Comparative study of biological glues: cryoprecipitate glue, two-component fibrin sealant, and "French" glue

BACKGROUND: Although biological glues have been used clinically in cardiovascular operations, there are no comprehensive comparative studies to help clinicians select one glue over another. In this study we determined the efficacy in controlling suture line and surface bleeding and the biophysical properties of cryoprecipitate glue, two-component fibrin sealant, and "French" glue containing gelatin-resorcinol-formaldehyde-glutaraldehyde (GRFG). METHODS: Twenty-four dogs underwent a standardized atriotomy and aortotomy; the incisions were closed with interrupted 3-0 polypropylene sutures placed 3 mm apart. All dogs had a 3- by 3-cm area of the anterior wall of the right ventricle abraded until bleeding occurred. The animals were randomly allocated into four groups: in group 1 (n = 6) bleeding from the suture lines and from the epicardium was treated with cryoprecipitate glue; in group 2 (n = 6) bleeding was treated with two-component fibrin sealant; group 3 (n = 6) was treated with GRFG glue; group 4 (n = 6) was the untreated control group. The glues were also evaluated with regard to histomorphology, tensile strength, and virology. RESULTS: The cryoprecipitate glue and the two-component fibrin sealant glue were equally effective in controlling bleeding from the aortic and atrial suture lines. Although the GRFG glue slowed bleeding significantly at both sites compared to baseline, it did not provide total control. The control group required additional sutures to control bleeding. The cryoprecipitate glue and the two-component fibrin sealant provided a satisfactory clot in 3 to 4 seconds on the epicardium, whereas the GRFG glue generated a poor clot. There were minimal adhesions in the subpericardial space in the cryoprecipitate and the two-component fibrin sealant groups, whereas moderate-to-dense adhesions were present in the GRFG glue group at 6 weeks. The two-component fibrin sealant was completely reabsorbed by 10 days, but cryoprecipitate and GRFG glues were still present. On histologic examination, both fibrin glues exhibited minimal tissue reaction; in contrast, extensive fibroblastic proliferation was caused by the GRFG glue. The two-component and GRFG glues had outstanding adhesive property; in contrast, the cryoprecipitate glue did not show any adhesive power. The GRFG glue had a significantly greater tensile strength than the two-component fibrin sealant. Random samples from both cryoprecipitate and the two-component fibrin glue were free of hepatitis and retrovirus. CONCLUSIONS: The GRFG glue should be used as a tissue reinforcer; the two-component fibrin sealer is preferable when hemostatic action must be accompanied with mechanical barrier; and finally, the cryoprecipitate glue can be used when hemostatic action is the only requirement.     

Thoracoscopic pleural tent

Lung volume reduction has been performed in patients with advanced emphysema to relieve dyspnea and improve exercise tolerance. Median sternotomy and video-assisted thoracoscopy have been proposed as equally adequate approaches; however, prolonged postoperative air leakage is the most prevalent complication in all series. For this reason, on the basis of the experience achieved with the median sternotomy approach, buttressing of the suture line with different materials and techniques for space reduction have been proposed. We describe a technique to create a pleural tent after thoracoscopic volume reduction. The thoracoscopic creation of a pleural tent is feasible and results in a duration of postoperative air leaks and hospital stays similar to that achieved with stapler line buttressing.     

Axillary vein puncture over the second rib

BACKGROUND: Video-assisted thoracic operations usually require single-lung ventilation under general anesthesia. However, for high-risk patients with other underlying pulmonary diseases, one has to consider risks of general anesthesia itself. METHODS: Four high-risk patients (4 men; mean age, 73 years) with intractable secondary pneumothorax and other underlying pulmonary diseases were treated by video-assisted thoracic operations under local and epidural anesthesia. Absorbable polyglycolic acid sheets and fibrin glue were used to control the air leakage. RESULTS: The mean duration of the procedure was 108 minutes. Pain and cough reflex were well controlled, and spontaneous breathing and hemodynamics were well maintained during the operation. The mean duration of the postoperative chest drainage was 5 days. No significant postoperative complication was encountered. No pneumothorax had recurred at a mean follow-up of 16 months. CONCLUSIONS: Video-assisted thoracic operations can be performed safely under local and epidural anesthesia for the treatment of intractable secondary pneumothorax in high-risk patients. The air leakage can be controlled with the use of polyglycolic acid sheets and fibrin glue without bullectomy.     

Successful video-assisted thoracoscopic bullectomy and Nd-YAG laser ablation

We report here two cases of giant/multiple emphysematous bullae treated with video-assisted thoracoscopy. The first case was a 35-year-old male who was referred to our hospital because an abnormal shadow was casually pointed out in a chest roentgenogram. Chest computed tomographic scan showed giant bulla in the left upper lobe. The second patient was a 37-year-old male who had a symptom of shortness of breath on exertion. Chest roentgenogram and computed tomographic scan revealed multiple bullae at bilateral apical regions. They were performed resection of bulla with stapler and Nd-YAG laser ablation to the emphysematous surroundings using video-assisted thoracoscopy. They had recovered sufficiently to be discharged from our hospital. We think Nd-YAG laser ablation is effective to prevent postoperative air leakage and recurrence of bullae because it makes surrounding tissue tight and continuous.     

Treatment of hemopneumothorax under thoracoscopic guidance: a case report

A 32-year-old man was admitted to our hospital complaining of chest pain and increasing dyspnea. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the left hemithorax. Shock developed following drainage of 1,500 ml hemorrhagic pleural fluid. Following blood transfusion, emergency surgery was carried out. At operation under thoracoscopic guidance, a bleeding artery originating from the apex of the thoracic cavity and a bulla on the upper lobe were noted. The artery was successfully ligated with surgical clip, and the bulla was resected using EndoGIA. This case report indicates that hemopneumothorax can be safely operated on under thoracoscopic guidance after the patient has recovered from shock by adequate blood transfusion.     

Using ARROWSMITH: a computer-assisted approach to formulating and assessing scientific hypotheses

The usefulness of Xe-133 and Tc-99m-MAA single photon emission computed tomography (SPECT) in identifying areas to be resected during video-assisted thoracoscopic lung reduction surgery for emphysema was examined. Twenty-nine patients with advanced emphysema were examined using Xe-133 and Tc-99m-MAA SPECT prior to and following surgery. For the Xe-133 dynamic SPECT, patients inhaled Xe-133 gas for 6 minutes. Equilibrium and subsequent washout SPECT images were acquired every 30 seconds for 6 to 7 minutes during spontaneous breathing. Ventilation was quantified by Xe-133 clearance time (T1/2) in addition to visual assessment. The patients underwent unilateral thoracoscopic volume reduction in the regions with abnormal Xe-133 retention and Tc-99m-MAA defect. All patients demonstrated marked, heterogeneous Xe-133 retention and Tc-99m-MAA defects preoperatively. The worst functioning areas were identified as nonventilated and noflow areas, or areas with air trapping and low perfusion. These changes were found even in patients with diffuse and symmetrical impairments on chest CT. After surgery, most of these "target areas" disappeared and pulmonary function tests demonstrated significant improvement. T1/2 correlated closely with the percent predicted FEV1 (%FEV) and 6-minute walk distance before and after surgery (p<0.0001). Xe-133 and Tc-99m-MAA SPECT imaging was useful in identifying "target areas" in the emphysematous lung. Directed unilateral thoracoscopic volume reduction based on these SPECT images is an effective treatment for emphysema.     

Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience

PURPOSE: We investigated the effect of percutaneous drainage for the treatment of emphysematous pyelonephritis. MATERIALS AND METHODS: A retrospective analysis was done of 25 patients with emphysematous pyelonephritis who were treated initially with computerized tomography (CT) guided percutaneous drainage during a 10-year period. The patients were concomitantly treated with antibiotics, fluids, and correcting blood glucose and/or ureteral obstruction. We also compared our results of percutaneous drainage to CT findings. RESULTS: CT identified 12 patients with emphysematous pyelonephritis who had gas with little fluid and 13 who had gas with renal or perirenal fluid collections. In 20 of 25 patients (80%) antibiotic therapy combined with percutaneous drainage constituted the only treatment required. Three patients (12%) whose clinical status improved after percutaneous drainage subsequently underwent elective nephrectomy without further complications. Two patients (8%) died of multiple organ failure. There was no correlation between the gas patterns of emphysematous pyelonephritis and initial success with the antibiotics and percutaneous drainage. There were no recurrences and no complications during a followup of 1 to 10 years (mean 5). Mean duration of treatment was 5.54 weeks (range 1 to 12.6). CONCLUSIONS: CT is an efficient imaging method for diagnosis, guiding the drainage procedures and monitoring response to percutaneous drainage of emphysematous pyelonephritis. Antibiotic therapy combined with CT guided percutaneous drainage of emphysematous pyelonephritis is an acceptable alternative to antibiotic therapy with surgical intervention.     

Thoracoscopic lobectomy in the animal model

To evaluate the possibility of a pure thoracoscopic lobectomy by preparation and selective division of hilar structures we performed left cranial lobectomies in 5 G?ttingen mini-pigs. The vessels and the main bronchus were isolated and divided by an Endo-GIA stapler. As an alternative technique we used clips or endoscopic ligation. Inside the thoracic cavity the resected lobes were divided into 2 or 3 parts by the Endo-GIA. They could be extracted without destroying the tissue therefore making macroscopic examination possible. The intraoperative blood loss was minimal and all the pigs survived the operation. Two pigs were sacrificed initially, the remaining three one month later. These three showed no evidence of pleural fistula or atelectasis in remaining lung tissue either macroscopically or histologically. It appears that thoracoscopic selective lobectomy is technically possible at least in pig studies. Further studies will show whether thoracoscopic lobectomy in patient with malignancy is as effective as open radical thoracotomy techniques and if endoscopic mediastinal division is possible.     

Effects of Nd:YAG laser irradiation on morphometry and lung function in elastase-induced emphysema in rats

BACKGROUND & OBJECTIVE: Although thoracoscopic laser ablation therapy has been hailed as an effective surgical treatment for diffuse emphysema, no one has as yet made an in-depth study of the efficacy of this treatment. This investigation was undertaken to research the effects of laser pneumoplasty on an animal model of emphysema. STUDY DESIGN/MATERIALS AND METHODS: Eight weeks after elastase treatment, the rats' left lungs were irradiated using contact Nd:YAG laser. Pulmonary function tests were performed 4 weeks after irradiation and the lungs were prepared for histologic examination. RESULTS: Dense fibrous scars beneath the pleura were observed at 4 weeks after irradiation. Although mean linear intercept values of irradiated lungs were not much lower than those in the non-irradiated elastase-treated group, laser irradiation caused a significant decrease in lung volume. While there was no significant difference in quasistatic compliance, elastic recoil pressure of the lung increased to control levels at total lung capacity volume. CONCLUSION: We conclude that laser therapy does not cause normalization of compliance, or improvement in the deeper part of the emphysematous lung, but rather a peripheral volume reduction and "encasement effect" on the lungs as a result of fibrotic scars.     

Respiratory function and surgical reduction of lung volume

Emphysema is characterised by an enlargement of the terminal air spaces. Destructions of alveolar walls lead to a loss of the lung elastic recoil. The driving pressure for expiration is decreased and the outward forces acting on the bronchioles are lost, leading to bronchiolar collapse and airflow limitation. Hyperinflation of the lungs and overdistension of the chest wall cause the respiratory muscles to operate in unfavourable conditions. Patients with advanced emphysema have decreased quality of live: they are dyspneic at rest and are unable to perform exercise. Surgical excision of parts of diffusely emphysematous lungs (Lung Volume Reduction Surgery, LVRS) has been proposed since many years. Expansion of the remaining lung should increase lung elastic recoil and restore the outward forces on the bronchioles. It has been demonstrated that LVRS reduces dyspnea symptoms, improves exercise tolerance and enhances the quality of live. LVRS increases lung elastic recoil, airway conductance and maximal expiratory flow, reduces dynamic hyperinflation and improves the efficiency of the respiratory muscles. These improvements are maintained for at least 12 to 18 months. Preoperative evaluation, surgical-induced modifications of pulmonary functions and postoperative exercise training are exposed.     

Successful treatment of a giant bulla by thoracoscopic excision and laser ablation

A 39-year-old male complaining of shortness of breath on mild exertion. Radiographs revealed that a giant bulla occupied more than half the area of the right lung field. Thoracoscopic excision of the giant bulla was performed using some autosutures. After the emphysematous lesion was consolidated by laser ablation, it was sutured using PDS thread. The bulla in the left lung was similarly excised 3 weeks after the first procedure. The FEV1.0% improved from 72% to 89% after excision and laser ablation of a giant bulla and bullae. Thoracoscopic excision and laser ablation of a giant bulla appears to be an effective alternative to conventional thoracotomy.     

Local resection of pulmonary lesions by Nd-YAG laser without suturing

Local excision of 67 pulmonary lesions in 5 patients was performed with the Nd-YAG laser. There were 2 women and 3 men with an average age of 68 years. The patients consisted of three cases of metastatic lung cancer (65 lesions), one hamartoma (One lesion) and one organized pneumonitis (one lesion). The lesion was first enucleated by a contact method using an Nd-YAG laser scalpel, then the crater of the resected lesion in the normal lung tissue was coagulated with a defocused laser beam. The craters of 52 of the 67 resected lesions which were shallow seated in the lung were left open, but the other 15 resected lesions were closed with sutures. Total blood loss was less than 100 ml. There was no bleeding or air leakage (30 cm water pressure) during the post operative days in 4 of the 5 patients, but one patients (one lesion) had to be treated by bronchoscopic endobronchial embolization against a persistent air leak. This lesion was 2.5 cm in diameter and 4 cm deep in the lung on CT. The other lesions were also measured by CT. The tumor size was 1.4 +/- 0.7 cm and the depth was 2.4 +/- 1.0 cm. The Nd-YAG laser is very suitable for local resection of peripheral lung lesions without suturing.     

Opening of infectious giant bulla with use of video-assisted thoracoscopic surgery

In 5 cases, an infectious giant bulla was opened with the use of video-assisted thoracoscopic surgery (VATS). Because all bullae adhered to the thoracic wall and were noncommunicating with the airway, they were opened without complete resection, leaving their inside walls at the lung and lateral walls on the thoracic wall. The expansion of remnant lung was excellent, and postoperative air leakage did not occur in any case. The postoperative vital capacity and FEV1 improved significantly over the preoperative condition (p<0.01). Because the bronchial communication of bulla is frequently obliterated after infection within the bulla, opening of a bulla is curative and simpler, more effective, and less invasive than complete resection.     

Three cases of primary lung cancer unexpectedly discovered during the operation of pneumothorax

It is well known that emphysematous bulla is thought to be often associated with lung cancer. However, it is very rare that lung cancer predisposing to pneumothorax as initial manifestation. We performed surgical operations of four hundred and one cases of spontaneous pneumothorax, and discovered three cases of lung cancer during the operation. However, these three cases occupied the 30% of the patients with pneumothorax who were older than 65 years. The two of them were adenocarcinomas which were situated in the wall of bullae, but did not perforated the bullous wall. The other one was squamous cell carcinoma which was apart from the bullous lesion. This shows that we should always be careful of the associated lung cancer when we care elderly patients with pneumothorax.     

Detection of emphysematous bullae in spontaneous pneumothorax by three-dimensional computed topography

The patient was a 20-year-old woman with spontaneous pneumothorax, who had had pneumothorax twice on each side. Three-dimensional computed topographic (CT) images were made as follows. The range 12.5 cm caudad from the pulmonary apex was scanned by rapid helical CT, and three-dimensional images were obtained with the surface-rendering technique at a voxel extraction threshold ranging-850 HU to 1,600 HU. The three-dimensional CT images provided a stereotactic rendering of the lung surface. Irregular findings were observed at both pulmonary apices; they indicated the presence of one emphysematous bulla in the right lung and many emphysematous bullae of various sizes in the left lung. These findings were highly consistent with the sites and structures of the emphysematous bullae, as observed during thoracoscopy, which suggests that three-dimensional CT is a useful method for diagnosing and evaluating emphysematous bullae in patients with spontaneous pneumothorax.     

Thoracoscopic repair of traumatic diaphragmatic rupture. A case report

A 51-year-old man with a traumatic diaphragmatic rupture is presented. Preoperatively, diaphragmatic rupture and herniation of the stomach into the left thoracic cavity were suspected. Under thoracoscopic guidance, the stomach and omentum were repositioned in the abdominal cavity using Babcock forceps, and then the rupture site was closed using an endoscopic hernia stapler. The postoperative course was uneventful and the patient was discharged from our hospital with no symptoms.     

Colovaginal anastomosis: a unique complication of end-to-end anastomosis stapler use in low anterior resection

Anastomotic staplers have been used in colorectal surgery for several years. End-to-end stapler use for low anterior resection, as well as for other procedures, is common in surgical practice. These staplers have allowed more extended, lower resections of the colorectum without loss of bowel continuity or sphincter function. There have been reported complications of stapler use, with anastomotic stricture and leakage being the most common. We report here a unique complication of direct colovaginal anastomosis using the end-to-end stapler during a low anterior resection of an early-stage rectal adenocarcinoma.     

Normal predicted values of CT indices reflect emphysematous alterations in the lung

In order to obtain normal values and 95% confidence limits of various CT indices, healthy adult subjects with no history of smoking (n = 36) underwent CT scanning under a variety of conditions. By then applying the normal limits thus obtained to CT images of COPD patients (n = 45), we examined the sensitivity for detecting abnormal emphysematous changes in the lung fields. To measure emphysematous alterations, we used the average value of lung CT densities (ROI), the maximally appearing value in a CT histogram (Hist. Peak), the relative area with low CT densities below -910 HU (%LDA) and the total cross-sectional area (Area) in each lung section. Regardless of the section thickness (10 mm or 1 mm), the lung volume level at which the breath was held or the site from which CT images were taken (upper, middle or lower lung field), no significant correlation was observed between the CT indices associated with emphysematous changes and the subjects' age. This allowed us to define, independently of the subjects' age, normal values and 95% confidence limits for the CT indices. Among the CT indices surveyed, %LDA was found to be the most sensitive indicator for detecting emphysematous abnormalities. In so far as the extent of emphysema may be determined by lung CT density, classical CT images of 10-mm section thickness appear to have a sufficiently high sensitivity for the detection of emphysematous abnormalities, such that high-resolution CT may be unnecessary.     

Pathogenesis of systemic air embolism during bronchoscopic Nd:YAG laser operations

BACKGROUND: The occurrence of systemic air embolism during bronchoscopic neodymium:yttrium-aluminum garnet laser operations has been suspected. Here we describe its mechanism. METHODS: Two patients with embolic cardiac and neurologic complications after bronchoscopic neodymium: yttrium-aluminum garnet laser tumor ablation are described. A subsequent third patient was monitored for intracardiac and aortic air by transesophageal echocardiography. A review of the literature and safety recommendations are discussed. RESULTS: The appearance of systemic air emboli was related to the use of the laser fiber air coolant at high flow and resolved by decreasing the air flow. The presence of intracardiac and aortic air was associated with hypotension and inferior ischemic electrocardiographic changes. CONCLUSIONS: Systemic air embolism during bronchoscopic laser operations is a potentially catastrophic complication and is related to the use of gas-cooled laser fibers and contact probes. We recommend using the noncontact mode whenever possible and maintaining the coaxial coolant air flow at the minimum level or using a fluid coolant if contact is necessary.     

Infected emphysematous bullae in a patient with diabetes mellitus

A 42-year-old woman with diabetes mellitus was admitted to our hospital because of fever, coughing, and dyspnea. Coarse crackles were audible and respiratory sounds were weak in the right lung field. Laboratory examination revealed a high erythrocyte sedimentation rate, a high level of serum C-reactive protein, a high blood sugar level, and hypoxemia. A chest roentgenogram revealed cystic lesions with fluid levels, and an infiltration shadow in the right lung field. A chest computed tomographic scan revealed many cystic lesions with fluid levels and an infiltration shadow. Our diagnosis was infected emphysematous bullae. A tube was inserted percutaneously for drainage and to allow injection of antibiotics into the cystic lesion. The cystic lesion then vanished. Percutaneous drainage and washing with antibiotics can be used to treat infected emphysematous bulla that have thick closed cystic walls.