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Ann Thorac Surg 1996;62:1485-1488
© 1996 The Society of Thoracic Surgeons

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Original Article: General Thoracic

In Vitro Comparison Between Argon Beam Coagulator and Nd:YAG Laser in Lung Contraction Therapy

Department of Surgery III, Nara Medical College, Nara, Japan

Accepted for publication June 8, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The Argon Beam Coagulator (ABC) and neodymium:yttrium-aluminum garnet (Nd:YAG) laser are used for lung tissue contraction. Assessing the damage of treated lung tissue is helpful in choosing devices for pulmonary volume reduction by pneumoplastic procedures.

Methods. We assessed the damage of in vitro lung lobes resected at operation for pulmonary carcinoma. Samples were irradiated with noncontact Nd:YAG laser and ABC. One hundred forty-four samples obtained from 24 lobes were examined by light microscopy. The lung tissue showing destructive degeneration at the pleura and slight coagulation at the residual parenchyma was defined as showing "air leak pattern" based on a previously reported experiment of the air inflation test.

Results. At the power of clinical use (Nd:YAG, 15 W; ABC, 80 W), most of the visceral pleura treated with the Nd:YAG laser was classified as presenting amorphous degeneration, and that treated with ABC showed destructive degeneration. Air leak pattern occurred in all samples treated with ABC. At the power of 40 W, ten (42%) of 24 visceral pleuras irradiated with the Nd:YAG laser were classified as presenting destructive degeneration, and of those irradiated with the ABC, 18 (75%) showed destructive degeneration (p < 0.05). Air leak patterns were found in 3 (13%) of the samples treated with the Nd:YAG laser and in 16 (63%) of those treated with the ABC (p < 0.05).

Conclusions. The ABC had more potential to damage the pleura and less potential to produce underlying parenchymal coagulation in the lung tissue than did the Nd:YAG laser. This information may be useful in the selection of devices for pulmonary volume reduction by pneumoplastic procedures.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 1488.

Patients with emphysema have been surgically treated by reducing the volume of the lung using video-assisted thoracoscopic surgical procedures with laser or electrosurgical technique [1–4]. The most commonly used equipment in the treatment is the neodymium:yttrium-aluminum garnet (Nd:YAG) laser and the Argon Beam Coagulator (ABC), an electrosurgical device. The potential damages to the lung tissue associated with laser and electrosurgical treatments differ with the equipment and the technique. Several morphologic examinations of the lung tissue treated with Nd:YAG laser or electrosurgical devices have been reported [5–9]. Although some reports indicate that the contact-mode electrosurgical device has greater potential to inflict damage to lung tissue than does the Nd:YAG laser, the damage of the pleura and underlying parenchyma caused by a noncontact-mode electrosurgical device such as the ABC remains unclear. In the present study, we conducted a morphologic examination of the lung tissue damage to assess immediate responses of the pleura and underlying parenchyma treated by ABC in comparison with those of the Nd:YAG laser.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
We examined lung lobes resected during the treatment of lung carcinoma obtained from 24 patients, 11 men and 13 women, ranging in age from 51 to 73 years (mean ± standard deviation, 62.8 ± 5.9 years). These lung lobes were washed in normal saline solution to remove blood and coagula from the surface to make conditions equal. After cleaning, a normal portion of the inflated lung with air in the parenchyma was treated for 1.5 seconds within a circle 7 mm in diameter. With an Nd:YAG laser (CL50; SLT Japan, Tokyo, Japan), the continuous-wave mode was selected and the lung was treated at the powers of 7, 15, and 40 W. With an ABC (Birtecher-ABC; Medicon, Tokyo, Japan), the pleura was treated at the powers of 40, 80, and 120 W. From the same area of the lobe resected at the time of operation, three specimens treated by Nd:YAG and 3 specimens treated by ABC were harvested. A total of 144 samples, including normal portions of the lung obtained from 24 lobes, were examined by light microscopy.

Microscopic findings of the degenerated visceral pleura were classified into three patterns: coagulative, amorphous, and destructive degeneration, the discrimination of which has previously been published elsewhere [10]. In brief, coagulative degeneration shows contraction of elastic fiber and collagen, amorphous degeneration shows amorphously changed collagen and severely contracted elastic fiber, and destructive degeneration shows a destroyed pleura in which neither elastic fibers nor collagen is discernible. Thermal injury of the lung tissue with destructive degeneration at the pleura and slight coagulation at residual parenchyma was defined as showing "air leak pattern" based on the experiment previously reported [10]. Lesions exhibiting these microscopic findings were demonstrated to be the most common site of air leak by the air inflation test in which the lung lobe was submerged in normal saline solution and inflated through the airway to detect any air leak in degenerated lung tissue.

Data were statistically evaluated using a computer statistical package (Stat View II; Abacus Concepts, Inc., Berkeley, CA). The ² test was used as appropriate. Statistical significance was defined as a p value less than 0.05.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The common patterns of degenerated lung tissues caused by Nd:YAG laser at 15 W or ABC at 80 W are illustrated in Figure 1. The visceral pleura irradiated by an Nd:YAG laser showed amorphous degeneration. In contrast, the pleura treated by ABC exhibited destructive degeneration. The incidences of each type of pleural tissue degeneration after Nd:YAG laser and ABC irradiation at each power are shown in Table 1. At the power of 7 or 15 W, destructive degeneration did not occur when the Nd:YAG laser was applied. At 40 W of Nd:YAG laser power, destructive degeneration was noted in 10 samples (42%). In contrast, ABC at the power of 40 W produced destructive degeneration in 18 samples (75%) (p < 0.05 compared with Nd:YAG at 40 W). At 80 and 120 W, destructive degeneration was observed in all samples.

View larger version (161K): [in this window] [in a new window]   Fig 1. . Nontreated normal lung tissue (A, B) and the common pattern of degenerated lung tissue caused by neodymium:yttrium-aluminum garnet laser or the Argon Beam Coagulator at the power of clinical use in a circle 7 mm in diameter. Samples irradiated with neodymium:yttrium-aluminum garnet laser at the power of 15 W revealed amorphous degeneration of the visceral pleura and some coagulation of the underlying parenchyma (C, D). Samples treated with the Argon Beam Coagulator at the power of 80 W showed destructive degeneration of the visceral pleura and little coagulation of the underlying parenchyma (E, F). Because air leak was quite common in this type of microscopic findings, we defined this as "air leak pattern." (Elastica-van Gieson's stain; A, C, E x40; B, D, F x200; all before 22% reduction.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Devices used for contraction treatment of the lung tissue include the ABC, carbon dioxide laser, and Nd:YAG laser [2–4]. The setting power of the Nd:YAG laser ranges from 10 to 15 W for the treatment of emphysema [4] and 12 to 35 W for bullae [12]. The ABC is set at 80 W for the treatment of bullous emphysema [2]. Lewis and co-workers [2] reported treatment of 8 patients with end-stage bullous emphysematous disease, who were considered to be at high risk for thoracotomy, using video-assisted thoracoscopic surgery with an ABC and bullectomy with a linear cut stapler. Hospitalization averaged 13.6 days, and all patients showed subjective improvement. The postoperative complication of air leak occurred in 7 patients (88%). Torre and Belloni [13] reported Nd:YAG laser treatment using video-assisted thoracoscopic surgery in 14 patients with bleb disease. There were no side effects and the treatment was successful in 13 patients. Little and co-workers [4] reported laser treatment of diffuse emphysema using the Nd:YAG laser. A total of 55 procedures were performed. Prolonged air leak occurred in 9 patients (13%), and moderate to severe subcutaneous emphysema in 25 (45%). Most patients noticed improvement of ventilatory capacity.

Common complications related to the operation for emphysema are a delayed or incomplete reexpansion of the lung and prolonged air leak. Most lungs will reexpand provided that air leak is absent. The incidence of destructive degeneration in the pleura corresponds to the incidence of air leak [10]. The control of air leak secondary to pleural degeneration, therefore, is important in perioperative care. In our in vitro examination of the resected lung, the ABC caused destructive degeneration in the pleura more frequently than the Nd:YAG laser at the power of clinical use and even at 40 W, which is the minimum power of the ABC. Moghissi and Neville [6] reported that Nd:YAG laser treatment can contract the alveolae in the parenchyma, thus preventing air leak. In contrast, coagulation diathermy (contact-mode electrocautery) can only degenerate superficial tissue, thus having little effect in preventing air leak from the parenchyma. In our experiment, the incidence of air leak pattern in the samples treated with the ABC was greater than that in the Nd:YAG laser-treated samples not only at energies of clinical use (Nd:YAG, 15 W; ABC, 80 W) but also at the same energy of 40 W.

In conclusion, the ABC had more potential to damage the pleura and less potential to produce underlying parenchymal coagulation in the lung tissue than did the Nd:YAG laser. This information may be useful in the selection of devices for pulmonary volume reduction by pneumoplastic procedures.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Sawabata, Department of Surgery III, Nara Medical College, 840 Shijho-cho, Kashihara City, Nara 634, Japan.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Noriyoshi Sawabata Takashi Tojo Soichiro Kitamura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sawabata, N. Articles by Kitamura, S. Search for Related Content PubMed PubMed Citation Articles by Sawabata, N. Articles by Kitamura, S. Related Collections Related Article