Interact CardioVasc Thorac Surg 2007;6:529-533. doi:10.1510/icvts.2007.153080
© 2007 European Association of Cardio-Thoracic Surgery
Best evidence topic - Thoracic general |
Can tissue adhesives and glues significantly reduce the incidence and length of postoperative air leaks in patients having lung resections?
Jeymi Tambiah,
Randolph Rawlins,
Daniel Robb and
Tom Treasure*
Department of Thoracic Surgery, Guy's Hospital, St. Thomas's Street, London, UK
Received 26 February 2007;
received in revised form 11 April 2007;
accepted 12 April 2007
*Corresponding author. Tel./fax: +44 207 1881034.
E-mail address: tom.treasure{at}gmail.com (T. Treasure).
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Abstract
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A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the intraoperative use of surgical adhesives in patients undergoing lung resection would reduce the incidence and length of postoperative air leaks. The reported search strategy identified 261 papers of which 12 were considered to represent the best evidence available. The author, journal, publication date, patient groups studied, study types, relevant outcomes, results and study weaknesses were tabulated. We conclude that six of the identified randomised trials found a significant reduction in air leak duration, but five found no significant difference. In contrast to significant reductions in air leak, only two studies identified a reduction in time to chest drain removal. Also, only two studies found a significant reduction in length of stay. There are multiple issues surrounding these studies ranging from identifying the optimal glue and delivery system, dealing with the learning curve of surgeons and robust protocols for chest drain removal to selection of patients suitable for surgical adhesive usage. Thus, routine usage of surgical adhesive for all operations cannot yet be recommended, although there is a wide range of adhesives available to surgeons which may be useful in selected situations.
Key Words: Lung neoplasms; Lobectomy; Fibrin tissue adhesives; Sealants; Air leak
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
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2. Three-part question
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In [adult patients undergoing lung resection], does [intraoperative use of surgical adhesives] reduce the [incidence and length of postoperative air leaks]?
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3. Clinical scenario
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You have just completed a right upper lobectomy in a 67-year-old smoker for non-small cell carcinoma. He had multiple adhesions and an incomplete fissure and on testing there were many air leaks. A colleague has been trying out a spray-on glue to reduce air leaks and thus you ask for this glue to be brought into theatre and apply it liberally. The air leak stops on day one, the drains are all removed on day 3 and he is discharged on day 5. You wonder whether you should use this glue for all your lobectomy patients and thus resolve to look this up in the literature.
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4. Search strategy
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Medline 1950 to Jan 2007 using the OVID interface.
[exp lung neoplasms/OR lung neoplasm.mp/OR lung carcinoma.mp OR lung cancer.mp OR pneumonectom$.mp OR lobectom$.mp OR lung resection.mp OR pulmonary resection$.mp OR Thoracotom$.mp] AND [exp Tissue Adhesives/OR tissue adhesive.mp OR exp Fibrin Tissue Adhesive/OR sealant.mp OR vivostat.mp OR fibrin glu$.mp OR TachoComb.mp OR bioglue.mp OR focalseal.mp].
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5. Search outcome
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A total of 261 papers were identified using the reported search of which 12 represented best evidence on the subject. These studies are summarised below (Table 1).
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6. Comments
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A total of 12 papers (11 trials and one systematic review) have been cited in the comparison table. Apart from Tansley et al. [2], all were included in the comprehensive Cochrane Systematic Review written by Serra-Mitjans et al. [3]. Most trials looked at three primary outcomes: air leak duration, length of time of intercostal drainage, length of hospital stay. Seven trials use fibrin-based sealants, three trials use polyethylene-glycol-based sealants, and one trial uses a glutaraldehyde-based sealant.
The basic conclusions are: six trials found a significant reduction in the duration of air leak after use of a sealant as compared to controls [2, 4–8], however, five trials found the difference to be non-significant [9–13].
Only two trials found a significant reduction in the time of intercostal drainage compared to controls [2, 7], six trials found the difference to be non-significant [5, 8, 9, 11, 13].
Only two trials found length of hospital stay to be significantly shorter in groups treated with sealant compared to their controls [2, 9], whilst seven trials found a non-significant difference [4, 5, 7, 8, 10, 11, 13].
We conclude that there is weak evidence that sealants may reduce the duration of air leaks following lung resection surgery but it is unlikely their use influences the length of time of intercostal drainage or length of hospital stay for the patient.
However, there are several points which need clarification when looking at these trials in detail. Further work will be needed to answer the question definitively. Some of the issues which need addressing are as follows: - The outcome measures. The majority of trials did not define management of intercostal drains postoperatively. This is highly variable between institutions. Also, blinding of observers postoperatively was not always clearly stated. Therefore, using time of drainage as an outcome measure and subsequently length of hospital stay as another primary outcome measure (as this must depend on time of drainage) seems flawed. The only definitive outcome measure which can be reliably used when comparing results between studies is postoperative air leak duration.
- The sealant properties. There were seven trials using fibrin based sealants, three trials using polyethylene-glycol-based sealants and one trial using a glutaraldehyde-based sealant. Of the seven studies using fibrin-based sealants, postoperative air leak duration was significantly reduced in three trials but made no difference in the remaining four. Of the three studies using polyethylene-glycol-based sealants, two found a significant reduction in postoperative air leak duration compared to a single trial which found it made no difference. The single trial using a glutaraldehyde-based sealant found a significant reduction in postoperative air leak duration in its treatment group as opposed to its controls. Therefore, the type of sealant used will influence the results. More work needs to be performed to define this more clearly.
- The mode of application of sealants, e.g. sprays vs. syringe ‘spot’ application.
- Practicalities of usage have to be considered. For example, light wands, autologous blood, collagen fleece, time added to surgery, etc.
- General problems with the set up of these trials, e.g. learning curve/experience of surgeon; single vs. multicentre studies; number of patients recruited, etc.
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7. Clinical bottom line
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We conclude that six of the identified randomised trials found a significant reduction in air leak duration, but five found no significant difference. In contrast to significant reductions in air leak, only two studies identified a reduction in time to chest drain removal. Also, only two studies found a significant reduction in length of stay. There are multiple issues surrounding these studies ranging from identifying the optimal glue and delivery system, dealing with the learning curve of surgeons and robust protocols for chest drain removal to selection of patients suitable for surgical adhesive usage. Thus, routine usage of surgical adhesive for all operations cannot yet be recommended, although there is a wide range of adhesives available to surgeons which may be useful in selected situations.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact Cardiovasc Thorac Surg 2003; 2:405–409.[Abstract/Free Full Text]
- Tansley P, Al-Mulhim F, Lim E, Ladas G, Goldstraw P. A prospective, randomized, controlled trial of the effectiveness of BioGlue in treating alveolar air leaks. J Thorac Cardiovasc Surg 2006; 132:105–112.[Abstract/Free Full Text]
- Serra-Mitjans M, Belda-Sanchis J, Rami-Porta R. Surgical sealant for preventing air leaks after pulmonary resections in patients with lung cancer [update of Cochrane Database Syst Rev 2001;(4):CD003051; PMID: 11687173]. [Review] [32 refs]. Cochrane Database of Systematic Reviews (3): CD003051, 2005.
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Abstract
1. Introduction