95% CI, 1.7%-4.7%) groups. The shortest chest tube duration and length of stay were observed in the wedge resection + staple line covering ± other group (2.1 d; 95% CI, 1.4-2.9 and 3.3 d; 95% CI, 2.6-4.0, respectively).
The variability in reported outcomes and the lack of published multicenter randomized controlled trials highlights a need for more robust investigations into the optimal surgical technique in the management of PSP. Based on the limited quality studies available, this systematic review favors wedge resection + chemical pleurodesis and wedge resection + pleural abrasion + chemical pleurodesis in terms of recurrence rate after surgery for PSP.

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Original articleGeneral thoracicEfficacy of Polyglycolic Acid Sheet After Thoracoscopic Bullectomy for Spontaneous Pneumothorax

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Ann Thorac Surg

Lancet

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Spontaneous pneumothorax

N Engl J Med

Recurrence of primary spontaneous pneumothorax

Thorax

Impact of additional pleurodesis in video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax

Surg Endosc

Staple line coverage with absorbable mesh after thoracoscopic bullectomy for spontaneous pneumothorax

Surg Endosc

Original article
General thoracic
Efficacy of Polyglycolic Acid Sheet After Thoracoscopic Bullectomy for Spontaneous Pneumothorax