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SEALING CUT LUNG SURFACES WITH PLASTIC ADHESIVE
SEALING CUT L U N G SURFACES W I T H PLASTIC ADHESIVE John L. Sawyers, M.D., and John Vasko, M.D., Nashville,
Tenn.
T
HE problems associated with leakage of air and blood from lacerated and abraded lung surfaces are familiar to most surgeons. Certainly the ad vantages of retaining all available functioning lung are recognized and are being utilized by chest surgeons whenever possible. However, the threat of air and blood leakage along with infection from the cut raw surfaces, in spite of present suture techniques, has resulted in removal of more lung than necessary on many occasions. The compromise of lung from folding and distortion at sutured surfaces can result in space problems or compromise of function. Lobectomy is sometimes done when segmental resection would suffice because of the problem of numerous air leaks. The introduction and rapid development of the new plastic adhesives, such as methyl 2-cyanoacrylate (Eastman 910 monomer), provide a useful surgical adjuvant to closure of these cut surfaces. The following experimental study was undertaken to evaluate the use of this adhesive. METHOD
Twenty unselected mongrel dogs were used in this study. The animals were anesthetized with intravenous pentobarbital in a 30 mg. per kilogram dosage and maintained on a positive pressure respirator during the operative procedure. A routine fifth intercostal thoracotomy was then performed. A variety of large wedge or segmental resections were done in either chest of these animals with removal of significant portions of the operated lobe. A non-crushing vascular clamp was first placed across the lobe selected and the portion of lung resected. The cut lung surface was then sponged relatively dry and painted with the plastic adhesive, Eastman 910.* No sutures were used and every attempt was made to avoid lung distortion. The adhesive was then allowed to dry for 2 minutes and the atraumatic clamp was released. The lung was then thoroughly inflated and tested for leaks. Any residual leaks were resealed in the same manner. The chest was then closed in a routine fashion and aspirated. These animals were then kept isolated for one week to prevent contagion from other dogs, but were not given antibiotics or any other special care. Tenn.
From the Department of Surgery, Vanderbilt University School of Medicine, Nashville, Received for publication Nov. 26, 1962 ; revised and re-submitted June 14, 1963. ♦Supplied through courtesy of Bthicon, Inc., Somerville, New Jersey.
526
Vol. 46, No. 4
SEALING CUT LUNG KUKl'AOES
527
October, 1963 RESULTS
A total of 20 animals were used in this experiment. The survivors were sacrificed at various postoperative periods which ranged from 2 to 6 months (Table I ) . All dogs survived until sacrifice, at which time the pleural cavity was re-explored through the old operative site with careful mobilization of the previously treated pulmonary lobe. Lobectomy was performed and sections of the treated lung surface were submitted for pathological examination.
Pig. 1.—The cut lung surface is covered with a smooth glistening surface 3 weeks after sealing with the plastic adhesive.
TABLE I. RESULTS IN 20 A N I M A L S T H A T SURVIVED AFTER THE U S E OP PLASTIC ADHESIVE TO SEAL CUT L U N G SURFACE* PROCEDURE
1
12 Air leaks Wedge resections 7 Hemothorax Segmental resections 1 Abraded lung *Follow-up until sacrificed—2 weeks to 6 months.
RESULTS
0 0
In all animals, both long- and short-term survivors showed complete sealing at the site of application of the plastic adhesive with a minimum of adhesions, usually to adjacent lung, pleura, or mediastinum. In only 2 dogs were the ad hesions severe, and, in one of these, a large area of lung surface had been abraded and sealed. Particularly in the survivors of 3 weeks or longer, the area of sealing was smooth and appeared covered with glistening pleura with only minimal contraction from scarring (Fig. 1). The involved lobes were fully expanded in each case. In no instance was there evidence of unusual inflammatory reaction or tissue necrosis.
528
8AWYEBS AND
VASKO
J. Thoracic and Cardiovas. Surg.
Microscopic sections of the sealed lung surfaces from these dogs were re viewed. The long-term survivors showed a thin layer of fibrous scar tissue over lying normal lung, with evidence of phagocytosis. The phagocytic cells appeared to be filled with debris, which may be the plastic monomer (Fig. 2). In those animals sacrificed before 4 weeks, the tissue response also showed evidence of chronic inflammation (Pig. 3). This inflammatory response subsides over a period of a few weeks and the scar becomes thinner, leaving a smooth pleura-like surface of fibrous tissue which is not much thicker than normal pleura.
Fig. 2.—At sacrifice, 4 months following application of the adhesive, the cut lung surface shows a thin layer of fibrous scar with underlying phagocytes ingesting the foreign body.
Fig. 3.—At sacrifice, 3 weeks following application of the adhesive, the cut lung surface shows a thicker scar with evidence of chronic inflammation.
Vol. 46, No. 4 October, 1963
SEALING CUT LUNG SURFACES
529
DISCUSSION
With the advent and development of the new plastic adhesives, a number of obvious advantageous uses have become apparent which could make them a valuable surgical adjuvant. Their use in vascular anastomosis has already been extensively investigated. 1 ' 2 Eeeently, several other applications have been advo cated including bronchial stump closure3 and the sealing of cut liver surfaces.4 The use of methyl 2-cyanoacrylate to seal cut lung surfaces in lieu of sutur ing is encouraging. The technique is simple and without apparent prohibitive inflammatory response. However, some precaution must be observed in the use of the adhesive. The lung surface must be relatively dry as moisture hastens polymerization which may occur too quickly. Only a thin layer of adhesive need be applied, with care taken not to put the plastic monomer on normal lung tissue. The methyl 2-cyanoacrylate used in this study differs from the commercial adhesive in that it does not contain the thickening agent, plasticizer, and in hibitor present in the commercial material. It is unlike more conventional ad hesives in that polymerization occurs without the use of excessive pressure, heat, catalyst, or added solvent. The plastic adhesive is stated to be self-sterilizing.5 Our work would support this, as no evidence of empyema was encountered in this study. Experimental work by Cantrell 6 has shown the efficacy of preventing al veolar air leaks with the use of powdered gelatin sponge. All vessels and recog nizable bronchi were clamped and ligated in his experimental animals. In this study, the adhesive proved to be effective in preventing not only alveolar air leaks, but also air leaks from major segmental bronchi and blood leaks from several large vessels. No attempt, other than application of the adhesive, was done to control leakage from the cut lung surface. A series of 7 control animals died within a few minutes up to 3 days. It was necessary to control hemorrhage in these dogs by ligation so that they would not bleed to death on the operating table. All control animals died of tension pneumothorax from air leaks through the cut lung surface. The time-honored method of dealing with air leaks following partial pul monary resections has been water-sealed drainage, with or without suction, to draw off the accumulated air from the pleural cavity until healing occurs to obliterate the small air leaks. This interval may be prolonged with resulting discomfort for the patient. Suture closure of all raw lung surface sacrifices normal pulmonary tissue by enfolding and may distort the bronchovascular structures. The use of a plastic adhesive prevented these difficulties in the ex perimental animal. SUMMARY
Twenty dogs that underwent either segmental or extensive wedge resection of the lung had the raw lung surface sealed with methyl 2-cyanoacrylate (East man 910 monomer) without the use of ligatures or sutures. Follow-up studies to 6 months have revealed good results from this simple technique.
SAWYERS AND VASKO
530
J. Thoracic and Cardiovas. Surg.
The results of this study indicate that plastic adhesive may prove to be an important adjuvant to pulmonary surgery. REFERENCES 1. Healey, J . E., Jr., Clark, R. L., Gallager, H. S., O'Neill, P., and Sheena, K. S.: Nonsuture Repair of Blood Vessels, Ann. Surg. 155: 817, 1962. 2. Carton, C. A., Kessler, L. A., Seidenberg, B., and Hurwitt, E. S.: Experimental Studies in Surgery of Small Blood Vessels. I I . Patching of Arteriotomy Using a Plastic Ad hesive, J . Neurosurg. 18: 188, 1961. 3. Hoaley, J . E., Jr., Sheena, K. S., Gallager, H. S., Clark, R. L., and O'Neill, P . : The Use of a Plastic Adhesive in the Technique of Bronchial Closure, S. Forum 13: 153, 1962. 4. Marable, S. A., and Wagner, D. E . : The Use of Rapidly Polymerizing Adhesives in Mas sive Liver Resection, S. Forum 13: 264, 1962. 5. Fassett, D. W., Eandabush, E. L., Emley, 1. C , and Granlich, L. B . : Microbiological Growth From Eastman 910 Monomer and Adhesive, Cohesivenews 1, No. 3 : 5, 1961. 6. Cantrell, J . E., and Welch, G. H., J r . : The Prevention of Alveolar Air-Leaks Following Pulmonary Eesection, S. Forum 8: 469, 1957.
Tenn.
T
HE problems associated with leakage of air and blood from lacerated and abraded lung surfaces are familiar to most surgeons. Certainly the ad vantages of retaining all available functioning lung are recognized and are being utilized by chest surgeons whenever possible. However, the threat of air and blood leakage along with infection from the cut raw surfaces, in spite of present suture techniques, has resulted in removal of more lung than necessary on many occasions. The compromise of lung from folding and distortion at sutured surfaces can result in space problems or compromise of function. Lobectomy is sometimes done when segmental resection would suffice because of the problem of numerous air leaks. The introduction and rapid development of the new plastic adhesives, such as methyl 2-cyanoacrylate (Eastman 910 monomer), provide a useful surgical adjuvant to closure of these cut surfaces. The following experimental study was undertaken to evaluate the use of this adhesive. METHOD
Twenty unselected mongrel dogs were used in this study. The animals were anesthetized with intravenous pentobarbital in a 30 mg. per kilogram dosage and maintained on a positive pressure respirator during the operative procedure. A routine fifth intercostal thoracotomy was then performed. A variety of large wedge or segmental resections were done in either chest of these animals with removal of significant portions of the operated lobe. A non-crushing vascular clamp was first placed across the lobe selected and the portion of lung resected. The cut lung surface was then sponged relatively dry and painted with the plastic adhesive, Eastman 910.* No sutures were used and every attempt was made to avoid lung distortion. The adhesive was then allowed to dry for 2 minutes and the atraumatic clamp was released. The lung was then thoroughly inflated and tested for leaks. Any residual leaks were resealed in the same manner. The chest was then closed in a routine fashion and aspirated. These animals were then kept isolated for one week to prevent contagion from other dogs, but were not given antibiotics or any other special care. Tenn.
From the Department of Surgery, Vanderbilt University School of Medicine, Nashville, Received for publication Nov. 26, 1962 ; revised and re-submitted June 14, 1963. ♦Supplied through courtesy of Bthicon, Inc., Somerville, New Jersey.
526
Vol. 46, No. 4
SEALING CUT LUNG KUKl'AOES
527
October, 1963 RESULTS
A total of 20 animals were used in this experiment. The survivors were sacrificed at various postoperative periods which ranged from 2 to 6 months (Table I ) . All dogs survived until sacrifice, at which time the pleural cavity was re-explored through the old operative site with careful mobilization of the previously treated pulmonary lobe. Lobectomy was performed and sections of the treated lung surface were submitted for pathological examination.
Pig. 1.—The cut lung surface is covered with a smooth glistening surface 3 weeks after sealing with the plastic adhesive.
TABLE I. RESULTS IN 20 A N I M A L S T H A T SURVIVED AFTER THE U S E OP PLASTIC ADHESIVE TO SEAL CUT L U N G SURFACE* PROCEDURE
1
12 Air leaks Wedge resections 7 Hemothorax Segmental resections 1 Abraded lung *Follow-up until sacrificed—2 weeks to 6 months.
RESULTS
0 0
In all animals, both long- and short-term survivors showed complete sealing at the site of application of the plastic adhesive with a minimum of adhesions, usually to adjacent lung, pleura, or mediastinum. In only 2 dogs were the ad hesions severe, and, in one of these, a large area of lung surface had been abraded and sealed. Particularly in the survivors of 3 weeks or longer, the area of sealing was smooth and appeared covered with glistening pleura with only minimal contraction from scarring (Fig. 1). The involved lobes were fully expanded in each case. In no instance was there evidence of unusual inflammatory reaction or tissue necrosis.
528
8AWYEBS AND
VASKO
J. Thoracic and Cardiovas. Surg.
Microscopic sections of the sealed lung surfaces from these dogs were re viewed. The long-term survivors showed a thin layer of fibrous scar tissue over lying normal lung, with evidence of phagocytosis. The phagocytic cells appeared to be filled with debris, which may be the plastic monomer (Fig. 2). In those animals sacrificed before 4 weeks, the tissue response also showed evidence of chronic inflammation (Pig. 3). This inflammatory response subsides over a period of a few weeks and the scar becomes thinner, leaving a smooth pleura-like surface of fibrous tissue which is not much thicker than normal pleura.
Fig. 2.—At sacrifice, 4 months following application of the adhesive, the cut lung surface shows a thin layer of fibrous scar with underlying phagocytes ingesting the foreign body.
Fig. 3.—At sacrifice, 3 weeks following application of the adhesive, the cut lung surface shows a thicker scar with evidence of chronic inflammation.
Vol. 46, No. 4 October, 1963
SEALING CUT LUNG SURFACES
529
DISCUSSION
With the advent and development of the new plastic adhesives, a number of obvious advantageous uses have become apparent which could make them a valuable surgical adjuvant. Their use in vascular anastomosis has already been extensively investigated. 1 ' 2 Eeeently, several other applications have been advo cated including bronchial stump closure3 and the sealing of cut liver surfaces.4 The use of methyl 2-cyanoacrylate to seal cut lung surfaces in lieu of sutur ing is encouraging. The technique is simple and without apparent prohibitive inflammatory response. However, some precaution must be observed in the use of the adhesive. The lung surface must be relatively dry as moisture hastens polymerization which may occur too quickly. Only a thin layer of adhesive need be applied, with care taken not to put the plastic monomer on normal lung tissue. The methyl 2-cyanoacrylate used in this study differs from the commercial adhesive in that it does not contain the thickening agent, plasticizer, and in hibitor present in the commercial material. It is unlike more conventional ad hesives in that polymerization occurs without the use of excessive pressure, heat, catalyst, or added solvent. The plastic adhesive is stated to be self-sterilizing.5 Our work would support this, as no evidence of empyema was encountered in this study. Experimental work by Cantrell 6 has shown the efficacy of preventing al veolar air leaks with the use of powdered gelatin sponge. All vessels and recog nizable bronchi were clamped and ligated in his experimental animals. In this study, the adhesive proved to be effective in preventing not only alveolar air leaks, but also air leaks from major segmental bronchi and blood leaks from several large vessels. No attempt, other than application of the adhesive, was done to control leakage from the cut lung surface. A series of 7 control animals died within a few minutes up to 3 days. It was necessary to control hemorrhage in these dogs by ligation so that they would not bleed to death on the operating table. All control animals died of tension pneumothorax from air leaks through the cut lung surface. The time-honored method of dealing with air leaks following partial pul monary resections has been water-sealed drainage, with or without suction, to draw off the accumulated air from the pleural cavity until healing occurs to obliterate the small air leaks. This interval may be prolonged with resulting discomfort for the patient. Suture closure of all raw lung surface sacrifices normal pulmonary tissue by enfolding and may distort the bronchovascular structures. The use of a plastic adhesive prevented these difficulties in the ex perimental animal. SUMMARY
Twenty dogs that underwent either segmental or extensive wedge resection of the lung had the raw lung surface sealed with methyl 2-cyanoacrylate (East man 910 monomer) without the use of ligatures or sutures. Follow-up studies to 6 months have revealed good results from this simple technique.
SAWYERS AND VASKO
530
J. Thoracic and Cardiovas. Surg.
The results of this study indicate that plastic adhesive may prove to be an important adjuvant to pulmonary surgery. REFERENCES 1. Healey, J . E., Jr., Clark, R. L., Gallager, H. S., O'Neill, P., and Sheena, K. S.: Nonsuture Repair of Blood Vessels, Ann. Surg. 155: 817, 1962. 2. Carton, C. A., Kessler, L. A., Seidenberg, B., and Hurwitt, E. S.: Experimental Studies in Surgery of Small Blood Vessels. I I . Patching of Arteriotomy Using a Plastic Ad hesive, J . Neurosurg. 18: 188, 1961. 3. Hoaley, J . E., Jr., Sheena, K. S., Gallager, H. S., Clark, R. L., and O'Neill, P . : The Use of a Plastic Adhesive in the Technique of Bronchial Closure, S. Forum 13: 153, 1962. 4. Marable, S. A., and Wagner, D. E . : The Use of Rapidly Polymerizing Adhesives in Mas sive Liver Resection, S. Forum 13: 264, 1962. 5. Fassett, D. W., Eandabush, E. L., Emley, 1. C , and Granlich, L. B . : Microbiological Growth From Eastman 910 Monomer and Adhesive, Cohesivenews 1, No. 3 : 5, 1961. 6. Cantrell, J . E., and Welch, G. H., J r . : The Prevention of Alveolar Air-Leaks Following Pulmonary Eesection, S. Forum 8: 469, 1957.