Which bioabsorbable sheet is optimal for combined application with fibrin sealant against alveolar air leakage?

Abstract

Background: There are few basic comparative data on the sealing effect of various bioabsorbable sheets in combination with fibrin sealant (FS), which is a more effective tool for the control of alveolar air leakage than the single use of FS alone. The objective of this study was to investigate which bioabsorbable sheet had the best sealing effect against alveolar air leakage when used in combination with FS, in terms of material quality, weaving pattern, and/or thickness.

Methods: Standardized 20 mm × 30 mm pleural defects were covered with three pieces of the following sheets using the Rub + Soak B technique in an ex vivo porcine lung model. Seal-breaking burst pressure (SBBP) was compared between groups. Experiment 1: 0.15 mm-thick (Group 1), 0.3 mm-thick (Group 2) and 0.5 mm-thick (Group 3) non-woven polyglycolic acid (PGA) felt were compared. Experiment 2: 0.15 mm-thick non-woven PGA felt (Group 1), 0.15 mm-thick meshed oxidised regenerated cellulose (ORC) (Group 4); 0.11 mm-thick woven PGA (Group 5) and 0.18 mm-thick knitted PGA (Group 6) were compared. Experiment 3: TachoSil^® alone (Group 7), TachoSil^® combined with FS (Group 8) and 0.15 mm-thick non-woven PGA felt (1 piece) (Group 9) were compared.

Results: In Experiment 1, SBBP was significantly higher in Group 1 than in Group 3. The SBBP in Group 2 was significantly higher than that in Group 3. In Experiment 2, SBBP in Group 4 was significantly lower than that in Groups 1, 5, and 6. In Experiment 3, SBBP in Group 7 was significantly lower than that in Groups 8 and 9.

Conclusions: Regarding the sheet thickness of PGA felt, the 0.15 mm was the most effective. Regarding the material quality, the ORC was the least suitable. TachoSil^® combined with FS was comparable to the most effective 0.15 mm-thick non-woven PGA felt.

Keywords: Alveolar air leakage; bioabsorbable sheet; combined application technique; fibrin sealant (FS); lung surgery.

Video 1

Experimental procedure. The experimental procedure of Group 1 is demonstrated in the video as followings: (I) a standardized 20 mm × 30 mm pleural defect was created with the lung expanded at an intra-airway pressure of 10 cmH₂O using electric cautery; (II) massive air leaks from the uncovered pleural defect were seen along with the linear increase of intra-airway pressure; (III) fibrinogen solution was rubbed on the pleural defect with the lung expanded at an intra-airway pressure of 6 cmH₂O; (IV) 0.15 mm-PGA felt was impregnated with thrombin solution; (V) attachment of the sheets to the pleural defect with the lung expanded at an intra-airway pressure of 6 cmH₂O; (VI) seal-breaking burst pressure was visually measured using a digital manometer with a graphical display demonstrating sequential pressure change. PGA, polyglycolic acid.

Figure 1

Size of bioabsorbable sheet and modality of covering. (A) Modality with three pieces. In Groups 1, 2, 3, 4, 5, and 6, three pieces of 15 mm × 30 mm sheets were attached over and over, with their margin doubled to cover the 5 mm-width outer margin of the standardized 20 mm × 30 mm pleural defects. (B) Modality with one piece. In Groups 7, 8, and 9, one piece of 40 mm × 30 mm sheet was attached to cover the 5 mm-width outer margin of the standardized 20 mm × 30 mm pleural defects.

Figure 2

Macroscopic photographs of the applied covering technique. (A) Group 1 (PGA0.15), 0.15 mm-PGA felt; (B) Group 2 (PGA0.3), 0.3 mm-PGA felt; (C) Group 3 (PGA0.5), 0.5 mm-PGA felt; (D) Group 4 (ORC), ORC sheet; (E) Group 5 (W-PGA0.11), Vicryl Mesh Woven; (F) Group 6 (K-PGA0.18), Vicryl Mesh Knitted; (G) Group 7 (TachoSil), TachoSil; (H) Group 8 (FS + TachoSil), fibrin sealant + TachoSil; (I) Group 9 (1p-PGA0.15), 0.15 mm-Neoveil (1 piece). PGA, polyglycolic acid; ORC, oxidised regenerated cellulose; FS, fibrin sealant.

Figure 3

Comparison of SBBP in each experiment. (A) Experiment 1. The SBBP in Group 1 was significantly higher than that in Group 3 (*, P<0.05) and showed a trend toward higher pressure than Group 2 (P=0.161). The SBBP in Group 2 was significantly higher than that in Group 3 (*, P<0.05). (B) Experiment 2. The SBBP in Group 4 was significantly lower than that in Groups 1, 5 and 6, respectively (*, P<0.05). (C) Experiment 3. The SBBP in Group 7 was significantly lower than that in Groups 8 and 9 (*, P<0.05). There was no significant difference between Groups 8 and 9 (P=0.981). SBBP, seal-breaking burst pressure; PGA, polyglycolic acid; ORC, oxidised regenerated cellulose; FS, fibrin sealant.

Figure 4

SBBP comparison across all experiments. When all the Groups across Experiments 1, 2, and 3 were compared, Group 4 showed the lowest seal-breaking burst pressure, followed by Groups 3 and 7. SBBP, seal-breaking burst pressure; PGA, polyglycolic acid; ORC, oxidised regenerated cellulose; FS, fibrin sealant.

Figure 5

Histological findings. Histological findings of PTAH staining in Group 9 (0.15 mm thick-PGA felt (Neoveil^®) (A) and Group 8 (fibrin sealant + TachoSil^®) (B). The firmly fixed layers of fibrin and fabrics covering the pleural defects, and the penetration of the fibrin clot into the lung tissue were significant in both groups. Magnification: 12×. NS, Neoveil^® sheet; CP, clot penetration into the tissue; TS, TachoSil; PTAH, phosphotungstic acid hematoxylin.