HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) 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): Henri L. Porte Alain J. Wurtz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Porte, H. L. Articles by Wurtz, A. J. Search for Related Content PubMed PubMed Citation Articles by Porte, H. L. Articles by Wurtz, A. J. Related Collections Lung - other

Ann Thorac Surg 2001;71:1618-1622
© 2001 The Society of Thoracic Surgeons

---

Original article: general thoracic

Randomized controlled trial of a synthetic sealant for preventing alveolar air leaks after lobectomy

^a Clinique Chirurgicale, Hôpital Calmette, Lille, France

Accepted for publication January 20, 2001.

Address reprint requests to Dr Porte, Clinique Chirurgicale, Hôpital Calmette, Bd du Professeur Leclercq, 59037 Lille Cedex, France
e-mail: awurtz{at}chru-lille.fr

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. The intraoperative application of synthetic surgical lung sealant (SLS) to surfaces leaking air or at risk of air leaks has been advocated to reduce alveolar air leaks (AAL) after lobectomy.

Methods. This study was designed to investigate the effectiveness of SLS in reducing AAL in patients considered intraoperatively to have moderate to severe AAL, after all conventional measures to reduce such leaks had been used. Over 17 months, 124 patients undergoing standard lobectomy were randomized to standard closure of parenchymal surgical sites, with or without SLS.

Results. In treated patients, the mean numbers of intraoperative AAL after application of SLS were significantly smaller than in untreated patients (38.5 mL versus 59.9 mL, p = 0.0401). Postoperatively, the mean time to last observable AAL was shorter in the treated group (33.7 hours versus 63.2 hours, p = 0.0134) and the mean percentage of patients free of AAL at days 3 and 4 was smaller (87% versus 58.5%, p = 0.002). However, the occurrence of incomplete lung expansion after drain removal, and the length of the postoperative hospital stay due to prolonged AAL, were not different. In the treatment group, 4 patients developed localized empyema and incomplete lung expansion without bronchopleural fistula 7, 12, 15, and 20 days, respectively, after operation. In these 4 patients, inserted chest tubes drained infected sealant.

Conclusions. Surgical lung sealant may be a useful adjunct to conventional techniques for reducing moderate and severe AAL after lobectomy, but its use seems to increase the risk of postoperative empyema.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The occurrence of prolonged alveolar air leaks (AAL) after pulmonary lobectomy is one of the most common problems for thoracic surgeons. It results in longer periods of intercostal drainage, thus increasing morbidity, the length of postoperative hospitalization, and costs [1–4]. As new products are currently being developed to treat AAL in the operating room, we conducted a clinical randomized study to determine whether the routine use of a standard quantity of the synthetic surgical lung sealant (SLS) (Advaseal, Johnson and Johnson, distributed in Europe by Ethicon), would reduce the number and duration of postoperative AAL after standard uncomplicated lobectomy.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Study objectives
The goals of our study were twofold. The first goal was to determine the safety of SLS after its application to surface leaking air or areas at risk of leaking air after lobectomy, by surveillance for unexpected adverse events during follow-up. The second goal was to assess (1) the percentage of demonstrated AAL effectively sealed at operation after SLS application; (2) the durability of AAL sealing, by measuring postoperative AAL through the thoracostomy tube in the treatment and control groups, from postoperative days 0 to 6; and (3) the potential effect of SLS on the in-hospital stay in the treatment group compared with the control group.

Synthetic absorbable surgical sealant
The SLS used in this study consists of two components, a primer and the sealant, sold with an application system of two syringe-type applicators (one loaded with the primer solution and the other with the sealant solution) and a fiberoptic light wand. The two solutions are made up by reconstituting two vials of dry powder with the corresponding aqueous solutions. The reconstituted solutions are then loaded into corresponding syringe-type applicators equipped with nylon brush tips through which the sealant can be applied. The primer is an aqueous solution of a copolymer of polyethylene glycol with end caps of acrylate, which is brushed onto the lung target tissue to act as a wetting solution before the sealant is applied, and helps the sealant to achieve good adherence. Next, a bed of the polymer sealant is applied and photopolymerized by visible xenon light, which transforms the sealant solution into a cross-linked hydrogel. Visible light illumination from the xenon arc lamp (470 to 520 nm) at intensity of 100 mw/cM is used for 40 seconds to initiate polymerization. Theoretically the sealant acts as a barrier to AAL for 14 days and should be absorbed and eliminated from the body over a period of 10 to 16 months. The process of sealant absorption occurs by slow hydrolysis, thus releasing biocompatible components that are metabolized or cleared by the kidneys.

A fixed quantity of SLS, sold in France for US$300 in a kit with 20 mL of primer solution and 20 mL of sealant solution, was applied to the lung surfaces leaking air or at risk of leaking air in patients randomized for its use, regardless of the surface and the quantity of AAL measured before treatment.

Patient selection and alveolar air leak management
This study was performed in a single institution over a period of 17 months (October 1998 through March 2000). Patient consent was obtained before the operations, all of which were performed by the 2 senior authors (A.W. and H.P.) with the same surgical techniques, including use of staplers to create uncompleted fissure plans. Only patients undergoing standard lobectomy or bilobectomy were eligible for inclusion in the study. Patients undergoing sleeve lobectomy associated with any segmental resection or redo-thoracotomy were excluded. The sample size was calculated for the main study end point of preventing postoperative AAL. The sample size was based on published data for the persistence of AAL after lobectomy, and on the hypothesis that by postoperative day 4, the proportion of patients with AAL would have decreased from 30% in the control group to 10% in the SLS-treated group. Using the ² test and one-sided test of significance, a sample size of 58 patients in each group was calculated to be adequate for an overall power of 80% in this study (type I error: = 0.05; type II error: ß = 0.2). After the respective procedures, areas of AAL were closed by conventional techniques, including electrocautery and monofilament material or staplers where possible. The operated lung was then ventilated to an airway pressure of 20 mm Hg to assess the degree of AAL. Randomized patients only included those judged intraoperatively to have moderate to severe AAL according to the ventilator volumes after all conventional techniques to bring them under control had failed (minimum leaks of 40 mL and maximum leaks of 120 mL).

After AAL evaluation, patients were entered into either the treatment or control group. In the control group, patients underwent no further procedures. For patients assigned to the treatment group, SLS was applied to all identified surgical sites leaking air or at risk of leaking air while ventilation was suspended for 3 to 8 minutes (mean 5 minutes). After photopolymerization, the lung was insufflated and ventilated again to an airway pressure of 20 mm Hg.

Management of intercostal drains and assessment of the postoperative hospital stay
Before chest closure, all patients had two intercostal drains placed apically (anterior and posterior) with basal holes. Drains were placed postoperatively under negative pressure suction of 20 mm Hg and always removed on the sixth postoperative day without a clamping test, even in cases of persistent AAL. The drains were never removed before day 6 even in cases of AAL cessation. Lung expansion was evaluated after removal of the drains. A small Monaldi drain was inserted into the chest cavity in case of persistent large pneumothorax after drain removal. Only hospital stays prolonged because of AAL or adverse effects of SLS (ie, empyema) were taken into account in the total in-hospital stay calculation, excluding hospital stays prolonged because of social or cultural reasons, which we frequently encounter in France. Postoperatively, patients who developed bronchopleural fistula or required assisted ventilation for more than 24 hours before drain removal on postoperative day 6 were excluded from the final statistical analysis.

Assessment of alveolar air leak modalities
Perioperative AAL were measured with the CATO M33285 ventilator (Drager Inc, Lubeck, Germany) before and after SLS application on double-lung ventilation with a pressure of 20 mm Hg and an insufflated volume of 10 mL/kg at a frequency of 12 cycles/min. The calculated AAL was the difference between the insufflated and exufflated volumes, excluding the leaks into the circuit that were previously calculated on double-lung calculation while the surgeon was opening the chest. Postoperative AAL were graded from the bubble count in the Pleur-Evac Sahara S-1100 (Genzyme Cergy, Pontoise, France) scale ranging from 0 (absence of AAL) to 7 (major AAL) during expiration every morning for more than three different respiratory cycles. The time to last observable AAL was recorded for all patients.

Follow-up
Treated patients underwent a clinical examination and chest computed tomography (CT) scan 3 months after operation and then every 6 months in case of any abnormality found on the first CT scan.

Statistical studies
The two groups were compared using either the ² test or Fisher exact test for categoric variables, and the Student’s t test for numeric variables (including perioperative AAL after SLS application, the daily quantity of AAL on the Pleur-Evac scale from postoperative days 1 to 6, the time to the last observable AAL, the percentage of patients free of AAL on postoperative days 3, 4, and 6, and the postoperative in-hospital stay due to persistent AAL or to empyema after SLS application).

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
During the 17-month period, a total of 124 patients were eligible for enrollment in the trial. Sixty-two were randomly assigned to the experimental group and 62 to the control group.

30-day postoperative morbidity and mortality
In the control group, 1 patient developed a bilateral lung infection requiring high-pressure ventilation on day 4; this patient died on day 20. In the treatment group, 3 patients also required assisted ventilation for nonfatal lung infections of the nonoperated lung between days 2 and 5. In these 4 patients, who were on assisted ventilation for more than 24 hours before the sixth postoperative day, AAL could not be evaluated according to the study protocol. These patients were not included in the analysis, as their complications were unrelated to AAL or lung sealant application. In the treatment group, 4 patients developed systemic sepsis, associated with major sputum of infected SLS in 2 of them, without bronchopleural fistula. Loculated collection and incomplete lung expansion were ascertained by CT scan (Fig 1) on postoperative days 7, 12, 15, and 20. All 4 patients required chest tube thoracostomy for 6, 25, 11, and 20 days, respectively, to drain infected sealant according to bacteriologic studies in all cases. The prolonged hospital stay of these 4 patients was considered to be a consequence of SLS application. Overall, 59 patients in the treatment group and 61 in the control group were included in the final statistical analysis. The clinical features of both groups of patients (Table 1) were matched for age, emphysema (definition based on CT and macroscopical and microscopical aspect of the lung), professional exposure to silicosis for more than 5 years, type of operation performed, incidence of malignancy, duration of operation excluding lung surgical sealant application, and number of perioperative AAL before SLS treatment.

View larger version (88K): [in this window] [in a new window]   Fig 1. Chest computed tomography scans (A) 7 and (B) 12 days after lobectomy in 2 patients who had systemic sepsis without bronchopleural fistula and loculated empyema (arrows) requiring additional percutaneous drainage for 6 and 25 days, respectively.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The management of AAL after lobectomy has evolved during the last decade, thanks to the experience acquired in lung volume reduction [5]. The average duration of intercostal drainage has diminished because most surgeons now remove the drains at the time of the last observable AAL, when expansion of the remaining lung parenchyma is complete. The wall suction levels applied to the drains have also diminished, and some advocate water rather than suction sealing in case of massive AAL [6]. Other methods, that is, provocative clamping followed by chest tube removal despite persistent AAL and outpatient chest tube management using Heimlich valves instead of venting pleural air, have also helped to shorten the average in-hospital stay [6–8]. Nevertheless, persistent AAL is still an almost universal daily problem for thoracic surgeons. In patients with emphysematous lungs, the smallest pinhole after monofilament suture or on a staple line can result in extensive AAL, despite correct use of conventional techniques to avoid them [5]. In patients with tuberculosis, dilated bronchus, or a history of professional exposure to silicosis, dissection of an incomplete fissure can be extremely difficult, because of the inflammatory process around the arteries and bronchus, so that the use of staplers in such situations can be hazardous. Consequently, the usefulness of an adhesive product in such settings is still questionable. This dilemma is reflected in numerous studies, whose authors reported the use of various products in various circumstances, in an attempt to prove their efficacy [9–12]. In this setting, fibrin glue has been the adhesive material most widely used in thoracic operations during the last 10 years. However, interest in this product has decreased since the randomized trials conducted by Fleisher and colleagues [13], Wong and Goldstraw [4], and our team [14] demonstrated that there was no difference between the treated and control groups in the numbers of postoperative air leaks, in the duration of thoracic drainage, and in hospitalization due to insufficient fibrin glue adhesion to lung tissue. For surgical procedures on the lung, the ideal adhesive substance should be a synthetic biodegradable material, which would avoid antigenicity [15] and the risks of disease transmission associated with human or animal-source material, and should be strong enough to remain sealed and withstand the normally expected pressures of an inflated lung without affecting the healing process.

The SLS used in the present study was shown to adhere four times more strongly and withstand pressures 12 times greater than fibrin glue, and was capable of expanding to more than 70% of its original size. Histologic evaluation of the antigenicity of the sealant material has been shown to be similar to that of suture materials [16, 17]. Macchiarini and colleagues [18] performed a randomized trial with SLS on 30 patients. They found that the substance was easy to use and apply in all anatomic areas and did not elicit any clinically demonstrable host response. Intraoperatively, the material was able to eliminate all AAL on normal and diseased lung tissue. After the operation, the proportion of AAL-free patients was significantly higher in the treatment group. In addition, there was a tendency toward shorter times to chest tube removal and shorter hospitalization times in treated patients. In the present study, we confirmed the efficacy of SLS in reducing perioperative and postoperative AAL after lobectomy, in patients who had moderate or severe AAL before SLS application and after all the conventional measures to reduce AAL had been used. We showed that the mean time to the last observable AAL was shorter in the treated group (33.70 hours versus 63.22 hours). Nevertheless, the mean in-hospital stay was not different in the control and treated groups, mainly because of the higher percentage of empyema cases in the treated group. Accordingly, it seems that SLS does not maintain its adhesive properties over time, as suggested by the similar percentages of AAL found on the sixth postoperative day in both groups. Consequently, we suggest that in some circumstances, SLS does not adhere sufficiently to the lung, and acts as a foreign body in the chest cavity, creating impermeable pleural space liable to be infected. We base this hypothesis on two facts: first, in the 4 patients with empyemas, infected SLS was evacuated through the chest tubes inserted postoperatively (Fig 1); second, postoperative CT scan displayed a similar image in 20 other patients of the treated group, who experienced a normal recovery without any signs of infection.

The efficacy of SLS in reducing perioperative and postoperative AAL should in theory help to reduce the average duration of postoperative drainage after lobectomy. Nevertheless, the advantage of this product has to be counterbalanced by the potential risk of localized empyema, which normally is exceptional after standard lobectomies without bronchopleural fistula. Consequently, since the completion of the present study, we use SLS only in patients with major perioperative AAL, that is, more than 120 mL according to ventilator measurement.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The authors thank Ethicon Inc, for financial support for this study.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

1. Kirsh M.M., Rotman H., Behrendt D.M., Orringer M.B., Sloan H. Complications of pulmonary resection. Ann Thorac Surg 1975;20:215-236.[Abstract]
2. Keagy B.A., Lores M.E., Starek P.J.K., Murray G.F., Lucas C.L., Wilcox B.R. Elective pulmonary lobectomy: factors associated with morbidity and operative mortality. Ann Thorac Surg 1985;40:349-352.[Abstract]
3. Duque J.L., Ramos G., Castrodeza J., et al. Early complications in surgical treatment of lung cancer: a prospective, multicenter study. Ann Thorac Surg 1997;63:944-950.[Abstract/Free Full Text]
4. Wong K., Goldstraw P. Effect of fibrin glue in the reduction of post-thoracotomy alveolar air leak. Ann Thorac Surg 1997;64:979-981.[Abstract/Free Full Text]
5. Cooper J.D. Technique to reduce alveolar air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038-1039.[Abstract]
6. Cerfolio R.J., Tummala R.P., Holman W.L., et al. A prospective algorithm for the management of alveolar air leaks after pulmonary resection. Ann Thorac Surg 1998;66:1726-1731.[Abstract/Free Full Text]
7. Kirschner P.A. Provocative clamping and removal of chest tubes despite persistent alveolar air leak. Ann Thorac Surg 1992;53:740-741.[Medline]
8. Ponn R.B., Silverman H.J., Federico J.A. Outpatient chest tube management. Ann Thorac Surg 1997;64:1437-1440.[Abstract/Free Full Text]
9. Matthew T., Spotnitz W., Kron I.L., Tribble C.G., Nolan S.P. Four years’ experience with fibrin sealant in thoracic and cardiovascular surgery. Ann Thorac Surg 1990;50:40-44.[Abstract]
10. Nomori H., Horio H. Gelatin-resorcinol-formaldehyde-glutaraldehyde glue-spread stapler prevents alveolar air leakage from the lung. Ann Thorac Surg 1997;63:352-355.[Abstract/Free Full Text]
11. Feito B.A., Rath A.M., Longchampt E., Azorin J. Experimental study on the in vivo behaviour of a new collagen glue in lung surgery. Eur J Cardiothorac Surg 2000;17:8-13.[Abstract/Free Full Text]
12. Tsuda T., Nakamura T., Yamamoto Y., et al. Prevention of postoperative alveolar air leakage from lungs using a purified human collagen membrane-polyglycolic acid sheet. Ann Thorac Surg 1999;68:339-342.[Abstract/Free Full Text]
13. Fleisher A.G., Evans K.G., Nelems B., Finley R.J. Effect of routine fibrin glue use on the duration of alveolar air leaks after lobectomy. Ann Thorac Surg 1990;49:133-134.[Abstract]
14. Wurtz A., Gambiez L., Chambon J.P., Saudemont A. Evaluation de l’efficacité d’une colle de fibrine en chirurgie d’exérèse pulmonaire partielle. Lyon Chir 1992;88:368-371.
15. Mitsuhata H., Horiguchi Y., Saitoh J. An anaphylactic reaction of topical fibrin glue. Anesthesiology 1994;81:1074-1077.[Medline]
16. Ranger W.R., Halpin D., Sawhney A.S., Lyman M., Locicero J. Pneumostasis of experimental alveolar air leaks with a new photopolymerized synthetic tissue sealant. Am Surg 1997;63:788-795.[Medline]
17. Alleyen C.H., Jr, Cawley C.M., Barrow D.L., et al. Efficacy and biocompatibility of a photopolymerized, synthetic, absorbable hydrogel as a dural sealant in a canine craniotomy model. J Neurosurg 1998;88:308-313.[Medline]
18. Macchiarini P., Wain J., Almy S., Dartevelle P. Experimental and clinical evaluation of a new synthetic, absorbable sealant to reduce alveolar air leaks in thoracic operations. J Thorac Cardiovasc Surg 1999;117:751-758.[Abstract/Free Full Text]

This article has been cited by other articles:

				G. Rocco, E. A. Rendina, F. Venuta, M. R. Mueller, S. Halezeroglu, H. Dienemann, D. V. Raemdonck, and H. J. Hansen The use of sealants in modern thoracic surgery: a survey Interactive CardioVascular and Thoracic Surgery, July 1, 2009; 9(1): 1 - 3. [Full Text] [PDF]

				A. D'Andrilli, C. Andreetti, M. Ibrahim, A. M. Ciccone, F. Venuta, U. Mansmann, and E. A. Rendina A prospective randomized study to assess the efficacy of a surgical sealant to treat air leaks in lung surgery Eur. J. Cardiothorac. Surg., May 1, 2009; 35(5): 817 - 821. [Abstract] [Full Text] [PDF]

				C. Moser, I. Opitz, W. Zhai, V. Rousson, E.W. Russi, W. Weder, and D. Lardinois Autologous fibrin sealant reduces the incidence of prolonged air leak and duration of chest tube drainage after lung volume reduction surgery: a prospective randomized blinded study. J. Thorac. Cardiovasc. Surg., October 1, 2008; 136(4): 843 - 849. [Abstract] [Full Text] [PDF]

				A. Droghetti, A. Schiavini, P. Muriana, A. Folloni, M. Picarone, C. Bonadiman, C. Sturani, R. Paladini, and G. Muriana A prospective randomized trial comparing completion technique of fissures for lobectomy: stapler versus precision dissection and sealant. J. Thorac. Cardiovasc. Surg., August 1, 2008; 136(2): 383 - 391. [Abstract] [Full Text] [PDF]

				U. Anegg, R. Rychlik, and F. Smolle-Juttner Do the benefits of shorter hospital stay associated with the use of fleece-bound sealing outweigh the cost of the materials? Interactive CardioVascular and Thoracic Surgery, April 1, 2008; 7(2): 292 - 296. [Abstract] [Full Text] [PDF]

				J. Tambiah, R. Rawlins, D. Robb, and T. Treasure Can tissue adhesives and glues significantly reduce the incidence and length of postoperative air leaks in patients having lung resections? Interactive CardioVascular and Thoracic Surgery, August 1, 2007; 6(4): 529 - 533. [Abstract] [Full Text] [PDF]

				U. Anegg, J. Lindenmann, V. Matzi, J. Smolle, A. Maier, and F. Smolle-Juttner Efficiency of fleece-bound sealing (TachoSil(R)) of air leaks in lung surgery: a prospective randomised trial Eur. J. Cardiothorac. Surg., February 1, 2007; 31(2): 198 - 202. [Abstract] [Full Text] [PDF]

				M. Gika, M. Kawamura, Y. Izumi, and K. Kobayashi The short-term efficacy of fibrin glue combined with absorptive sheet material in visceral pleural defect repair Interactive CardioVascular and Thoracic Surgery, February 1, 2007; 6(1): 12 - 15. [Abstract] [Full Text] [PDF]

				P. Tansley, F. Al-Mulhim, E. Lim, G. Ladas, and P. Goldstraw A prospective, randomized, controlled trial of the effectiveness of BioGlue in treating alveolar air leaks J. Thorac. Cardiovasc. Surg., July 1, 2006; 132(1): 105 - 112. [Abstract] [Full Text] [PDF]

				P. Thomas, G. Massard, H. Porte, C. Doddoli, X. Ducrocq, and M. Conti A new bioabsorbable sleeve for lung staple-line reinforcement (FOREsealtrade mark): report of a three-center phase II clinical trial. Eur. J. Cardiothorac. Surg., June 1, 2006; 29(6): 880 - 885. [Abstract] [Full Text] [PDF]

				I. Matsumoto, Y. Ohta, M. Oda, Y. Tsunezuka, M. Tamura, K. Kawakami, and G. Watanabe Free Pericardial Fat Pads Can Act as Sealant for Preventing Alveolar Air Leaks Ann. Thorac. Surg., December 1, 2005; 80(6): 2321 - 2324. [Abstract] [Full Text] [PDF]

				M. Kawamura, M. Gika, Y. Izumi, H. Horinouchi, N. Shinya, M. Mukai, and K. Kobayashi The sealing effect of fibrin glue against alveolar air leakage evaluated up to 48h; comparison between different methods of application Eur. J. Cardiothorac. Surg., July 1, 2005; 28(1): 39 - 42. [Abstract] [Full Text] [PDF]

				Y. Sakamaki, T. Kido, T. Fujiwara, K. Kuwae, and M. Maeda A Novel Procedure Using a Tissue Expander for Management of Persistent Alveolar Fistula After Lobectomy Ann. Thorac. Surg., June 1, 2005; 79(6): 2130 - 2132. [Abstract] [Full Text] [PDF]

				M. S. Allen, D. E. Wood, R. W. Hawkinson, D. H. Harpole, R. J. McKenna, G. L. Walsh, E. Vallieres, D. L. Miller, F. C. Nichols III, W. R. Smythe, et al. Prospective randomized study evaluating a biodegradable polymeric sealant for sealing intraoperative air leaks that occur during pulmonary resection Ann. Thorac. Surg., May 1, 2004; 77(5): 1792 - 1801. [Abstract] [Full Text] [PDF]

				G. Lang, A. Csekeo, G. Stamatis, L. Lampl, L. Hagman, G. M. Marta, M. R. Mueller, and W. Klepetko Efficacy and safety of topical application of human fibrinogen/thrombin-coated collagen patch (TachoComb) for treatment of air leakage after standard lobectomy Eur. J. Cardiothorac. Surg., February 1, 2004; 25(2): 160 - 166. [Abstract] [Full Text] [PDF]

				C. A. Keller Lasers, Staples, Bovine Pericardium, Talc, Glue and... Suction Cylinders?: Tools of the Trade To Avoid Air Leaks in Lung Volume Reduction Surgery Chest, February 1, 2004; 125(2): 361 - 363. [Full Text] [PDF]

				K. Ueda, Y. Kaneda, H. Sakano, T. Tanaka, T.-S. Li, and K. Hamano Obstacles for shortening hospitalization after video-assisted pulmonary resection for lung cancer Ann. Thorac. Surg., December 1, 2003; 76(6): 1816 - 1820. [Abstract] [Full Text] [PDF]

				T. Fabian, J. A. Federico, and R. B. Ponn Fibrin glue in pulmonary resection: a prospective, randomized, blinded study Ann. Thorac. Surg., May 1, 2003; 75(5): 1587 - 1592. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) 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): Henri L. Porte Alain J. Wurtz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Porte, H. L. Articles by Wurtz, A. J. Search for Related Content PubMed PubMed Citation Articles by Porte, H. L. Articles by Wurtz, A. J. Related Collections Lung - other