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BACKGROUND Postoperative prolonged air leakage is a frequent complication after lung resection. We have developed a new sealant based on a hydrophobically modified Alaska pollock-derived gelatin (ApGltn) sealant. The purpose of this study was to evaluate the adhesive strength of the ApGltn sealant in comparison with a fibrin sealant using a new spray system in ex vivo and in vivo models. METHODS Pleural defects in ex vivo and in vivo porcine models were created, to which the ApGltn sealant or the fibrin sealant was applied. The pressure resistance was assessed with a stepwise increase in airway pressure to confirm air leakage from the sealing site. Tissue samples covered with each sealant were obtained for histologic assessment. RESULTS In the ex vivo experiment, the leak pressures of the ApGltn sealant were significantly greater than those of the fibrin sealant (102.94 ± 15.6 cm H2O and 28.37 ± 5.1 cm H2O, respectively) (P < .01). In the in vivo experiment, the leak pressures of the ApGltn sealant were also significantly greater than those of the fibrin sealant (68.82 ± 18.04 cm H2O and 43.33 ± 7.13 cm H2O, respectively) (P = .043). The histologic examination confirmed that the ApGltn sealant adhered tightly to both the pleura and the surface of the pleural defect. CONCLUSIONS The ApGltn sealant has sufficiently high adhesive quality in ex vivo and in vivo porcine lungs, which could be considered suitable and effective for use in the prevention of air leakage from the lungs.

Following non-anatomical resection of lung parenchyma with a Nd:YAG laser, a coagulated surface remains. As ventilation starts, air leakage may occur in this area. The aim of the present study was to investigate, whether additional coagulation either before or after ventilation has an additional sealing effect. Freshly slaughtered porcine heart-lung blocks were prepared. The trachea was connected to a ventilator. Using a Nd:YAG laser (wavelength: 1320 nm, power: 60 W), round lesions (1.5 cm in diameter) with a depth of 1.5 cm were applied to the lung using an 800-μm laser fiber (5 s per lesion). Group 1 (n = 12) was control. Additional coagulation was performed in group 2 (n = 12) without and in group 3 (n = 12) with ventilation restarted. Air leakage (ml) from the lesions was measured. The thickness of each coagulation layer was determined on histological slices. Differences between individual groups were analyzed by one-way ANOVA (significance p < 0.05). After resection, 26.2 ± 2.7 ml of air emerged from the lesions per single respiration in group 1. Air loss in group 2 was 24.6 ± 2.5 ml (p = 0.07) and in group 3 23.7 ± 1.8 ml (p = 0.0098). In comparison to groups 1 and 2 thickness of the coagulation layers in group 3 was significantly increased. After non-anatomical porcine lung resection with a Nd:YAG laser, additional coagulation of the ventilated resection area can reduce air leakage.

Summary A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: what is the optimal level of suction on digital chest drainage devices following pulmonary lobectomy? Altogether 367 papers were found using the reported search, of which 4 randomized controlled trials using digital chest drainage devices represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The new digital drainage systems enhance early mobilization as recommended in the enhanced recovery after surgery programme. There is, however, no consensus on the optimal level of suction to apply after pulmonary lobectomy. This is especially the case for digital drainage devices. Surgeon preference will likely continue to guide practice, until the evidence gives clear-cut recommendations. According to the current data, a low suction reduces total fluid drainage and perhaps air leak duration compared to higher suction levels in both video-assisted thoracoscopic surgery and open pulmonary lobectomies using digital drainage devices, although the evidence is not overwhelming.

OBJECTIVES The objective of this study was to determine the variation in intrapleural pressure (IPP) with and without air leakage using a digital chest drainage system (DCS) for each pressure setting. METHODS In this retrospective single-centre study, we analysed 49,553 h of air leakage after anatomical lung resection in 714 patients between 2018 and 2020. The transition of mean IPP and mean air leak flow was monitored using DCS, and the association between mean IPP and mean air leak flow was examined. The relationship between the transition of mean IPP and air leakage according to the varying suction pressures on DCS was also investigated. RESULTS Overall, 272 patients (38.1%) showed air leakage after surgery. The mean IPP in patients without air leakage was −12.0 ± 2.9 cmH2O and maintained at about −12 cmH2O constantly, while the mean IPP in patients with air leakage was −8.3 ± 1.9 cmH2O, which changed to −12 cmH2O instantly if air leakage disappeared (P CONCLUSIONS The change in IPP on a DCS is useful for detecting air leakage. Furthermore, management with a mild suction setting on DCS makes it easy to recognize the disappearance of postoperative air leakage.

The use of free fat pads is effective for repairing pulmonary air leakage clinically. It has been reported that the free pericardial fat pad (FPFP) used to repair the lung remained at the transplanted site in many cases according to images. However, no information is available regarding what type of actual changes these free fat pads with no blood supply undergo. We examined changes in an FPFP that was used to repair pulmonary air leakage in a patient who underwent a surgery for lung cancer 1 year ago. Although the FPFP transplanted to the pleural defect remained without deforming morphologically in this patient 1 year after the first surgery, pathological findings suggested fat necrosis surrounded by fibrous tissue. Our findings suggest that while free fat pads used for pulmonary air leakage repair presumably are not engrafted, they should remain on the lung surface in a thoracolithiasis-like condition.

In the present study we present a unique maneuver, using both fibrin glue and polyglycolic acid (PGA) sheets, for repairing intraoperative pulmonary air leakage, and report our clinical results. Based on the results from in vitro experiments, we retrospectively investigated the clinical effects of our method for repairing intraoperative pulmonary air leakage in 377 consecutive patients, who underwent a pulmonary resection for primary lung cancer or metastatic lung tumors from 2004 to 2009. From April 2004 through September 2007, repair of intraoperative pulmonary air leakage was performed in 204 patients using only fibrin glue. From October 2007 through December 2009, the repair was performed in 173 patients with a unique application of both fibrin glue and PGA sheets, i.e., (1) rubbing fibrin glue A solution, (2) applying a PGA sheet cut to an appropriate size, (3) rubbing fibrin glue B solution on the PGA sheet, and (4) reapplying fibrin glue A solution and rubbing. The mean duration of postoperative pleural drainage was significantly shorter in the latter time period when both fibrin glue and PGA sheets were used than in the former period when fibrin glue was used alone. The incidence of prolonged air leakage longer than 1 week was also significantly lower in the latter era than in the former era. Our unique application of both fibrin glue and PGA sheets for the intraoperative repair of pulmonary air leakage effectively resulted in a shortening of the duration of postoperative pleural drainage.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether blood pleurodesis is effective for cessation of persistent air leak (PAL). Altogether more than 43 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that autologous blood pleurodesis has superior outcomes when compared with conservative management for treatment of postoperative PAL. In addition, for PAL causing pneumothorax, blood pleurodesis [optimal volume 100 ml (from two studies)] should be considered in patients who are unsuitable for surgery, talc pleurodesis is ineffective or not viable (including cases complicated by acute respiratory distress syndrome) and a prompt resolution is required. Some 70-81% of patients treated for postoperative air leak resolved within 12 h and 95-100% within 48 h vs. a mean of 3-6.3 days (from two studies) with simple drainage. Resolution of pneumothorax with blood pleurodesis was also significantly shorter (P0.01). Overall success rates (from all studies) were 92.7% (n=133) from patients having undergone pulmonary surgery (76.6% in one injection, n=111), and 91.7% (n=109) of patients with pneumothorax. Recurrence rates were between 0 and 29% compared with 35-41% for simple drainage, although one controlled study in which the recurrence rate was improved from 16% in controls to 0% in the blood pleurodesis group (at 12-48 months). Minor complication (empyema/fever/pleural effusion) rates varied between studies (0-18%), although they show reduced incidence in line with improving technique over time. A controlled study looking at acute respiratory distress syndrome complicated by pneumothorax showed a significant reduction in mortality (odds ratio 0.6), time to cessation of air leak (P0.01), weaning time (P0.01) and intensive treatment unit (ITU) stay (P0.01) whilst another randomized control study showed significant reduction in hospital stay following pulmonary resection (P0.001).

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.

Objective: We worked to devise a new way to prevent postoperative persistent air leaks in high-risk pulmonary surgery patients. Methods: From November 1993 to June 2002, 60 patients with difficult to control intraoperative pulmonary air leakage were treated using bioabsorbable polyglycolide felt patches soaked in fibrin glue to cover the leakage site. Results: After application, the felt patch adhered tightly to the lung surface without peeling off, enabling good leakage closure with only 2 ml of fibrin glue used. Air leakage was controlled successfully in 52 (86.7%) of the 60. Four of the 8 patients in whom this method failed to stop air leakage also developed mild pyothorax, with 2 requiring a second operation by video-assisted thoracic surgery. Leakage was eventually controlled in all patients, with no postoperative deaths relating to air leakage. Conclusions: Fibrin-glue-soaked bioabsorbable felt patches effectively seal intraoperative intractable air leaks. Felt patch use may increase the risk of postoperative infection. It should be considered for use on patients with fistulas that cannot be controlled by direct closure or otherwise intraoperatively and who may potentially develop uncontrollable air leakage postoperatively.

BACKGROUND Velopharyngeal insufficiency (VPI) is a disorder in which air leaks out through the nose, reducing performance quality and capacity in wind and brass players. There have been limited studies on the prevalence of this potentially career-threatening disorder. AIMS To identify the prevalence of VPI in a sample of conservatorium level woodwind and brass student instrumentalists in Australia. METHODS Wind and brass students from four music institutions were recruited by email invitation to complete an online survey. Results from 77 musicians were analysed for their knowledge and experience of VPI. Musicians who had experienced VPI provided information on the characteristics, symptoms and treatment or advice sought for the disorder. RESULTS Of the 77 musicians included in the analysis, 44% had heard of VPI, 30% were aware of other musicians who had experienced VPI and 39% had personally experienced VPI. CONCLUSIONS The results suggest that VPI may be a common occurrence in wind and brass players. Informal discussions with colleagues and music teachers also suggest that VPI is a frequent phenomenon. This group of musicians represents the largest sample surveyed about VPI to date.

To strengthen the sealing effect of fibrin glue for pulmonary air leakage, atelocollagen was mixed with the glue and the mixing effect was examined.A mixture of fibrinogen and thrombin with atelocollagen was used as a test sample. The concentrations of atelocollagen were adjusted to levels of 0%, 0.375%, 0.75%, 1.1%, and 1.5%. We next performed air leakage tests on a plastic cap with pin holes and swine lung and also measured the elasticity and the adhesion strength.The pressure required to rupture the sealant on a plastic cap with pin holes increased as the concentration of atelocollagen increased, and the bursting pressures were significantly higher in the glue with 0.75%, 1.1%, and 1.5% of atelocollagen than in the glue without atelocollagen (p0.01 and p0.001). The air leakage pressure on the swine lung was significantly higher in the glue with 0.375%, 0.75%, and 1.1% of atelocollagen than in the glue without atelocollagen (p0.05 and p0.01), and it was the highest with 0.75%. The elasticity of the glue significantly increased as the concentration of atelocollagen increased (p0.001). However, the adhesion strength of the glue significantly decreased as the concentration of atelocollagen increased (p0.05 to p0.001).The mixing of atelocollagen with fibrin glue more effectively sealed pulmonary air leakage due to an increased elasticity of the glue while its adhesion strength decreased. The optimal concentration of atelocollagen in the fibrin glue to obtain the best sealing effect was 0.75%.

This study was conducted to examine the efficacy and side effects of gelatin-resorcinol formaldehyde-glutaraldehyde (GRFG) glue, when used for preventing or sealing pulmonary air leakage during lung surgery. Formaldehyde-glutaraldehyde (FG) jelly was prepared by mixing FG fluid with 2.5% carboxymethyl cellulose to increase its viscosity. A GRFG glue-spreading stapler was employed to prevent air leakage from the staple line when cutting emphysematous lung tissue in 26 patients, 25 of whom underwent video-assisted thoracoscopic surgery (VATS) and 1, open thoracotomy. A glue-sealing procedure was employed to stop existing pulmonary air leakage in a further 36 patients, 28 of whom underwent VATS and 8, open thoracotomy. The glue-spreading stapler technique prevented air leakage in all 26 patients (100%), while the glue-sealing procedure for pulmonary air leakage stopped air leakage in 31 of the 36 patients (86%). Two patients who underwent glue sealing for air leakage from a deeply cut lung surface suffered massive pulmonary air leakage on postoperative day (POD) 1 and 6, respectively, and required repeat surgery to suture the lung fistula. A transient fever of 38 degrees-39 degrees developed on POD 7 in 6 of the 62 patients (9.7%), but no other complications were observed. These results demonstrated that GRFG is safe and effective in preventing or stopping pulmonary air leakage in the peripheral lung, but not for stopping air leakage from a deeply cut lung.

Objective More than 2300 clinical papers have been published on the surgical applications of fibrin sealant (FS), with the largest number in the speciality of cardiothoracic surgery. The purpose of this review of the literature was to find and evaluate controlled studies published in the field of cardiothoracic surgery, to clarify the indications and emphasize the benefits of FS available to the practising surgeon. Methods A database of the surgical publications of FS was created. Up to the end of 1995, at least 24 controlled clinical studies had been published; these may be divided into 20 studies with a positive outcome and 4 studies where the results were not different from the controls. In none of the studies was the clinical result worse after the use of FS. Results In most of the cardiac studies, FS was successfully used at bleeding sites in reoperations and in congenital heart surgery. Postoperative bleeding may also be reduced by the anterior mediastinal spray application of FS or by preparing woven Dacron prostheses with the sealant. In addition, Fs has been found to improve results after type A aortic disections and, by adding an antibiotic to the sealant, the postoperative infection rate for active endocarditis of the aortic root can be reduced. In pulmonary surgery FS can be used to reduce pulmonary air leakage, however the results of some studies diverge due to different clinical test conditions and the inclusion of only a small number of patients in the "negative" studies. In none of the controlled studies of esophageal surgery could FS prevent leakage from esophageal anastomoses. Conclusions Fibrin sealant is safe when it is applied properly, but there is a learning curve for surgeons who start using it. An autologous sealant or a sealant containing human instead of bovine thrombin is preferred, since repeated use of bovine thrombin may induce coagulopthies. The number of controlled clinical studies of FS is currently increasing, with the majority of the papers revealing a beneficial effect of FS when it is used as a hemostatic or sealing agent in cardiothoracic surgery.

Pulmonary air leaks include a number of clinical conditions characterized by overdistension and rupture of the alveolar wall with air leaking from the intra-alveolar space into the surrounding tissue. Air leaks are more common and more severe among neonates with pulmonary diseases that are characterized by poor lung compliance (e.g., respiratory distress syndrome) or by airway obstruction (e.g., meconium aspiration syndrome).

We prospectively audited the implementation of a protocol for management of air-leaks and intercostal drains after thoracic surgical procedures. Out of the 99 patients who underwent thoracic surgical procedures during a 3-month period, 41 presented a postoperative air-leak on day 1. The protocol was strictly followed in 95% of the cases. The median drainage-time and hospital-stay were 3 and 4 days, respectively. The incidence of insertion of postoperative drains was 3%. Most of the nursing staff found the protocol user-friendly and easy to apply. A protocol for the management of postoperative air-leaks and intercostal drains can be implemented with high-compliance low complications.

Prolonged air leak following bullectomy is a common problem and increases the morbidity of the procedure and hence the hospital stay for patients. Different surgical methods have been used to decrease the duration of the air leak. One of the common methods is the use of sealant material, synthetic or biological, over which either a stapler or suture closure is made. We report the use of the wall of the resected bulla as a sealant material to achieve pneumostasis with stapler/suture reinforcement, with good results.

We report a case of cardiac tamponade due to air leak and fatal pneumopericardium that occurred after commercial flight transportation of a premature infant with chronic lung disease without respiratory distress. We review and discuss aspects of flight pathophysiology, and conclude that careful preparation before, and close monitoring during, commercial flight transportation is necessary for premature infants.