J Thorac Cardiovasc Surg 2006;131:495-496
© 2006 The American Association for Thoracic Surgery
Using Surgicel to buttress the staple line in lung volume reduction surgery for chronic obstructive pulmonary disease
Jang-Ming Lee, MD, PhD,
Jen-Deh Pan, MD,
Wei-Cheng Lin, MD,
Yung-Chie Lee, MD, PhD
*
Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
Received for publication August 2, 2005; accepted for publication September 9, 2005.
* Address for reprints: Yung-Chie Lee, MD, PhD, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan, Republic of China. 7, Chung-Shang South Rd, Taipei, Taiwan (Email: wuj{at}ha.mc.ntu.edu.tw).
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Dr W. Lee
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Although effective for palliating the symptoms of chronic obstructive pulmonary disease (COPD), lung volume reduction surgery for COPD is highly vulnerable to postoperative major or persistent air leakage.
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Staple line reinforcement has been developed to prevent this complication, including using polyglycolic acid,
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bovine pericardial strips,
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or autologous parietal pleura.
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These materials either carry a high cost
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or take a substantial amount of time for preparation.
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A low-cost and easily available material for staple buttressing is needed to facilitate its clinical application. We report a new technique using oxidized regenerated cellulose (Surgicel, Johnson & Johnson) for lung volume reduction surgery for COPD.
Clinical Summary
Patient 1
A 72-year-old man with COPD complained of progressive exertional dyspnea unresponsive to bronchodilator treatment. He had left pneumothorax and received a thoracoscopic wedge resection on the pulmonary left upper lobe 4 years ago. Chest computed tomography revealed diffuse emphysematous change of the bilateral lung, especially in the right middle lobe. For intractable dyspnea, video-assisted thoracic surgery for lung volume reduction surgery on the right lung was arranged. About 30% of the pulmonary right upper lobe at the apex and 50% of the right middle lobe at the basal portion was resected with a continuous staple line (Figure 1, B, C, and D). Before the lung resection, a strip of Surgicel, 4 x 8 cm, was tied on each site of the staple (Figure 1, A). The working port on the anterior axillary line of the fourth intercostal space was enlarged to 3 cm to prevent dislocation of fixed Surgicel during staple introduction. A total of 7 sets of Endo-GIA, 60 x 4.8 mm, and 2 sets of Endo-GIA, 45 x 4.8 mm, staples (Tyco Health Care, US Surgical) were used during the operation. It took 2 hours for the entire surgical procedure. The patient was extubated the day after the operation, with no air leakage found from the chest tube. The chest tube was removed 3 days later, and the patient was discharged 7 days after the operation.
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Figure 1. A, Surgicel tied on each site of the staple. B, Lung specimens, 15 x 4 and 5 x 3 cm, were excised from the right upper lobe and right middle lobe, respectively. C, Lung surface after resection (before saline pleural irrigation). D, Lung surface after resection (after saline pleural irrigation).
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Patient 2
A 56-year-old man with bullous emphysema had exertional dyspnea for 10 years. He had an episode of right tension pneumothorax before admission. He underwent endotracheal intubation and right chest tube thoracostomy in our emergency department for pneumothorax-induced respiratory failure. Chest computed tomography disclosed diffuse pulmonary emphysema with multiple small- to median-sized bullae in the bilateral lungs, especially in the right middle and lower lobes, and 2 huge bullae of 13 cm in diameter in the right lower lobe. Lung volume reduction surgery with bullectomy was suggested after he was weaned from a ventilator. During the operation, a thoracotomy through the seventh intercostal space was created for precise excision of the multiple lesions. Part of the pulmonary right upper and lower lobes with the most evident bullous formations was resected with 5 and 2 sets of GIA 90 x 4.8–mm and 50 x 4.8–mm staples (Tyco Health Care, US Surgical), respectively. Before staple application, one strip of Surgicel was tied on each side of the staple to buttress the staple line, as previously described. The surgical procedure took 2 hours and 30 minutes in total. The patient was extubated on the day of the operation. Minimal air leakage was noted from the chest tube after the operation, and the tube was removed 6 days after the operation, the same day as patient discharge.
Discussion
The oxidized cellulose compound Surgicel is currently indicated for hemostasis during surgical intervention. In pigs Surgicel coverage with local electroablation can significantly decrease air leakage from pleural tears.
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Our preliminary experience demonstrated that using Surgicel to buttress the staple line can effectively prevent postoperative air leakage after lung volume reduction surgery either in open or thoracoscopic procedures. Only a few minutes are required to attach it to the staple. The fixed Surgicel did not interfere with the staple application during lung resection. However, to avoid dislocation of the Surgicel fixed in the staple, we suggest a slight enlargement to the working port for staple application during the video-assisted thoracic surgery procedure. In contrast to other expensive buttress materials, Surgicel is commonly used in the operating theater, with a cost less than 5% of the bovine pericardium used in this country. Further studies examining efficacy and safety are necessary.
References
- Cooper JD, Patterson GA, Sundaresan RS, Trulock EP, Yusen RD, Pohl MS, et al. Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg 1996;112:1319-1330.[Abstract/Free Full Text]
- Kawamura M, Kase K, Sawafuji M, Watanabe M, Horinouchi H, Kobayashi K. Staple-line reinforcement with a new type of polyglycolic acid felt. Surg Laparosc Endosc Percutan Tech 2001;11:43-46.[Medline]
- Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038-1039.[Abstract]
- Lee YC, Chang YL, Chen CW, Chien NC, Huang PM. Use of autologous pleural flap buttress in thoracoscopic lung volume reduction surgery. J Thorac Cardiovasc Surg 2003;126:298-299.[Free Full Text]
- Luh SP, Chou HH, Tsai TP, Chen JY, Chou MC, Wang YH, et al. Effect of Surgicel coverage with topical electrocauterization for preventing and sealing pulmonary air leakage. Int Surg 2004;89:190-194.[Medline]
