Oxidized regenerated cellulose in thoracic surgery: potential game-changer or hidden danger?

I recently read the article by Ochi et al., titled “Efficacy and safety of applying oxidized regenerated cellulose sheets to the parietal pleura of open chest wounds in thoracic surgery: a prospective randomized controlled trial protocol” (1). This study addresses the significant clinical challenge of preventing postoperative intrapleural adhesions in thoracic surgery, a field known for its complexity. The potential benefits of oxidized regenerated cellulose (ORC) in this setting are promising (1). However, considering ORC’s applications in other surgical fields, particularly in breast-conserving surgery (BCS), I believe there are critical factors that could enhance the study design and improve the safety and effectiveness of ORC in thoracic procedures.

ORC is a widely used bioabsorbable hemostatic agent that controls bleeding and has bactericidal properties due to its acidic nature, which inhibits bacterial growth (2). In BCS, ORC is also utilized as a filler to improve cosmetic outcomes in patients with partial breast defects, with positive effects observed in several studies (3,4).

Despite these advantages, ORC use is not without risks, especially related to its incomplete absorption (5-8). The retention of ORC can trigger foreign-body reactions, chronic inflammation, seroma formation, allergic reactions and granulomatous responses, sometimes necessitating surgical removal (2,5,6). The thoracic cavity presents a unique challenge due to its confined space, housing critical structures such as the lungs, heart and major blood vessels. This makes the risks associated with ORC more pronounced in this setting; a thorough risk assessment is needed to understand how ORC behaves in the pleural cavity and its effects on surrounding tissues.

The issue of incomplete absorption is especially relevant in thoracic surgery, as it has been documented in breast surgery. Retained ORC may provoke foreign-body reactions that can exacerbate inflammation, disrupt healing or impair respiratory function. Given the proximity of vital organs in the thoracic cavity, retained ORC could complicate healing and lead to more severe complications. Understanding ORC’s absorption kinetics and its interaction with pleural tissues is crucial to optimizing patient outcomes.

Additionally, ORC’s ability to induce fibrogenesis, while beneficial in preventing pleural adhesions, could also lead to excessive fibrosis (2,5,8). This risk has been documented in BCS, where retained ORC can mimic recurrent malignancy, abscess or fat necrosis on imaging due to its distinct radiological features (9). In thoracic surgery, similar diagnostic ambiguities could interfere with postoperative monitoring, resulting in delayed diagnoses or unnecessary invasive procedures that may complicate patient management (8). To mitigate these risks, radiologists must be properly informed about ORC’s use in thoracic surgery and standardized imaging protocols should be developed to differentiate ORC-induced changes from pathological findings.

Moreover, the study protocol by Ochi et al. focuses on pleural adhesions as the primary endpoint. While this is an important measure, it would be beneficial to include secondary endpoints to assess potential adverse effects, such as chronic inflammation, foreign-body reactions and diagnostic misinterpretations on imaging. The study’s open-label design could introduce bias, particularly in evaluating adhesion severity or imaging outcomes. Incorporating a blinded evaluation process would enhance the study’s rigor and provide more objective, reliable data.

Based on these considerations, I propose the following recommendations to enhance the study design and optimize the safe and effective clinical use of ORC in thoracic surgery (Figure 1):

• Patient selection: a thorough preoperative assessment should be conducted to identify appropriate candidates for ORC application; patients with conditions such as poorly controlled diabetes, immune suppression or those undergoing neoadjuvant chemotherapy should be excluded as they are at higher risk for complications.
• Surgical technique: the amount of ORC applied during surgery should be carefully controlled; excessive use of ORC can lead to heightened fibrosis and foreign-body reactions. A precise calibration of the ORC volume is essential to ensure that it adequately fills the surgical cavity without overwhelming the tissue, potentially exacerbating inflammation. In BCS, we have developed an appropriate technique for meticulous ORC placement which could be adapted for thoracic surgery to optimize patient outcomes and minimize complications (10).
• Postoperative management: prophylactic antibiotics should be considered to prevent infections associated with ORC use. Early recognition and management of postoperative complications, including allergic reactions, are essential; medications such as corticosteroids and antihistamines may help manage allergic responses or inflammatory reactions.
• Radiological protocols: ORC use should be documented in surgical reports to guide radiologists during follow-up imaging; radiologists must be trained to recognize ORC-induced changes and differentiate them from pathological findings. Developing clear imaging protocols will help prevent unnecessary procedures and ensure prompt identification of complications.
• Comprehensive study endpoints: future studies should include secondary endpoints to assess long-term outcomes, such as the impact of ORC on chronic inflammation, imaging artifacts and patient quality of life; monitoring these factors will provide a more comprehensive understanding of ORC’s clinical utility and its limitations in the thoracic setting.

Figure 1 Recommendations for optimizing ORC outcomes in thoracic surgery. ORC, oxidized regenerated cellulose.

In conclusion, while ORC shows promise in thoracic surgery, it is important to carefully consider the potential risks. While it may help prevent pleural adhesions, concerns such as incomplete absorption, foreign-body reactions and excessive fibrosis need to be addressed. A better understanding of how ORC interacts with thoracic tissues, along with a well-designed study, is essential to ensure its safety and effectiveness. By selecting patients more carefully, controlling the amount of ORC used, improving postoperative care and establishing clear radiological protocols, we can maximize ORC’s benefits while reducing its risks. Ultimately, further research on its long-term effects will reveal whether ORC is a true game-changer or a hidden danger in thoracic surgery.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-20/coif). The author has no conflicts of interest to declare.

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