Staple line coverage with suture fixation of polyglycolic acid patch for primary spontaneous pneumothorax
Highlight box
Key findings
• Postoperative air leakage can be reduced by applying a polyglycolic acid (PGA) patch to the staple line and fixing it with sutures during pneumothorax surgery.
What is known and what is new?
• To reduce the recurrence of pneumothorax after surgery, PGA patches were applied to the staple lines.
• Air leakage was reduced when the PGA patches were sutured to the staple lines where air leakage was likely. When multiple sutures were applied, the duration of air leakage was reduced, compared with when a single suture was applied.
What is the implication, and what should change now?
• When performing surgery to treat primary spontaneous pneumothorax, applying a PGA patch to the staple line and suturing it multiple times could reduce the duration of postoperative air leakage.
Introduction
Primary spontaneous pneumothorax (PSP) is a condition characterized by an accumulation of air in the pleural space of a patient without concomitant lung disease. In cases of recurrence, tension pneumothorax, or persistent air leakage, surgical intervention is considered. Thoracoscopic resection of the blebs is currently the most widely performed surgical procedure, and video-assisted thoracic surgery (VATS) is accepted as a standard surgery (1). Postoperative pneumothorax recurrence occurs in 9.5% to 24.5% of cases (1,2), and additional procedures, such as parietal pleural abrasion or pleurectomy after wedge resection, have been attempted to reduce recurrence. The use of absorbable mesh to reinforce the visceral pleura has been reported in several efforts to reduce recurrence (1,3-9). Persistent postoperative air leakage is the most common early complication after surgery. This condition is known to prolong the hospital length of stay and increase the risk of complications such as pleural infection. Therefore, efforts to minimize air leakage after surgery have been made. To reduce air leakage after surgery, the following methods were tried at different times: (I) placing an absorbable polyglycolic acid (PGA) patch on the staple line and securing it with adhesive; (II) suturing the PGA patch once to the staple line; and (III) applying multiple sutures. It was hypothesized that performing sutures would prevent the PGA patch from dislodging as the lung expands and reinforce the staple line, which may be vulnerable to air leakage. Our purpose in this study was to determine whether suturing a patch to the staple line was more effective in reducing postoperative air leakage than simply reinforcing the staple line with a patch and fibrin glue. We aimed to evaluate its usefulness by comparing the postoperative air leakage days, date of chest tube removal, and duration of hospital stay. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2726/rc).
Methods
Study design
This retrospective study was conducted using the medical records of patients who underwent thoracoscopic surgery for PSP between September 2013 and February 2023. The inclusion criteria were cases in which an absorbable PGA sheet and fibrin glue were applied during surgery. To reduce variation by surgeon, only cases in which one surgeon was responsible for both the surgery and postoperative management were included. Patients under 40 years of age were included. The exclusion criteria were pre-existing lung disease, previous ipsilateral thoracic surgery, and the use of five or more staples. Three methods for attaching the PGA patch to the staple line were used: multiple sutures (group A), a single suture (group B), and fibrin adhesive alone (group C). In group A, suturing was performed at (I) both ends of the staple line; (II) the point where two staplers overlapped; and (III) the center of the 60 mm staple line. In group B, suturing was performed at the center of the entire staple line. Cases involving multiple sutures were performed from December 2021 to February 2023 (group A), and those involving one suture were performed from March 2017 to February 2022 (group B). The surgeries that applied only the absorbable patch and fibrin glue were performed from September 2013 to May 2017 (group C).
Surgical management
In all cases, double-lumen endotracheal intubation was performed under general anesthesia to achieve single-lung ventilation. A single port was used as much as possible. We typically created a 3 cm port in the anterior axillary line of the third or fourth intercostal space. We routinely used a 5 mm, 30-degree thoracoscope. Bullectomy was performed using an endoscopic stapling device (Medtronic, SigniaTM, Endo GIATM, USA). In group A, we applied a PGA patch [NEOVEIL® felt (NV-M-015G), 100 mm × 50 mm × 0.15 mm, Gunze, Kyoto, Japan] that covered the entire staple line and sutured it to the staple line using 4-0 polydioxanone sutures (PDS, Ethicon, USA) at both ends and wherever else was deemed necessary. Additional fixation was mainly performed at the overlap of two staples or at the center of the 60 mm staple line. After suturing, fibrin glue (Greenplast, Green Cross Corp., Yongin, Korea) was sprayed on the PGA patch (Figure 1). In group B, a single-point suture was placed in the center of the staple line to prevent displacement of the PGA patch, regardless of the total length of the staple line. After suturing, fibrin glue was sprayed on the PGA patch. In group C, the PGA patch covered the entire staple line and was sprayed with fibrin glue without suture fixation. A 16 Fr chest tube was then inserted and secured.
Postoperative management
An analog drainage system was used. Air leakage was assessed qualitatively. After surgery, continuous suction was performed at a negative pressure of 10–15 cmH2O. After confirming that the lung was expanded on the postoperative chest X-ray, the negative pressure was adjusted to 5–10 cmH2O. The assessment of air leakage was performed as follows. The patient was asked to cough while applying 10 cmH2O suction. If no air leakage occurred, it was defined as cessation of air leakage. If there was no air leak on the first postoperative day, the air leak was defined as day 1. If air leak stopped on the second postoperative day, the air leakage day was defined as day 2. The patient was discharged the day after the chest tube was removed, so long as a chest X-ray revealed no abnormalities.
Ethical statement
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of Ilsan Paik Hospital, Inje University (IRB No. 2023-03-010). The requirement for informed consent was waived because the study is retrospective.
Data collection
We analyzed patient characteristics, operative details, and postoperative outcomes. The clinical data included the baseline characteristics of the patients, operation time, days of postoperative air leakage, day of chest tube removal, postoperative hospital stay, and postoperative complications. As baseline characteristics, we considered age, sex, body mass index (BMI), smoking history, surgical indication, number of blebs, number of wedge resections, number of incisions and cartridges, and past history of pneumothorax. These data were all compared among the surgical groups.
Statistical analysis
The statistical analyses in this study were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA) and R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria). The general characteristics of the study subjects are presented as the mean ± standard deviation for continuous variables and the number (percentage) for categorical variables. Comparisons among the three groups were performed using analysis of variance (ANOVA) or the Kruskal-Wallis test for continuous variables and the Chi-squared test or Fisher’s exact test for categorical variables. Comparisons between two groups were performed using Student’s t-test or the Mann-Whitney U test for continuous variables and the Chi-squared test or Fisher’s exact test for categorical variables. A generalized linear model was fitted. After fitting the model, the mean value of air leakage duration by group and 95% confidence intervals were visualized using the R package ggeffects. The Bonferroni method was used to correct for multiple comparisons. Bleb characteristics, which could act as a confounding variable, were included as a covariate in the correction. All tests were two-sided, and P<0.05 was considered statistically significant.
Results
This study included 135 patients with PSP who underwent surgery between September 2013 and February 2023. Of those patients, 28 (20.7%) were in group A and received multiple sutures, 34 (25.2%) were in group B and each received a single suture, and 73 (54.1%) were in group C and received only fibrin glue. The groups did not differ with statistical significance in terms of age, sex, laterality, BMI, or smoking history (Table 1).
Table 1
| Variables | Group A (n=28) | Group B (n=34) | Group C (n=73) | P value |
|---|---|---|---|---|
| Age (years) | 20.46±5.93 | 21.09±5.59 | 19.97±4.33 | 0.56 |
| Sex | ||||
| Male | 26 (92.9) | 31 (91.2) | 68 (93.2) | 0.94 |
| Female | 2 (7.1) | 3 (8.8) | 5 (6.9) | |
| Pneumothorax site | ||||
| Right | 13 (46.4) | 14 (41.2) | 34 (46.6) | 0.86 |
| Left | 15 (53.6) | 20 (58.8) | 39 (53.4) | |
| BMI (kg/m2) | 18.4±1.65 | 18.9±2.34 | 18.8±2.06 | 0.63 |
| Smoking | ||||
| No | 21 (75.0) | 25 (73.5) | 59 (80.8) | 0.65 |
| Yes | 7 (25.0) | 9 (26.5) | 14 (19.2) |
Data are presented as mean ± standard deviation or n (%). Group A, multiple sutures; group B, a single suture; group C, fibrin adhesive alone. BMI, body mass index.
All VATS procedures were performed without open thoracotomy conversion or mortality. No statistical differences among the three groups were observed in the surgical indications, operative time, postoperative complications, number of incisions, number of wedge resections, or number of cartridges used. However, a statistical difference was observed in the presence of one or multiple blebs (Table 2). To correct for that, the results were verified using the Bonferroni test for multiple comparisons. After that adjustment, a statistically significant decrease in the number of air leakage days was observed in groups A and B, compared with group C (Figure 2). Additionally, the number of days to chest tube removal and the postoperative length of stay were significantly shorter in group A than in groups B and C (Table 2). In the comparison of the three groups, there was no statistical difference in postoperative air leakage days between groups A and B. A pairwise comparision was also performed between groups A and B in their pairwise comparision the postoperative air leakage days was statistically significantly shorter in group A than in group B (P=0.047) (Figure 3).
Table 2
| Variables | Group A (n=28) | Group B (n=34) | Group C (n=73) | P value (3 groups) | Bonferroni† | P value (A vs. B) |
|---|---|---|---|---|---|---|
| Operative indication | 0.27 | – | – | |||
| Ipsilateral recurrence | 7 (25.0) | 16 (47.1) | 18 (24.7) | |||
| Contralateral recurrence | 5 (17.9) | 4 (11.8) | 16 (21.9) | |||
| Tension pneumothorax | 11 (39.3) | 8 (23.5) | 21 (28.8) | |||
| Other | 5 (17.9) | 6 (17.7) | 18 (24.7) | |||
| Operation time (min) | 45.9±12.2 | 42.1±15.2 | 43.8±11.5 | 0.49 | – | 0.28 |
| Complication | 0.76 | – | 0.89 | |||
| No | 27 (96.4) | 33 (97.1) | 72 (98.6) | |||
| Yes | 1 (3.6) | 1 (2.9) | 1 (1.4) | |||
| Incision | 0.17 | – | 0.27 | |||
| Single | 24 (85.7) | 32 (94.1) | 69 (94.5) | |||
| Two | 4 (14.3) | 2 (5.9) | 2 (2.7) | |||
| Three | 0 (0.0) | 0 (0.0) | 2 (2.7) | |||
| Specimen | 1.2±0.39 | 1.4±0.61 | 1.4±0.51 | 0.13 | – | 0.15 |
| Cartridges | 2.4±0.63 | 2.4±0.81 | 2.5±0.77 | 0.72 | – | 0.69 |
| Bleb character | <0.001 | – | 0.35 | |||
| Single | 14 (50.0) | 21 (61.8) | 15 (20.6) | |||
| Multiple | 14 (50.0) | 13 (38.2) | 58 (79.5) | |||
| Air leakage (days) | 0.0±0.19 | 0.3±0.62 | 0.8±1.09 | <0.001 | a, b < c | 0.047 |
| Air leakage 1st day | <0.001 | – | 0.08 | |||
| No | 27 (96.4) | 28 (82.4) | 36 (49.3) | |||
| Yes | 1 (3.6) | 6 (17.7) | 37 (50.7) | |||
| Tube removal (days) | 1.1±0.36 | 2.0±0.52 | 2.4±1.07 | <0.001 | a < b, c | <0.001 |
| Postoperative stay (days) | 2.3±0.55 | 3.3±1.17 | 3.5±1.06 | <0.001 | a < b, c | <0.001 |
Data are presented as mean ± standard deviation or n (%). †, a, multiple suture group (group A); b, single suture group (group B); c, no suture group (group C).
Discussion
Although PSP is generally not a serious condition, it can present challenging complications such as tension pneumothorax, recurrent pneumothorax, or persistent air leakage. Since the introduction of thoracoscopy, VATS has become the standard of care. Recurrence occurs in between 9.5% and 24.5% of patients with pneumothorax after wedge resection alone (1). Various methods to minimize the risk of recurrence have been tested, including mechanical pleurodesis and reinforcing staple lines with PGA mesh or Vicryl patches. Another postoperative problem is persistent air leakage, which is a major cause of prolonged hospital stay after surgery. It can be caused by lung injury during manipulation, overlooked small bullae, or staples applied to blebs rather than healthy tissue (7,10,11). Air leakage can be caused by factors related to staplers. These include long staple lines, additional mechanical stress applied by the stapler, and excessive tissue tension associated with staple application (2). There are reports that mesh coverage can reduce air leaks as well as reduce the recurrence of air after pneumothorax surgery (12).
We used PGA mesh and fibrin sealant in staple lines to reduce recurrence and air leakage after pneumothorax surgery. However, we experienced cases where the mesh dislodged as the lung expanded after surgery. To prevent mesh dislodgment, we performed a single suture along the center of the staple line, fixating the patch and staple line. As this method was deemed insufficient for preventing air leakage from the suture line, the surgical technique was modified to incorporate multiple sutures in areas at high risk of air leakage. We hypothesised that areas of high surface tension along the staple line would create gaps between the staple and lung tissue, potentially causing air leakage. We anticipated that these areas would be the two ends of the staple line, the overlapping area of the two staplers, as well as the central portion of the 60 mm staple. We predicted that suturing the staple line with mesh and applying fibrin to these areas would minimize air leakage.
A statistical difference in air leakage days was observed between the sutured and non-sutured groups (groups A, B and group C, respectively). A comparison of the three groups revealed no statistically significant difference in air leakage days between the multiple-suture and single-suture groups (groups A and B, respectively) (Figure 2). However, a pairwise comparison was also performed between groups A and B, the postoperative air leak days was statistically significantly shorter in group A than in group B (Figure 3). Although the postoperative air leak was statistically shorter in group A at a pairwise comparison, the result was different when comparing the three groups. Therefore, it is assessed that there is a difference in the air leakage days between groups A and B, but it is not large.
Compared with groups B and C, group A experienced a statistically significant reduction in the number of days to tube removal and postoperative hospital stay; however, we performed pneumothorax surgery differently over time. Group C was treated first, followed by groups B and A in that order. Before multiple sutures were used, patients were observed for an additional day, even if there was no air leakage on the first postoperative day. However, with the use of multiple sutures, postoperative air leakage was deemed to be significantly less likely, and the chest tube was removed if there was no air leakage on the first postoperative day (13). Early discharge after surgery is associated with early chest tube removal. The mean air leakage days for groups A and B were 0.0±0.19 and 0.3±0.62, respectively. However, the mean number of days to chest tube and postoperative stay for groups A and B were 1.1±0.36, 2.0±0.52 and 2.3±0.55, 3.3±1.17, respectively (Table 2). Consequently, the reduction in both time to chest tube removal and time to discharge between groups A and B likely results from changes in postoperative care methods over time.
The present study had several limitations. This study was conducted over a period of approximately 10 years. During this time, postoperative management strategies and stapler techniques likely evolved. These time-related factors could have influenced the observed outcomes. The first, the altered strategies associated with the timing of chest tube removal resulted in further differences in chest tube in-placement and length of hospital stay between groups A, B, and C. This additional delay, independent of the reduction in air leakage, represents a significant limitation and requires careful interpretation of the results. Second, there were differences in the stapler devices used. All staplers used were manufactured by the same company. However, manual stapler bodies were used in early surgeries, while advanced second-generation electric stapler bodies have been used since around 2017. It is possible that the use of advanced technology stapler devices has reduced air leakage. In group C, the rate of air leakage on the first postoperative day was high at 50.7%. Although this group had a high rate of multiple blebs, air leakage was high even after adjusting for differences in blebs (Figure 2). However, it is difficult to attribute this solely to differences in surgical technique. Group C was the first group to undergo surgery. In groups A and B, the reduction of postoperative air leakage may be influenced by improvements in postoperative management or technological advancements in surgical instruments.
Conclusions
Using a PGA patch has been reported to reduce the recurrence and air leakage of pneumothorax after VATS. To our knowledge, this is the first clinical report of suturing the PGA patch to the staple line in order to reinforce it and reduce the duration of postoperative air leakage for PSP. Furthermore, using multiple sutures to reinforce the staple line may reduce the duration of air leakage, compared with using a single suture. However, this study has limitations in that it was a retrospective study and conducted over a period of near 10 years. Prospective studies are required to confirm these findings.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2726/rc
Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2726/dss
Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2726/prf
Funding: None.
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2726/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of Ilsan Paik Hospital, Inje University (IRB No. 2023-03-010). The requirement for informed consent was waived because the study is retrospective.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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