| @‘OΘ |
ΕIXVϊF1999N916ϊ
@‘Ά£‘
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"Treating Bullous Lung Disease With@Holmium YAG Laser in@
Conjunction With@Fibrin Glue and DEXONTM Mesh" |
Shizuka Kaseda, etc. |
1999N916ϊ
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Treating Bullous Lung Disease With@Holmium YAG Laser in Conjunction With@Fibrin
Glue and DEXONTM Mesh |
Shizuka kaseda, MD,1* Teruhiro Aoki, MD,1 Nanase Hangai, MD,1
Tadashi Omoto, MD,2 Shuzo Yamamoto, MD,2 and Hitoshi Sugiura, MD3
1Departments of Thoracic Surgery, Saiseikai Kanagawa-ken Hospital, Yokohama 221, Japan
2Department of Surgery Saiseikai Kanagawa-ken Hospital, Yokohama 221, Japan
3Department of Pathology, Clinical Research Laboratories, Kawasaki City, Ida Hospital
Kawasaki 221, Japan
Kawasaki 221, Japan
Background and Objective : Holmium YAG (Ho:YAG) laser energy is highly absorbed by water, and this property
is useful to uniformly ablate pulmonary bullae. The current study summarizes the data of a 39-month follow-
up of patients treated for bullae with a Ho:YAG laser.
is useful to uniformly ablate pulmonary bullae. The current study summarizes the data of a 39-month follow-
up of patients treated for bullae with a Ho:YAG laser.
Study Design/Materials and Methods : We used a Ho:YAG laser from August 1994 to April 1997 to treat small
pulmonary bullae in 50 patients. For the first five patients, Ho:YAG laser ablation was followed by resection for
histological assessment. In the next sex patients, fibrin glue was applied following bullae ablation with the Ho:
YAG laser. In all subsequent patients, a DEXONTM (polyglycolic acid)mesh patch soaked in fibrin glue was
employed after ablation.
pulmonary bullae in 50 patients. For the first five patients, Ho:YAG laser ablation was followed by resection for
histological assessment. In the next sex patients, fibrin glue was applied following bullae ablation with the Ho:
YAG laser. In all subsequent patients, a DEXONTM (polyglycolic acid)mesh patch soaked in fibrin glue was
employed after ablation.
Results : From the six patients receiving only the fibrin glue following laser ablation, delayed pneumothorax
developed in one patient. In the subsequent 39 patients patched with DEXIONTM mesh soaked in fibrin glue,
none encountered delayed pneumothorax.
developed in one patient. In the subsequent 39 patients patched with DEXIONTM mesh soaked in fibrin glue,
none encountered delayed pneumothorax.
Conclusion : The combined use of fibrin glue and DEXONTM mesh with the Ho:YAG laser may be an effective
technique for treating bullous lung disease. Lasers Surg. Med. 22: 219 - 222, 1998.
technique for treating bullous lung disease. Lasers Surg. Med. 22: 219 - 222, 1998.
c 1998 Wiley-Liss, Inc.
Key words : ablation; pulmonary bullae; DEXON? mesh, fibrin glue, Holmium:YAG laser
INTRODUCTION
The Holmium YAG (Ho:YAG) laser delivers invisible light in the infrared region, at a wavelength of 2.1 Κm, and
is 100 times better absorbed in water than the Nd:YAG laser, which is already widely used in medicine. The
energy delivered from the Ho:YAG laser, transmitted via an optic fiber, uniformly penetrates of tissue to a
depth of within 0.5 mm regardless of tissue pigments [1]. Having discovered these characteristics to be
particularly suitable for ablating bullae, which are comprised primarily of nonpigmented tissue, we have
introduced the Ho:YAG laser in treatment of pulmonary hullae of less than 3 cm in diameter. The ablated
sites were further treated with a DEXONTM (polyglycolic acid) mesh patch soaked in fibrin glue. This report
describes the technique and discusses our findings.
is 100 times better absorbed in water than the Nd:YAG laser, which is already widely used in medicine. The
energy delivered from the Ho:YAG laser, transmitted via an optic fiber, uniformly penetrates of tissue to a
depth of within 0.5 mm regardless of tissue pigments [1]. Having discovered these characteristics to be
particularly suitable for ablating bullae, which are comprised primarily of nonpigmented tissue, we have
introduced the Ho:YAG laser in treatment of pulmonary hullae of less than 3 cm in diameter. The ablated
sites were further treated with a DEXONTM (polyglycolic acid) mesh patch soaked in fibrin glue. This report
describes the technique and discusses our findings.
*Correspondence to: Shizuka Kaseda, Department of Thoracic Surgery, Saiseikai Kanagawa-ken Hospital, 6-6
Tomiyacho, Kanagawa-ku, Yokohama 221, Japan.
Tomiyacho, Kanagawa-ku, Yokohama 221, Japan.
Accepted 30 December 1997
PATIENTS AND METHODS
Fifty patients with bullous lung disease undergoing thoracoscopic surgery between August 1994 and April
1997 were included in the study.
1997 were included in the study.
All bullae of less than 3 cm in diameter were optic fiber from a distance of 2-3 cm ranging in from 5 to 10
pulses per second. Each bulla was scopic observation confirmed whitening of the bulla, which amounted to a
total energy ranging from 130 to 4,700 joules (mean } SD: 1,427 } 1,307).
pulses per second. Each bulla was scopic observation confirmed whitening of the bulla, which amounted to a
total energy ranging from 130 to 4,700 joules (mean } SD: 1,427 } 1,307).
In the first five patients, the pulmonary bullae were resected after laser ablation in order to confirm the
effect of the Ho:YAG laser (Fig.1). In the next six patients, bullae ablated with Ho:YAG laser were not
resected, and fibrin glue (BeriplastR, Behringwerke AG, Marburg, Germany) alone was applied to the treated
sites. Finally, in the remaining 39 patients, 9-cu patches of DEXONTM mesh (Davis Geck, Inc., Pearl River,
NY) soaked in fibrin glue solution were employed on the ablated sites to prevent delayed pneumothorax.
effect of the Ho:YAG laser (Fig.1). In the next six patients, bullae ablated with Ho:YAG laser were not
resected, and fibrin glue (BeriplastR, Behringwerke AG, Marburg, Germany) alone was applied to the treated
sites. Finally, in the remaining 39 patients, 9-cu patches of DEXONTM mesh (Davis Geck, Inc., Pearl River,
NY) soaked in fibrin glue solution were employed on the ablated sites to prevent delayed pneumothorax.
RESULTS
Histological examination of the resected bullae revealed uniform tissue degeneration extending to a depth of
from 0.3 to 0.5 mm; however, there was no evidence of damage done to the normal lung tissue below this
level (Fig.1). Among the six patients receiving fibrin glue alone following laser treatment, one (16.7)
developed delayed pneumothorax 6 weeks after the operation. On the other hand, in the 39 patients receiving
the DEXONTM mesh patch soaked in fibrin glue solution, none has shown any evidence of this complication
during 27 months of follow-up.
from 0.3 to 0.5 mm; however, there was no evidence of damage done to the normal lung tissue below this
level (Fig.1). Among the six patients receiving fibrin glue alone following laser treatment, one (16.7)
developed delayed pneumothorax 6 weeks after the operation. On the other hand, in the 39 patients receiving
the DEXONTM mesh patch soaked in fibrin glue solution, none has shown any evidence of this complication
during 27 months of follow-up.
DISCUSSION
Although the Nd:YAG laser is most widely used today in surgery of the respiratory tract [2-5], its energy is
poorly absorbed by nonpigmented tissue. When used to treat highly nonpigmented tissue such as bullae, Nd:
YAG laser energy is only poorly absorbed by the treatment site while possibly causing irreversible damage to
the underlying normal lung tissue. Furthermore, previous studies have reported a higher incidence of delayed
pneumothorax in patients treated with laser than those with endostapler alone [6]. These drawbacks have
limited the indication for Nd:YAG laser surgery.
poorly absorbed by nonpigmented tissue. When used to treat highly nonpigmented tissue such as bullae, Nd:
YAG laser energy is only poorly absorbed by the treatment site while possibly causing irreversible damage to
the underlying normal lung tissue. Furthermore, previous studies have reported a higher incidence of delayed
pneumothorax in patients treated with laser than those with endostapler alone [6]. These drawbacks have
limited the indication for Nd:YAG laser surgery.
On the contrary, since the Ho:YAG laser has a very high affinity for water, it is uniformly absorbed by any
water-bearing tissue regardless of its pigment [1]. Because the tissue irradiated with Ho:YAG laser energy
shrinks evenly up to 0.3-0.5 mm in depth, the Ho:YAG laser or recommending the application of fibrin glue and
DEXONTM mesh for treating pulmonary bullae, and we believe the present study is the first to attempt the
application of the Ho:YAG laser in combination with fibrin glue and DEXONTM mesh in treating bullae.
water-bearing tissue regardless of its pigment [1]. Because the tissue irradiated with Ho:YAG laser energy
shrinks evenly up to 0.3-0.5 mm in depth, the Ho:YAG laser or recommending the application of fibrin glue and
DEXONTM mesh for treating pulmonary bullae, and we believe the present study is the first to attempt the
application of the Ho:YAG laser in combination with fibrin glue and DEXONTM mesh in treating bullae.
Fibrin glue is a physiological adhesive consisting of fibrinogen and thrombin solutions; upon combining the two
components, the thrombin is responsible for converting the fibrinogen into fibrin. In surgery of the respiratory
tract, fibrin adhesive is often used to prevent air leakage after lung resection [7,8]. However, due to its weak
adhesive property, the glue easily detaches from the treated site. On the other hand, Morikawa et al.
demonstrated in their experimental study using dogs that an absorbent polyglycolic acid mesh (DEXONTM
mesh) patch possesses a much greater adhesive strength than the fibrinogen and thrombin mixture alone [9].
In our series of patients, one patient treated with the Ho:YAG laser and fibrin glue alone developed delayed
pneumothorax 6 weeks after surgery, indicating that the use of the Ho:YAG laser in conjunction with an
adhesive only, such as fibrin glue, increases the risk of developing delayed pneumothorax. Our clinical results
also revealed that the use of fibrin glue in combination with the DEXONTM mesh patch following holmium YAG
laser application prevents the occurrence of this complication.
components, the thrombin is responsible for converting the fibrinogen into fibrin. In surgery of the respiratory
tract, fibrin adhesive is often used to prevent air leakage after lung resection [7,8]. However, due to its weak
adhesive property, the glue easily detaches from the treated site. On the other hand, Morikawa et al.
demonstrated in their experimental study using dogs that an absorbent polyglycolic acid mesh (DEXONTM
mesh) patch possesses a much greater adhesive strength than the fibrinogen and thrombin mixture alone [9].
In our series of patients, one patient treated with the Ho:YAG laser and fibrin glue alone developed delayed
pneumothorax 6 weeks after surgery, indicating that the use of the Ho:YAG laser in conjunction with an
adhesive only, such as fibrin glue, increases the risk of developing delayed pneumothorax. Our clinical results
also revealed that the use of fibrin glue in combination with the DEXONTM mesh patch following holmium YAG
laser application prevents the occurrence of this complication.
Commercial fibrin glue for hemostats is available in Europe, Canada, and Japan. However the United States
Food and Drug Administration (FDA) has been reluctant to grant product licenses because of concerns about
virus transmission from human blood products, immune reactions against components in bovine blood
products, and a lack of prospective studies on product efficacy. Nevertheless, surgeons in United States use "
home-made" fibrin glues without restriction, and demand for cryoprecipitated human fibrinogen, the main
component of the glue, is on the increase.
Food and Drug Administration (FDA) has been reluctant to grant product licenses because of concerns about
virus transmission from human blood products, immune reactions against components in bovine blood
products, and a lack of prospective studies on product efficacy. Nevertheless, surgeons in United States use "
home-made" fibrin glues without restriction, and demand for cryoprecipitated human fibrinogen, the main
component of the glue, is on the increase.
An autologous fibrin glue is one way to avoid the risks of virus infections and unwanted immune responses.
However, these autologous fibrin glues are actually semi-autologous and are not free from foreign proteins
because they are co-administered with pooled plasma-derived bovine or human thrombin, and with bovine
aprotinin which acts a fibrinolytic stabilizer. A number of viral inactivation techniques have been developed to
reduce the risks of using pooled sources of human fibrinogen and human thrombin in fibrin glue. Some
commercial fibrin glues will be approved b the FDA in the very near future. If this is realized there will be no
need to use autologous fibrin glue even in the United States.
However, these autologous fibrin glues are actually semi-autologous and are not free from foreign proteins
because they are co-administered with pooled plasma-derived bovine or human thrombin, and with bovine
aprotinin which acts a fibrinolytic stabilizer. A number of viral inactivation techniques have been developed to
reduce the risks of using pooled sources of human fibrinogen and human thrombin in fibrin glue. Some
commercial fibrin glues will be approved b the FDA in the very near future. If this is realized there will be no
need to use autologous fibrin glue even in the United States.
While the use of the endostapler has recently been recommended for resection of bullous lesions of the lung,
particularly in emphysema [6], it is necessary to use a large number of endostaplers which are, in Japan, about
four times as expensive as in the United States. This is the reason why we refrain from using endostaplers.
The endostapler is also difficult to apply correctly in certain regions of the lung, such as hilar lesions,
because of technical difficulty or the high feasibility of injuring large vessels.
particularly in emphysema [6], it is necessary to use a large number of endostaplers which are, in Japan, about
four times as expensive as in the United States. This is the reason why we refrain from using endostaplers.
The endostapler is also difficult to apply correctly in certain regions of the lung, such as hilar lesions,
because of technical difficulty or the high feasibility of injuring large vessels.
The most significant advantage of the Ho:YAG laser is that it can evenly ablate 0.3 to 0.5 mm of tissue
regardless of the tissue pigment. This property of the Ho:YAG laser has proven to be useful in other
specialties in addition to thoracic surgery, such as urology [10,11], orthopedics [12,13], general
gastroenterological surgery [14,15], otorhinology. [16], and gynecology [17]. In the future, more noninvasive
surgery will be possible with the Ho:YAG laser in conjunction with the development of various new
biocompatible repair materials.
regardless of the tissue pigment. This property of the Ho:YAG laser has proven to be useful in other
specialties in addition to thoracic surgery, such as urology [10,11], orthopedics [12,13], general
gastroenterological surgery [14,15], otorhinology. [16], and gynecology [17]. In the future, more noninvasive
surgery will be possible with the Ho:YAG laser in conjunction with the development of various new
biocompatible repair materials.
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