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Ann Thorac Surg 2005;80:2324-2325
© 2005 The Society of Thoracic Surgeons
Department of Thoracic Surgery, Royal Brompton Hospital, Sydney St, London, SW3 6NP United Kingdom
(Email: p.goldstraw{at}rbh.nthames.nhs.uk).
In most patients, persistence of an alveolar air leak after pulmonary surgery is a nuisance, delaying mobilization, drain removal, and discharge home, and significantly increasing the costs of treatment. In a minority of patients persistence of an alveolar air leak after pulmonary surgery leads to added morbidity, empyema, and further surgery. Conventional surgical techniques (eg, suturing visceral pleural defects) are most effective when the lung injury is localized and the lung parenchyma is reasonably healthy. For larger, superficial injuries and when the lung is emphysematous, control by such techniques can be difficult and result in additional reduction in lung volume. Tissue glues present an attractive adjunct in such circumstances, but they are expensive and have their own potential risks. The search for the ideal product, preferably using only autologous tissues, is the Holy Grail of pulmonary surgery, attracting huge commercial interest. There have been many contenders, but most studies have lacked the scientific rigor necessary to show a benefit that outweighs the cost associated with such products. Those few studies that have been randomized do not present a compelling argument for any product at present.
Matsumoto and colleagues [1] describe a novel technique using autologous pericardial fat. This is sutured to the lung surface to plug the visceral pleural defect, the fat also acting as a pledget for the suture. Presumably the integrity of the fat plug is dependent on the overlying parietal pleura. A phase 1 study in dogs showed the technique to be feasible. A phase 2 study in 23 patients suggests that the technique is safe and may be efficacious. As the authors accept, a phase 3 randomized study is now necessary. The clinical model for the study should closely mirror the clinical situation in which conventional techniques fail to control air leak. Consented patients should be randomized during surgery if (1) there is an air leak; (2) this has not been controlled by conventional techniques, and (3) this is judged to be potentially troublesome by the operator. Until another technique has been shown to be effective in this model, the control arm should be no further treatment. Stratification should include grade of air leak and other risk factors.
Even if this technique is shown to be effective in this model, it remains doubtful whether many of us, faced with extensive superficial defects in the visceral pleura, will have the necessary patience and diligence for this technique. The convenience of a spray-on product will remain attractive.
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