Invited Commentary

Abstract

This article from Denmark by Pedersen and associates [1Pedersen T.B. Honge J.L. Pilegaard H.K. Hasenkam J.M. Comparative study of lung sealants in a porcine ex vivo model.Ann Thorac Surg. 2012; 94: 234-240Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar] brings a nice dose of scientific experimentation to a field in which there has been little such work. The clinical studies that have been carried out on surgical sealants remain controversial. Although these studies have in a few cases shown statistically significant differences, they have for the most part not shown what I estimate to be clinically significant improvements in valuable clinical outcomes such as duration of chest tube (CT) drainage, length of stay (LOS), or cardiopulmonary complications. I am in fact aware of only two among all of the many published studies (using BioGlue [2Tansley 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: 105-112Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar] and TachoSil [3Anegg U. Lindenmann J. Matzi V. Smolle J. Maier A. Smolle-Juttner F. Efficiency of fleece-bound sealing (TachoSil) of air leaks in lung surgery: a prospective randomised trial.Eur J Cardiothorac Surg. 2007; 31: 198-202Crossref PubMed Scopus (125) Google Scholar], respectively) that show statistically significant improvements in both CT duration and LOS. For TachoSil, a larger, multicenter study failed to confirm statistically significant improvements [4Marta G.M. Facciolo F. Ladegaard L. et al.Efficacy and safety of TachoSil versus standard treatment of air leakage after pulmonary lobectomy.Eur J Cardiothorac Surg. 2010; 38: 683-690Crossref PubMed Scopus (52) Google Scholar]. As for costs, only one study, using TachoSil, has addressed this, and the use of that product appear to be cost neutral, with the incremental expense of the material essentially equaling the savings derived by the minor reduction in LOS [5Anegg U. Rychlik R. Smolle-Jutner F. Do the benefits of shorter hospital stay associated with the use of fleece-bound sealing outweigh the cost of the materials?.Interact Cardiovasc Thorac Surg. 2008; 7: 292-296Crossref PubMed Scopus (25) Google Scholar]. With this background, it is useful to have the added information provided by this head-to-head evaluation of several commercially available sealants in a standardized, ex vivo pig lung model. This carefully done and reported study demonstrates that BioGlue and TachoSil create tissue seals with demonstrably higher burst pressures than the other sealants tested. Although the authors freely admit that aspects other than burst pressure may well be important in determining the in vivo efficacy of sealant products, and that their ex vivo model does not entirely reproduce the in vivo environment, it is nevertheless interesting that the two products that have perhaps the best clinical data supporting their use also performed best in this ex vivo study. It certainly would be interesting to see how the results in these nondiseased pig lungs would compare with those obtained in a model using emphysematous lungs, where sealants will likely prove to have their most useful application. Further expansion of the study to include other sealants with some demonstrated efficacy would also be of value. Ultimately, however, only additional clinical studies that include cost analyses, and those that focus on patient subgroups at greatest risk, will determine the appropriate role of sealants in pulmonary resection. I suspect that it will eventually be confirmed to be reasonable to use the most effective among these products in patients who are at highest risk for prolonged or complicated air leak (eg, those with moderate to severe emphysema) but that the routine use of sealants in all anatomic lung resection cases will not be supportable. Comparative Study of Lung Sealants in a Porcine Ex Vivo ModelThe Annals of Thoracic SurgeryVol. 94Issue 1PreviewLung sealants are often used to prevent alveolar air leaks after lung resection surgery. Some sealants have shown to be effective in clinical studies, but extensive comparative evaluation has not yet been conducted. We aimed to evaluate different sealant burst pressures in an ex vivo model mimicking air leakage after lung resection. Full-Text PDF