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ORIGINAL ARTICLES |
From the Department of Oncologic Thoracic Surgery (PPBM, BC, CL, IC), Istituto Nazionale Tumori, Milan, Italy; and the Statistical Unit (BM), Istituzioni Assistenziali Riunite, Pavia, Italy.
Correspondence: Address correspondence and reprint requests to: Pier Paolo Brega Massone, MD, Via Cascina Spelta 24/b, 27100 Pavia, Italy; Fax: 39-02-236-0486; E-mail: ppbm{at}virgilio.it
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ABSTRACT |
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Methods: We initiated a case-control study whereby 100 patients underwent precision resections for lung metastases. The subjects were divided into 2 groups, both with 50 patients: group 1 was treated with fibrin glue and group 2 with cauterization. Evaluation parameters consisted of the following: air leak duration, expected complications, drain time, and in-hospital stay.
Results: In group 1, air-leak time was 2.68 ± 1.72 days, versus 7.80 ± 8.52 for group 2 (P < .001). In group 1, there were 2% complications, whereas in group 2 there were 28% (P < .001). Drain time was 4.54 ± 1.83 days for group 1 and 9.54 ± 8.35 for group 2 (P < .001). In-hospital stay was 6.54 ± 1.83 days for group 1 and 11.54 ± 8.35 for group 2 (P < .001).
Conclusions: In the group treated with fibrin glue, we observed significant advantages. Our experience shows that the use of fibrin glue can improve aerostasis control in nonanatomical resections with high risk of air leak.
Key Words: Aerostasis • Air leak • Fibrin glue • Cauterization • Lung metastasis • Precision resection
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Among the most risky operations for this complication, lung metastasectomy by nonanatomical resection, such as a precision resection standard technique,2,3 seems to result in a higher percentage of prolonged air leaks. This kind of risk could be related to the multiplicity of secondary lesions, to their localization, to the basal conditions of pulmonary parenchyma, and to the possible adhesions in case of repetitive surgery, rather than to a real limitation of the procedure itself. The decision is made to perform a precision resection by using electrocautery to preserve as much pulmonary parenchyma as possible in the event that follow-up surgery is needed. In the attempt to reduce the incidence of air leaks, we have chosen to use a commercial fibrin glue (Tissucol; Baxter AG, Vienna, Austria) to take advantage of its biological features, such as the rapid and permanent adherence to tissue and the biostimulating power it provides for tissue regeneration.4,5
The aim of our study was to evaluate the usefulness of the modification introduced on the standard precision resection technique by the consecutive application of fibrin glue on the residual zones after resection of metastatic pulmonary lesions and its effect on the duration of air leak, drainage, complications, and length of stay.
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MATERIAL AND METHODS |
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The amount of Tissucol used correlates directly with the number of resections performed and the residual air-leaking zones, with a range 2 to 10 ml. We applied Tissucol to the pulmonary parenchyma excision surface manually by means of a syringe needle to precisely and gradually fill the cauterized area in patients selected for its use.
Surgical Technique
Precision resection technique was first described by Perelman2 in 1983 and later by Cooper et al.3 in 1986. The concept of this procedure is the nonanatomical resection of a small-dimension pulmonary nodule by electrocauterization. Precision resection is most commonly performed when metastatic disease is present and the need to preserve pulmonary parenchyma is necessary in the event that further surgical intervention is required. Parenchyma preservation is not obtainable with other surgical techniques, such as anatomical resections or wedge resections performed with staplers. The precision resection technique is generally performed with a sternotomic or thoracotomic approach, depending on the bilateralism or monolateralism of the metastatic lesions to be resected; it requires the insufflation of the lung to be operated on as an anesthesiological approach. Once the metastatic nodule is detected, electrocautery is used to outline a circle on the pleural surface that corresponds to the size of the core of lung to be excised; necessary radical margins are maintained (Fig. 1). The circular incision is then continued deeper to reach the normal parenchyma and to isolate the neoplastic lesion together with an adequate quantity of pulmonary parenchyma to ensure oncological radicality. At this moment, the pulmonary tissue containing the metastatic nodule is separated from the surrounding lung without bleeding, yet the presence of a small air leak is to be expected. On the operated lung, there remains a dry cavity with a black coagulated surface (Fig. 2). In our institute, to further reduce the incidence of air leak, we proposed to modify the standard precision resection technique by applying Tissucol after resection. We manually applied the Tissucol by means of standard-sized syringes on the electrocautery excision surface, filling the residual hole in the lung parenchyma. The final result was a complete filling of cauterized areas that could be compared with small basins in the lung parenchyma closed by a plug (Fig. 3). The complete absence of bleeding and a very low air leak at the moment of the Tissucol application are fundamental to the perfect adherence of the sealant to the pulmonary surface, ensuring the success of the technique. At this moment, we confirm fibrin glue adherence and seal to the lung surface.
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1.5 cm by use of the precision resection technique. All patients selected for our study underwent surgical resections as described previously; we included first operations and reoperations. We divided the patients into two groups, which were similar for age, sex, type of surgical approach, type of operation, number of resections performed, and type of pathology. Group 1 was composed of 50 subjects, who received multiple bilateral or ipsilateral precision resections with successive application of Tissucol on the excision residual zones. Thirty-three patients were male (66%), and 17 were female (34%), with an average age of 40.76 ± 17.21 years (median, 39 years; range, 12–73 years). The quantity of fibrin glue used was proportional to the number of precision resections performed and to the air-leaking zones after adhesiolysis, in case of reoperation. The control group, composed of 50 patients, underwent similar intervention with standard techniques; 29 subjects were male (58%), and 21 were female (42%), with an average age of 41.84 ± 17.66 years (median, 42 years; range, 12–76 years).
We decided to perform a case-control study to select two groups of patients with as many similar features as possible to evaluate the air leak in patients in the same condition (in particular, with the same number of resections and the same metastasis size and who were operated on by the same surgical equipment with the same modalities), trying to avoid bias that can influence results analysis.
The surgical approaches used in the subjects of both groups were median sternotomy for the treatment of bilateral metastases and thoracotomy for monolateral operations. Generally, we prefer, in case of thoracotomy, an anterolateral muscle-sparing approach, and we use a posterior muscle-sparing approach only in particular cases in which metastatic nodule removal is difficult by the anterior way. The surgical approaches were the same for both groups: median sternotomy in 26 cases (52%), thoracotomy in 6 (12%), median re-sternotomy in 6 (12%), and re-thoracotomy in 12 (24%).
All patients had two thoracic drains inserted before the closure. One tube was apically placed (anterior), and the second was basal, placed in the costophrenic sinus (posterior). Drains were postoperatively placed under 8 mm Hg of negative pressure. After the cessation of air leak, drains were taken off suction and removed after 24 hours if the lung was radiologically expanded and the drainage of pleural fluid was serous and <150 ml/24 hours.
We considered the following as comparison parameters between the two groups: air-leak duration, expected complications, drain-time duration, and length of postoperative course. The incidence of complications was evaluated by considering the time of prolonged air leak, and we established the cutoff to be 10 days.
We also evaluated the incidence of the postoperative air-leak duration versus the number of precision resections executed, of ipsilaterality versus bilaterality, and of iterative surgery versus first operation. For analysis of the number of the resections performed per patient, we considered 3 subgroups: the first for subjects submitted to <5 precise resections per operation, the second for 5 to 10 resections, and the last for >10 resections.
Statistical Analysis
We performed a descriptive statistical survey for all the variables included in the study, calculating frequencies, means, medians, and SD. The average values of air-leak duration, drain time, and length of postoperative course were compared in the two groups by using two-tailed Student’s t-tests (level of significance, .01) for unpaired data. The frequency of expected complications in the two groups was compared by 
2 test.
The incidence of the number of resections, of reoperations, and of ipsilaterality or bilaterality of the postoperative air leak was evaluated in each group by means of ANOVA. All data were analyzed withSPSS 6.0 for Windows (SPSS Inc., Chicago, IL).
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RESULTS |
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Group 2 patients underwent similar operations: bilateral multiple precision resections in 32 cases (64%) and ipsilateral resections in 18 (36%). Thirty-two first operations (64%) and 18 reoperations (36%) were performed.
The patient divisions into three subgroups, by using the criteria of the number of precision resections performed, as explained previously, and the complete data comparing the fibrin-sealant group versus the standard-technique group are listed inTable 1. All subjects in the two groups were operated on for lung metastases, and sarcoma was the most represented histotype (80% in group 1 and 72% in group 2).
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In the Tissucol group, there was 1 complication (2%), represented by air leak prolonged for >10 days, whereas in the standard-technique group there were 14 complications (28%; 14 patients with air leak >10 days). In the group treated with fibrin glue, the mean postoperative hospital stay was 6.54 ± 1.83 days (median, 6 days; range, 4–15 days), whereas in the control group, it was on average 11.54 ± 8.35 days (median, 9 days; range, 4–35 days).
Considering all the evaluation parameters, we noticed a statistically significant difference in favor of the group of patients treated with Tissucol. These values are listed inTable 2.
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DISCUSSION |
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For these reasons, the aim of our work was to identify a real situation with a very high risk of air leak in which the application of fibrin glue could represent an absolute indication and could actually prevent this very disabling complication. We reduced the indications of use of the product to those cases, such as multiple nonanatomical resections and reoperations, in which a lower aerostasis control could be expected and the possible use of fibrin glue, in case of results confirming its usefulness, could become a nonsubstitutable step of the operation.
The surgical treatment of lung metastases, particularly, represents a serious problem in aerostasis control; the possibility of finding multiple, bilateral, and, sometimes, deep nodules in the pulmonary parenchyma can lead to a higher incidence of air leak in the postoperative period.
Among the metastatic diseases, sarcomas,18,19 in comparison to other neoplasms,20 have the peculiarity of appearing as small-sized multiple nodules; this kind of metastatization constitutes the principal indication to precise resections technique and for this reason sarcomas represent the 76% in our series. In these rare tumors, in particular, surgery is the therapy of choice in the presence of lung metastases, because it can make the disease become chronic, so ensuring, in selected cases, long-term survival.21 The trend of lung metastases to relapse, together with the absence of valid alternative therapies, has led thoracic surgeons to perform multiple operations on the same patient, with the further risk of increasing aerostasis complications.22–24
Therefore, in performing metastasectomy, the rationale must be focused on saving as much parenchyma as possible in view of a possible relapse of the neoplastic disease and of a further need for surgical resections; the precision resection technique represents the most adequate procedure to reach this aim. However, we can deduce that many problems can influence the occurrence of an air leak: the resection number, the technique used, the underlying condition of the pulmonary parenchyma at the operation time, and a first operation versus a reoperation. Our institute has historical experience with surgical treatment of lung metastases,25–30 and the technique that we used (anatomical resection, wedge resection, and precision resection) depends on the lesions’ features—above all, on their dimension and localization.
We selected our series, excluding from the study all the cases submitted to major pulmonary resections or wedge resections performed with staplers; otherwise, we included the numerous patients submitted to precision resections with the technique described by Perelman2 and Cooper et al.3 for the excision of multiple nodules with dimensions 1.5 cm. On this basis, we selected two groups of patients with similar features to perform a precise statistical analysis. The patient’s age, the kind of treatment used (surgical approach, technique modality, and number of resections performed), and the kind of pathology had to be homogeneous to evaluate the control parameters (air-leak duration, drain time, possible expected complications, and hospital stay).
From the analysis of our data, we can conclude that the use of fibrin glue reduced the air-leak duration by a median of 2 days in group 1 and a median of 5 days in the group treated with the standard technique; in the same way, its use allowed the earlier removal of the thoracic drains (median, 4 vs. 7 days). The postoperative in-hospital stay was consequently reduced (median, 6 vs. 9 days), producing very important economic advantages (hospital charge reductions).
Only 1 patient (2%) in the group treated with Tissucol had a prolonged air leak of >10 days, versus 14 cases (28%) in the control group. We like to underline that these results led to a considerable improvement in the general clinical conditions and quality of life of patients submitted to metastasectomy. The rapid removal of thoracic drains allowed a quick mobilization and eliminated a source of pain and potential infection, considering that we were dealing with immunocompromised patients who had previously undergone numerous oncological treatments (surgical excision of the primary tumor, followed by chemotherapy, radiotherapy, and, sometimes, surgical resections of previous metastases). We can understand that these patients, who are often young, are stressed, psychologically compromised, and reluctant to undergo any other therapy.
The number of metastases and, consequently, the number of resections performed had a significant effect on postoperative air leak, whereas reoperation and bilateral resections did not influence this parameter. The results of our experience focused on the effectiveness of the use of fibrin glue in this kind of high-risk operation in preventing and reducing the complications related to aerostasis control and underlined the advantage obtained in terms of the cost-benefit ratio. For these reasons, the application of this sealant after the resection of metastatic nodules by means of electrocauterization has to be considered a real new surgical step intended to modify the standard technique.
Even if precision resections theoretically seem to be related to an increased incidence of prolonged air leak, they have to be preferred, in the presence of the above-mentioned indications, to stapler resections because they allow us to save more pulmonary parenchyma (granting better pulmonary function). This advantage becomes fundamental, considering the possibility of further operations in patients submitted to many treatments because of the high incidence of relapses, as in case of distant metastases.
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CONCLUSIONS |
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Footnotes |
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We studied fibrin glue effectiveness, in prevention of air leaks in nonanatomical lung resections, in 100 patients: 50 treated with original technique versus 50 with fibrin glue application. Fibrin glue improves aerostasis control in operations with high risk of air leaks.
Received for publication May 21, 2002. Accepted for publication November 8, 2002.
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REFERENCES |
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This article has been cited by other articles:
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  A. Belboul, L. Dernevik, O. Aljassim, B. Skrbic, G. Radberg, and D. Roberts The effect of autologous fibrin sealant (Vivostat(R)) on morbidity after pulmonary lobectomy: a prospective randomised, blinded study Eur. J. Cardiothorac. Surg., December 1, 2004; 26(6): 1187 - 1191. [Abstract] [Full Text] [PDF]
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