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Letters to the Editor |
Department of Surgery, Osaka Kosei Nenkin Hospital, 4-2-78 Fukushima, Fukushima-ku, Osaka City, Osaka 553-0003, Japan
Received 30 May 2008; accepted 2 June 2008.
* Corresponding author. Tel.: +81 6 6441 5451; fax: +81 6 6445 8900. (Email: itano{at}okn.gr.jp).
Key Words: Alveolar air leakage • Fibrin sealant • Bioabsorbable sheet • Combined application technique • Lung surgery
We are thankful for this opportunity to reply to Dr Isaka's letter to the Editor [1].
Our aim is to evaluate the optimal technique for combined application of fibrin sealant and bioabsorbable felt against alveolar air leakage, by comparing the newly developed Rub + Soak B method to various combined application techniques. Some studies have experimentally shown that the combined application of two materials is more effective than the fibrin sealant alone [2]; this combination is presently used widely in pulmonary surgery. In this context, we confirmed that the novel Rub + Soak B method was the most effective and reasonable combination technique wherein the sealing mechanism was supported by the physical properties of the fibrin sealant components [3]. However, Isaka has overlooked the main aspects of this study and has instead focused on a different issue; the pros and cons of possible pleural adhesion associated with the polyglycolic acid (PGA) sheet application. They have strayed from our study topic and have introduced other concepts. Authors should oppose and be wary of such an attitude.
Although the pros and cons of pleural adhesion have been debated, it should not be necessarily avoided only due to the undefined possibilities of re-thoracotomy unless the adhesion involves a massive portion of the lung surface. Pleural adhesion is a rather important useful phenomenon for the control of alveolar air leakage. In certain cases, immediate control of alveolar air leakage is prioritized to avoid complications. Avoidance of massive pleural adhesion should be considered for a more specific category of patients such as candidates for lung transplantation vulnerable to recurrent pneumothorax episodes (i.e., lymphangiomyomatosis or COPD).
With regard to Isaka's experience of postoperative pneumothorax recurrence, the negative impact of adhesion of the covered site on patient management is unclear. Pleural coverage for alveolar air leakage control is usually limited and might not encumber re-thoracotomy when it is needed. Massive adhesion, e.g., adhesion of entire lobes, might be rare.
Furthermore, creation of an acidic environment by polymer degradation by pleural coverage with a PGA sheet is unconfirmed, as it is only based on two separate studies [4,5]. Pleural adhesion in a group with PGA sheet coverage reported in a previous study [5] might not be valid: pleural coverage with the oversized, comparatively bulky PGA mesh in a rat chest with a large thoracotomy (Fig. 1) considering the excessive PGA amount might not occur clinically considering the excessive PGA amount and its subsequent influence on a living body. Non-specific inflammatory response caused by the acidic environment causing pleural adhesion has not been proven either.
References
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