GENERAL THORACIC

Controlling Air Leaks Using Free Pericardial Fat Pads as Surgical Sealant in Pulmonary Resection Takeshi Ikeda, MD, PhD, Masato Sasaki, MD, PhD, Narihisa Yamada, MD, Atsushi Takamori, MD, Sawaka Tanabe, MD, Akitoshi Okada, MD, Kayo Sakon, MD, Tae Mizunaga, MD, and Takaaki Koshiji, MD Division of Thoracic Surgery, Department of Surgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan

Background. This study evaluated the feasibility and efficacy of a new operative method for controlling intraoperative air leaks using free pericardial fat pads as a covering sealant in pulmonary resection. Methods. To manage air leaks that must be controlled in pulmonary resection at the first water sealing test, collected free pericardial fat was used as a covering sealant and sewn on by the suture closing the lesion. In cases of uncontrolled air leaks at the second sealing test, fibrin glue was used to fill the residual lesion between the fat and visceral pleura. Fifty-one eligible patients were enrolled in this study to evaluate the duration of postoperative air leaks and the condition of the implanted fat on chest computed tomography (CT) 6 months later. Results. The mean duration of postoperative air leaks was 1.05 ± 1.84 days in the 39 cases that received the

pericardial fat covering technique only and 2.66 ± 3.42 days in the 12 cases that received the pericardial fat covering technique combined with fibrin glue. Prolonged alveolar air leaks occurred in 1 case and 2 cases, respectively. No cases required conversion to conventional methods, and there were no further adverse events. On follow-up chest CT approximately 62.7% of obvious engrafted fat survived. Conclusions. Using free pericardial fat pads as a sealant to control air leaks in pulmonary resection is safe and has good feasibility and potent efficacy. This new method can be an innovative technique for preventing prolonged air leaks.

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technical problems while looking for an entirely new approach, we noted a previous report concerning the possibility of using free pericardial fat pads (FPFPs) as sealants for preventing air leaks [1]. The aim of this study was to assess the feasibility and efficacy of a new technology using FPFPs for intraoperative pulmonary air leaks.

he development of air leaks from lung parenchyma is one of the most common complications after pulmonary resection, and prevention of prolonged alveolar air leaks (PAALs: more than 7 days) is a significant issue in thoracic surgery to reduce the risk of postoperative complications. Not only the conventional methods, but also new techniques using various sealants have been adopted. However, there is no ideal technique for control of intraoperative pulmonary air leaks. To control intraoperative air leaks and reduce the incidence of PAALs there are some problems that must be overcome. These problems occur in cases with underlying pulmonary diseases with a structural disorder that causes fragility of lung parenchyma that makes it difficult to suture the lesion and results in a long time until the air leaks disappear. Similarly, systemic underlying disease causes systemic tissue fragility, and protracted wound healing is also a serious problem. In addition, air leaks from a delamination area of the hilum or a laceration involving stumps of autosutures cause difficulty in suturing or sealing because of the complex shape of the lesion causing the air leaks. To overcome the structural and

Accepted for publication Nov 17, 2014. Address correspondence to Dr Ikeda, Division of Thoracic Surgery, Department of Surgery, University of Fukui Faculty of Medical Sciences, 23-3 Matsuoka- Shimoaizuki, Eiheiji, Fukui 910-1193, Japan; e-mail: [email protected].

Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier

(Ann Thorac Surg 2015;99:1170–6) Ó 2015 by The Society of Thoracic Surgeons

Patients and Methods This study was performed with the approval of the Ethics Committee of the University of Fukui Faculty of Medical Sciences, and written informed consent was obtained from each patient enrolled in this study before the operation. The study was conducted from April 2011 to March 2013. To maintain uniformity of the procedure, only 1 expert operator (T. I.) from our institution was selected for this study. During that period the operator undertook 179 cases of pulmonary resection, of which 51 patients were eligible and enrolled in this study. On the assumption that operative methods must be adaptable to any operative case, there were no exclusion criteria and all pulmonary resections in our institution were potential subjects for this study during that period. However, operations for spontaneous pneumothorax and pneumonectomy were not included because there have been no cases of PAALs during these cases in the past decade in our institution. Pulmonary resections were 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.040

performed under general anesthesia with one-lung ventilation through a 6- to 8-cm lateral muscle-sparing thoracotomy by video-assisted thoracoscopic surgery. The FPFP harvesting was performed under complete thoracoscopic vision. On the other hand, suturing the lesion with the FPFP was performed by direct vision through the thoracotomy. The following conditions were set prospectively to ensure patient safety and maximize potential benefit, and the rules were followed strictly. Water sealing tests were to be performed at the end of the surgical procedure by inflating the residual lung with a pressure of 25 cm H2O. If air leaks were detected, the grade was to be classified subjectively into 3 groups as mild (countable bubbles), moderate (a stream of bubbles), or severe (coalescent bubbles), based on the previous report of D’Andrilli and colleagues [2]. The cases in the moderate to severe group were to undergo manipulation of pericardial fat to provide cover as a surgical sealant for air leaks, and the mild group was to be just observed because almost all mild cases are expected to resolve spontaneously, and this in fact occurred. The mean durations of air leaks and chest tube drainage were 2.36  1.26 days and 3.35  1.30 days, respectively. After the first manipulation to close and seal the air leaks was performed, a second water sealing test was to be performed to evaluate the effectiveness of the procedure. Patients showing mild or less leakage were regarded as curable cases requiring no further intervention and the operation was to be completed. If the air leaks remained moderate or greater after fat covering at the second sealing test, fibrin glue was to be sprayed between the fat and visceral pleura to fill the interspace. In cases in which air leaks still remained moderate or greater at the third water sealing test, the FPFP was to be abandoned and the procedure was to be converted to our conventional method using absorbable mesh and fibrin glue to ensure the patient’s safety. The strategy was to ensure that air leaks were controlled to the mild level or less by the end of the operation. After confirming disappearance of air leaks and that the fluid output was no more than 200 mL/day, a 24-hour chest tube clamping test was undertaken to confirm no apparent abnormalities on chest x-ray and the chest tube was then removed. The duration of chest tube drainage days was defined as from the day after operation to the day of chest tube removal. Follow-up chest computed tomography (CT) was performed 6 months later and the existence of the implanted FPFP was determined by comparing to the preoperative image. If a mass of at least greater than 10 mm in the longest diameter was seen as an obvious fat density in the same area that fat was implanted during the operation and was densely adjoined to adjacent tissue, the case was defined as an engrafted case as the fat was considered to have survived to become adherent to the lesion. Air leak duration in patients assigned to the 2 methods above was analyzed by the Student t test using JMP version 9. The differences were considered statistically significant when the p value was 0.05 or less.

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Techniques When moderate to severe air leaks were detected during the intraoperative sealing test, the following operative technique was carried out. First, pericardial fat was collected by the electric scalpel. The size of collected free pericardial fat depended on the range of the damaged lesion of lung parenchyma that needed to be covered. Suturing the pleura of the lung using FPFP was performed with a half-expanded affected-side lung. To reinforce the stump, the pleural junction was held between the fat. To avoid rupture of the suturing site the fistula was reefed loosely by absorbable line (4-0 PDS II; Ethicon, Somerville, NJ) in anticipation of full lung expansion. The basic technique of this method is repeated simple ligation so that the junction of the visceral pleura is sandwiched by the collected fat tissue to close and seal the laceration of the lung surface. First, the suture needle with thread was passed from the mediastinal pleural side of the fat. Next, the suture needle was passed through each edge of the laceration of the lung parenchyma with the visceral pleura. Last, the suture needle was passed through the fat from the reverse side, including mediastinal pleura, and the thread was tied loosely taking into account the state of fully expanded lung (Figs 1A and 1B). It is very important that each suture pass through the mediastinal pleura of the fat and the visceral pleura of the lung to maintain the strength of the junction. To treat a lesion with a visceral pleural defect, especially in the delamination area of the hilum, the suture must be passed through the vascular sheath or the bronchial sheath to maintain the strength of the suture technique. When the air leaks disappeared or remained mild or less at the second sealing test this manipulation was finished. However, when moderate or greater air leaks remained, fibrin glue (Beriplast P Combi-Set; CSL Behring Pharma, Tokyo, Japan) was sprayed between the fat and pleura widely to fill up the residual air leak lesion of the interspace to reinforce the sealant (Fig 2).

Results A total of 51 cases of lung resection fulfilled the inclusion criterion at the first water sealing test and were enrolled in this study. All intraoperative air leaks were controlled by the new technique with no problems. There were no cases that required conversion to conventional methods and there were no further adverse events. The pericardial fat covering technique was used in 39 cases. In this group, the mean durations of air leaks and chest tube drainage were 1.05  1.84 days and 3.94  1.91 days, respectively; PAALs occurred in 1 case. The pericardial fat covering technique combined with fibrin glue was used in 12 cases. In this group, the mean durations of air leaks and chest tube drainage were 2.66  3.42 days and 5.33  3.31 days, respectively; PAALs occurred in 2 cases. Follow-up chest CT was performed in all 51 cases, and fat engraftment was confirmed in 32

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Fig 1. (A) Model of laceration near the autosuture stump. To close the lesion the autosuture stump is involved in the ligation and each suture must be passed through each layer of pleura to maintain the strength of the junctional lesion. (B) Anticipating full lung expansion, ligation is performed slightly loosely to avoid rupture of the sutured lesion.

cases (Table 1). Representative images are shown in Figure 3. Air leak duration was compared between patients with and without engraftment. When the data of the 2 groups were pooled, the difference was significant. The duration

of air leaks was 0.718  1.17 (SD) days for cases with engraftment and 2.63  3.30 (SD) days for cases without engraftment (p ¼ 0.0043). Engraftment of fat was not observed in all 3 PAALs cases (Table 1). The PAALs occurred after pulmonary resection in 3 cases, for a rate of 5.8%. The designated operator performed another 128 cases of pulmonary resection other than operations for pneumothorax and pneumonectomy during the same period that did not require manipulation for controlling air leaks, and there were no PAALs. This means that the rate of PAALs was decreased to 1.67% of the total 179 cases of pulmonary resections performed by the designated operator over the 2 years using the new method.

Comment

Fig 2. When moderate or greater air leaks remain at the second water sealing test, using the device designed for spraying fibrin glue, the residual air leak lesion between the fat and pleura is widely filled by fibrin glue.

Air leaks from lung parenchyma represent the most common complication after pulmonary resection [3], and prevention of PAALs is a very important issue in thoracic surgery to reduce the risk of further postoperative complications. Generally, PAALs are defined as continuous air leakage for more than 7 days after pulmonary resection, with a reported incidence of about 15% to 25% [4–6]. The PAALs require long-term chest tube drainage with pain that not only increases the risk of infection such as empyema but also reduces mobility, which increases the risk of further complications that contribute significantly to morbidity and mortality, prolonged hospital stay, and higher costs [7]. To resolve PAALs additional treatments such as repositioning of a chest drain, pleurodesis using chemicals, or an autologous blood patch are often required; in the worst cases, surgical revision is needed. Because complete intraoperative control of air leaks is essential to prevent PAALs, not only conventional methods such as suturing, reefing, or stapling by autosuture but also new techniques including various sealant products such as covering by absorbable synthetic

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Table 1. Clinical Characteristics and Results of Patients Using Free Pericardial Fat Pads Variable

Pericardial Fat Covering (n ¼ 39)

Fat Covering þ Fibrin Glue (n ¼ 12)

Total (n ¼ 51)

26 13

10 2

36 15

4 11 21 3 1 (8 days) 26 (66.6%)

3 6 2 1 2 (9–10 days) 6 (50.0%)

7 18 23 4 3 32 (62.7%)

   

2.66  3.42 0.83  0.98 4.5  4.08 5.33  3.31

1.43  2.37 0.718  1.17 2.63  3.30 3.36  2.40

Sex Male (68.1  9.6 yearsa) Female (68.8  10.5 yearsa) Operative procedure Partial resection Segmentectomy Lobectomy Bilobectomy Prolonged air leak Engraftment of fat Duration of air leak (daysb) All cases Engrafted cases Not engrafted cases Duration of drainage (daysb) a

Mean value (years).

b

1.05 0.69 1.77 3.94

1.84 1.23 2.61 1.91

Mean value  SD (days).

materials [8] or fibrin glue [9] and fleece-bound sealants [10] have been adopted, and sometimes several methods are combined for intraoperative control of air leaks. However, there is no clear evidence supporting the choice of an ideal technique for control of intraoperative pulmonary air leaks. Additionally, the fibrin-based sealant is very costly and has an intrinsic risk of viral and prion infection [11], although the risk is very small, and polymeric synthetic products may increase the risk of bacterial infections leading to a higher incidence of empyema [8, 12]. To control intraoperative air leaks and reduce the incidence of PAALs, there are some problems that must be overcome. The problems occur with underlying pulmonary disease, such as pulmonary emphysema and interstitial lung disease, in which a structural disorder causes fragility of lung parenchyma that makes it difficult

to suture the lesion and results in a long delay in the disappearance of air leaks. Similarly, treatments for diabetes mellitus, steroid administration, and dialysis cause systemic tissue fragility and protracted wound healing is a serious problem. In addition, air leaks from the delamination area of the hilum or lacerations involving the autosuture stump cause difficulty in suturing or sealing because of the complex shape of the lesions causing the air leaks. To overcome the structural and technical problems, and looking for an entirely new way, we noted the previous report concerning the possibility of using FPFP as a sealant to prevent air leaks [1]. In that report using a canine air leak model, good effects of using FPFP were confirmed and 1 month after surgery the treated lungs were examined histologically. Histologic examination showed that the fat structure was maintained, although the feeding vessel to the fat mass could

Fig 3. Computed chest tomography shows survival of the fat used to stop the air leaks near the autosuture stump for partial resection of the peripheral lung (corresponding to Figs 1A, 1B). The mass indicated by arrow presents as fat of equal density in the lung (left image) and mediastinal (right image) windows, which could be consistent with fat engraftment.

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not be identified. Histologic examination also revealed that the defect of the visceral pleura of the excised edge of the lung was closed with a layer of granulation that formed between the excised edge of the lung and the fat mass. Based on the results of the animal study, Isao and colleagues investigated the safety and efficacy of the new method to control air leaks after pulmonary resection in clinical settings on a small scale and good results were obtained; compared with the results of other reported methods, their results were in no way found to be inferior [8, 12, 13]. However, the selection and exclusion criteria of the patients were not clear in their clinical trial and unfortunately they could not identify the fat mass on followup chest CT. There are still open questions concerning the utility of the method and the stability of the fat as a sealant. The aim of this study was to provide further validation of the feasibility and efficacy of the new technology using FPFP to treat intraoperative air leaks. Just 1 expert operator was selected for this study and all of the operator’s pulmonary resections were enrolled in this study. During the study period, 51 cases required intraoperative control of air leaks and pericardial fat-covering methods were adopted. Because the air leaks could not be controlled by the pericardial fat-covering technique alone in 12 of 51 cases, fibrin glue was added. All cases of intraoperative air leaks were controlled by the new techniques. In the latter half of the study period the rates of using fibrin glue decreased dramatically, likely due to the operator learning the best way to suture and adjust the tying for each case. The mean time for harvesting the FPFP was 54.1  1.61 seconds, and the mean number of harvest procedures during 1 operation was 1.58  0.852 (range, 1 to 4 times). The time for suturing the FPFP depended on the extent of the damaged area. The mean durations of air leaks and chest tube drainage of the 51 cases of the 2 groups were 1.43  2.37 days and 3.36  2.40 days, respectively, and PAALs occurred in 3 case. Recurrent air leaks were not seen after chest drain removal and there were no adverse effects after surgery. Consequently, the operator was involved in 179 cases of pulmonary resection during that period and the rate of PAALs was decreased to 1.67%. These results are comparable with the good results of other reported methods of controlling air leaks, although the study designs differed. In order to provide a reference for comparison the outcomes of controlling air leaks with conventional methods over the last 2 years in our institution were reviewed. The 163 cases of pulmonary resection fulfilled the same conditions as the present study, and in 49 cases conventional methods were used to control intraoperative air leaks. The mean durations of air leaks and chest tube drainage were 4.77  4.23 (range, 1 to 18) days and 5.83  4.32 (range, 1 to 19) days, respectively. The PAALs occurred in 12 (13.5%) cases (air leak duration, range 7 to 18 days). Reoperation was required in 2 cases for PAALs. Not only the clinical results but also the high rates of engraftment of the fat on imaging examination are noteworthy and interesting. It was confirmed that approximately 62.7% of cases showed obvious survival of

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engrafted fat on chest CT 6 months after surgery. The high rate of fat survival may first be attributed to the original suturing technique. The pericardial fat was placed on the lung surface with the mediastinal pleural side of the fat located laterally. By sandwiching the fat with the patient’s own mediastinal pleura and the visceral pleura of the lung the fat was sutured with appropriate strength and acquired good stability that contributed to fat engraftment. Second, using a large amount of fat may be a good factor for its survival as a small amount of fat may not tolerate ischemic conditions until angiogenesis begins for engraftment. In fact, there was a tendency that, with a larger amount of fat, the more likely was the fat to engraft. Air leak duration was compared between patients with and without fat engraftment. However, the number of cases was too small to obtain a significant difference in the fat covering technique group or the fat covering with fibrin group alone. However, when the 2 groups were combined the difference was significant. The duration of air leaks was 0.718  1.17 (SD) days for cases with engraftment and 2.63  3.30 (SD) days for cases without engraftment (p ¼ 0.0043). The reason why the duration of air leaks was shorter in engrafted cases is still unclear; it may come from just enough sealing with a large amount of fat resulting in engraftment or enough fat for engrafting may ensure the prevention of air leaks, or there may be some factors facilitating wound healing in the engraftment process. It is interesting that engraftment of fat was not observed in all 3 PAALs cases. Conventionally, adipocytes are considered to have a low tolerance for ischemic conditions and easily lapse into cell death with short-term ischemia. Recently, there have been reports that stromal cells that contain a population that has the potential to differentiate to various lineages are present in fat tissue [14]. The so-called fatderived stem cell is anticipated to be a new source of tissue stem cells that may substitute for bone marrow in tissue engineering. Adipose stromal cells are reported to act as perivascular cells in fat tissue with good tolerance for ischemia, and they are activated by necrosis of adipocytes and vascular endothelial cells caused by ischemia to proliferate, migrate, and differentiate. They play an important role in repair and regeneration of fat tissue remodeling [15]. All adipocytes are connected directly to capillary vessels for nutrition , and angiogenesis of capillary vessels is necessary for hyperplasia of adipocytes. Hypoxic stimulation facilitates the secretion of vascular endothelial growth factor and hormone growth factor from adipose stromal cells [16, 17]. Thus, adipose stromal cells in collected pericardial fat may have played an important role in the process of engraftment in the present study. Basic experiments are needed to clarify the fat engraftment process and how the cluster of cells is involved. Adipose tissue seems to have good potential not only for controlling pulmonary air leaks but also as a general reparative material in thoracic surgery. The advantage of this method is that using FPFPs to cover the lesion with simple ligation with no side effects

and with reinforcement of the ligated portion (the fat also acts as a felt pledget to avoid injury, especially in fragile lung parenchyma, by surgical suture), the flexibility of the fat allows it to fit any complex lesion so that continuous tight sealing could be achieved. It can be used for any lung lesion and multiple cases, and it can also save the time it takes for making a pedicled flap. Furthermore, prevention of fat dislodgement by coughing or sneezing can be done by a simple suturing technique, and the degree of air leakage can be measured by the sealing test after suturing the fat to determine whether fibrin glue is needed so that we can avoid abusing blood derivatives. To clarify the effect of FPFP, a prospective, randomized study with a greater number of patients comparing with existing methods will be necessary in the future. In conclusion, the use of FPFP to control air leaks in pulmonary resection was demonstrated to be safe, feasible, and have high efficacy. This new technology can be an innovative method for preventing PAALs, and FPFP may be useful as a general reparative material in thoracic surgery.

References 1. Isao M, Yasuhiko O, Makoto O, et al. Free pericardial fat pads can act as sealant for preventing alveolar air leaks. Ann Thorac Surg 2005;80:2321–4. 2. D’Andrilli A, Andreetti C, Ibrahim M, et al. A prospective randomized study to assess the efficacy of a surgical sealant to treat air leaks in lung surgery. Eur J Cardiothorac Surg 2009;35:817–21. 3. Moser C, Opitz I, Zhai W, et al. Autologous fibrin sealant reduces the incidence of prolonged air leak and duration of chest tube drainage after lung volume reduction surgery: a prospective randomized blinded study. J Thorac Cardiovasc Surg 2008;136:843–9. 4. Brunelli A, Monteverde M, Borri A, Salati M, Marasco RD, Fianchini A. Predictors of prolonged air leak after pulmonary lobectomy. Ann Thorac Surg 2004;77:1205–10. 5. Malapert G, Hanna HA, Pages PB, Bernard A. Surgical sealant for prevention of prolonged air leak after lung resection: meta-analysis. Ann Thorac Surg 2010;90:1779–85.

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6. Belda-Sanchis J, Serra-Mitjans M, Iglesias Sentis M, Rami R. Surgical sealant for preventing air leaks after pulmonary resections in patients with lung cancer. Cochrane Database System Rev 2010;1:CD003051. 7. Varela G, Jim enez MF, Novoa N, Aranda JL. Estimating hospital costs attributable to prolonged air leak in pulmonary lobectomy. Eur J Cardiothorac Surg 2005;27: 329–33. 8. Porte HL, Jany T, Akkad R, et al. Randomized controlled trial of synthetic sealant for preventing alveolar air leaks after lobectomy. Ann Thorac Surg 2001;71:1618–22. 9. Fabian T, Federico JA, Ponn RB. Fibrin glue in pulmonary resection: a prospective, randomized, blinded study. Ann Thorac Surg 2003;75:1587–92. 10. Lang G, Cseke€ o A, Stamatis G, et al. Efficacy and safety of topical application of human fibrinogen/thrombin-coated collagen patch (TachoComb) for treatment of air leakage after standard lobectomy. Eur J Cardiothorac Surg 2004;25: 160–6. 11. Kawamura M, Sawafuji M, Watanabe M, Horinouchi H, Kobayashi K. Frequency of transmission of human parvovirus B19 infection by fibrin sealant used during thoracic surgery. Ann Thorac Surg 2002;73:1098–100. 12. Wain JC, Kaiser LR, Johnstone DW, et al. Trial of novel synthetic sealant in preventing air leaks after lung resection. Ann Thorac Surg 2001;71:1623–9. 13. Allen MS, Wood DE, Hawkinson RW, et al. Prospective randomized study evaluating a biodegradable polymeric sealant for sealing intraoperative air leaks that occur during pulmonary resection. Ann Thorac Surg 2004;77: 1792–801. 14. Zuk PA, Zhu M, Ashjian P, et al. Human adipose tissue is a source of multipotent stem cells. Mol Biol Cell 2002;13: 4279–95. 15. Yoshimura K, Suga H, Eto H. Adipose-derived stem/progenitor cells: role in adipose tissue remodeling and potential use for soft tissue augmentation. Regen Med 2009;4: 265–73. 16. Rehman J, Traktuev D, Li J, et al. Secretion of angiogenic and antiapoptotic factors by human adipose stromal cells. Circulation 2004;109:1292–8. 17. Suga H, Eto H, Shigeura T, et al. IFATS collection: fibroblast growth factor-2-induced hepatocyte growth factor secretion by adipose-derived stromal cells inhibits postinjury fibrogenesis through a c-Jun N-terminal kinase-dependent mechanism. Stem Cells 2009;27:238–49.

INVITED COMMENTARY Controlling parenchymal air leaks after pulmonary resections is of paramount importance, inasmuch as a prolonged air leak frequently determines length of stay and may lead to significant morbidity and incremental costs. Although many different techniques have been described, including the use of synthetic sealants, there is no uniform approach to this problem. The study by Ikeda and colleagues [1] reports an innovative technique of addressing parenchymal air leaks, namely the use of free pericardial fat pads (FPFPs). Pedicled grafts, using either muscle or pericardial fat pad, are routine in thoracic surgical procedures, used primarily to cover bronchial stumps after anatomic resections. FPFPs are a much more attractive option in the case of parenchymal leaks, however, given the

Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier

ease of obtaining them and the almost unlimited supply and reach. In addition to demonstrating improved clinical outcomes (shorter air leak duration) compared with their standard operative techniques, the authors performed routine computed tomographic scans at 6 months to determine engraftment rates. Almost two thirds of the FPFPs used were indeed engrafted, and perioperative air leak duration correlated well with ultimate engraftment rates. This unique finding gives more validity to the FPFP concept. Intriguing additional questions arise: how important is the size of each graft (it seems that bigger may be better)? Is the technique easily reproducible? Could an FPFP be used instead of a pedicled graft to cover a bronchial stump? How would a FPFP compare with some of the commonly used sealants?

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Ann Thorac Surg 2015;99:1170–6

Controlling air leaks using free pericardial fat pads as surgical sealant in pulmonary resection.

This study evaluated the feasibility and efficacy of a new operative method for controlling intraoperative air leaks using free pericardial fat pads a...
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