AOSHIMA Hiroe

ISAKA Tamami

KANZAKI Masato

MATSUMOTO Takako

MITSUBOSHI Shota

OGIHARA Akira

OMATA Motoka

SHIDEI Hiroaki

Tokyo Women’s Medical University

A Successful Case of an ImplantedPolyglycolic-Acid Sheet Inside the Bulla forPreventing the Residual Cavity AfterVideo-Assisted Thoracoscopic Bullectomy著者名 MATSUMOTO Takako, OMATA Motoka, SHIDEIHiroaki, OGIHARA Akira, MITSUBOSHI Shota,AOSHIMA Hiroe, ISAKA Tamami, KANZAKI Masatojournal orpublication titleTokyo Women's Medical University Journalvolume 6page range 141-144year 2022-12-20URL http://hdl.handle.net/10470/00033374doi: 10.24488/twmuj.2022010―141―Case ReportTWMUJ 6: 141-144, 2022A Successful Case of an Implanted Polyglycolic-Acid Sheet Inside the Bulla forPreventing the Residual Cavity After Video-Assisted Thoracoscopic BullectomyTakako Matsumoto, Motoka Omata, Hiroaki Shidei, Akira Ogihara,Shota Mitsuboshi, Hiroe Aoshima, Tamami Isaka, and Masato KanzakiDepartment of Thoracic Surgery, Tokyo Women’s Medical University, Tokyo, Japan(Accepted July 4, 2022)(Advance Publication by J-STAGE September 5, 2022)Video-assisted thoracoscopic surgery (VATS) stapler bullectomy can be performed with minimal morbidity. The residualcavities are frequently observed postoperatively, especially in cases with wide large bullae. We describe a technique using anexclusive thoracoscopic approach utilizing a polyglycolic-acid (PGA) sheet for preventing the postoperative residual cavitiesin a patient with a large bulla. A 40-year-old man was referred to our hospital for progressive shortness of breath. Chest com-puted tomography (CT) revealed multiple bullae in the upper lobe of left lung. A large bulla had compressed a significantvolume of functional lung parenchyma; VATS stapler bullectomy was performed. This procedure excised no normal lung tis-sue and reduced the volume of the air-containing cavity with airtight repair. A PGA sheet inside the bulla reduced and pre-vented air leakage from the stapled margin. The patient was discharged and the postoperative course was uneventful. Com-pared with preoperative expiratory volume in 1 s (FEV1), postoperative FEV1 increased by 0.66 L. Postoperative chest CT 16months after surgery demonstrated no air-containing cavity. At 38 months after surgery, the patient had no symptoms.Keywords: bulla, bullectomy, polyglycolic-acid, air leakage, video-assisted thoracoscopic surgeryIntroductionThe development of surgical staplers has made video-assisted thoracoscopic surgery (VATS) bullectomy mucheasier, and a modification of the method suggested byNaclerio and Langer is routinely used.１，２VATS staplerbullectomy can be performed with minimal morbidityand similar outcomes to those obtained with open bullec-tomy.３However, residual cavities are frequently observedpostoperatively, especially in cases with wide large bul-lae.１-３We describe a technique using an exclusive thora-coscopic approach with a polyglycolic-acid (PGA) sheetfor preventing the postoperative residual cavities in a pa-tient with a large bulla.Case PresentationA 40-year-old man was referred to our hospital for pro-gressive shortness of breath. He was a non-smoker. Hisdyspnea was Grade I in a modified Hugh-Jones and Lam-bert grading system. There were no abnormal findings inCorresponding Author: Masato Kanzaki, Department of Thoracic Surgery, Tokyo Women’s Medical University, 8-1 Kawada-cho,Shinjuku-ku, Tokyo 162-8666, Japan. kanzaki.masato@twmu.ac.jpdoi: 10.24488/twmuj.2022010CopyrightⒸ 2022 Society of Tokyo Women’s Medical University. This is an open access article distributed under the terms of CreativeCommons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal source is properly credited.―142―Figure　1.　Computed tomography (CT) of the chest of a 40-year-old patient.  (A) Multiple bullae in the normal underlying healthy lung had compressed a significant volume of functional lung parenchyma (preoperatively). (B-D) At 16 months after surgery, no air-filled cavities and no compressed functional lung parenchyma were found in the left lung. The CT images from B to D were taken from the head side to the bottom.laboratory data. Computed tomography (CT) of the chestrevealed multiple bullae in the upper lobe of left lung(Figure 1A). A large bulla had compressed a significantvolume of functional lung parenchyma. VATS staplerbullectomy was performed to relieve compression of thefunctional lung parenchyma.Under general endotracheal double-lumen anesthesiawith split-lung ventilation, the patient was kept lying onthe healthy side and positioned in lateral decubitus. Wefirst used a 10-mm camera port in the 7 th intercostalspace (ICS) in the mid-axillary line, serving as an obser-vation port with a rigid 30-degree endoscope. The second(12-mm) port was placed in the anterior axillary line inthe 4th ICS, and the third (10-mm) port was placed alongthe 7th ICS in the posterior axillary line. Three-port com-plete VATS was performed.After identification, the largest bulla was puncturedopened longitudinally (Figure 2A and G). Upon openingthe air-filled cavities, the strands of fibrous septa wereexcised. After the loose strands of fibrous tissue werecut, those cavities were re-made into one space. A foldedPGA sheet was inserted through the 12-mm port, openedin the thoracic cavity, and then placed at the basal side ofthe bulla on the raw surface (Figure 2B, C, and H). Apart of the grasped wall of the bulla was excised with en-dostaplers, and the basal side of the bulla was left for pre-serving the lung tissue. We were able to observe the im-planted PGA sheet through the wall of the bulla (Fig-ure 2D, E, F, and I). It was important that this procedureexcised no normal lung tissue and reduced the volume ofthe air-containing cavity with airtight repair. The PGAsheet inside the bulla prevented air leakage from the sta-pled margin.The operation time was 143 min and the intraoperativeblood loss was 3 g. The patient was discharged unevent-fully. In his pulmonary function test, preoperative expira-tory volume in 1 s (FEV1) was 3.49 L, but postoperativeFEV1 increased to be 4.09 L at 6 months and 4.15 L at 18months after surgery. Postoperative chest CT at 16months demonstrated no air-containing cavity ( Fig-ure 1B-D). At 38 months after surgery, the patient hadno symptoms.DiscussionThe method of Naclerio and Langer has been reported to―143―Figure　2.　Schematic illustrations of the surgical procedure and photographs during surgery.  (A) After multiple bullae were identified, the largest bulla was opened longitudinally with a thoraco-scope. (B) After the strands of fibrous septa in the bulla were excised, a folded polyglycolic-acid (PGA) sheet marked with an asterisk (*) was opened in the thoracic cavity. (C) The PGA sheet was placed at the basal side of the bulla on the raw surface of the lung. (D) A part of the wall of the bulla was grasped with endoscopic grasping forceps. (E) A part of the grasped wall of the bulla was excised with endosta-plers. (F) The basal side of the bulla was left in order to preserve the lung tissue. The implanted PGA sheet was observable through the wall of the bulla. (G-I) All photographs were extracted from digital video data. (G) The largest bulla was opened longitudinally. (H) The folded PGA sheet was opened in the thoracic cavity and then placed at the basal side of the bulla on the raw surface of the lung. (I) A part of the grasped wall of the bulla was excised with endostaplers, and the basal side of the bulla was left intact in order to preserve the lung tissue.treat giant bullae and diffuse diseases.１，２In the operativeprocedure, bronchial orifices are closed by mattress su-tures after opening the air-containing cavities. Subse-quently, through-and-through mattress sutures are placedat the basal side of the bulla through the healthy lung tis-sue to obtain an airtight repair. Finally, the wall of bullais excised down to the previous suture line, and the lungsurface is imbricated with the visceral pleura by suturingthe edges of the removed wall of the bulla. Although thedevelopment of surgical staplers has made this procedureeasier, residual cavities are frequently observed postop-eratively, especially in cases with large bullae.２-５Recently, PGA sheets, covered with synthetic-absorbable material combined with fibrin glue, have beenused for preventing air leakage after the lung resection oflung cancer or pneumothorax. PGA has been used as ab-sorbable sutures and orthopedic pins in various surgeries.However, PGA is known to induce a strong inflamma-tory response.４As a result, PGA causes pleural adhesion.５Previously, we had observed a surgical case of postop-erative recurrence of pneumothorax, where the rupturedsites of visceral pleura were widely covered with PGAsheets after thoracoscopic bullectomy for preventing re-current pneumothorax. Strong pleural adhesion was―144―found between a part of PGA implantation and the parie-tal pleura. The adhesion was induced by a local inflam-matory response caused by the glycolic acid produced byhydrolysis following the operation. In our case, we util-ized this inflammatory response to prevent the develop-ment of postoperative residual cavities.This technique simplified bullectomy, reduced lung airleakage, preserved the healthy lung tissue by avoiding re-section, and prevented pleural adhesion.６This report de-scribes the preliminarily results of a procedure for clos-ing air pockets (blebs) and preserving the air-filled cavi-ties and the pleuro-pulmonary space, which remained inbulla, by implanting PGA.Sources of Funding : This research received no specificgrant from any funding agency in the public, commercial, ornot-for-profit sectors.Conflicts of Interest: The authors declare no conflicts ofinterest.Author Contributions : Takako Matsumoto and MasatoKanzaki conceptualized this study. All authors performed theprocedure and collated this paper as a group. Takako Matsu-moto wrote the first draft of the manuscript. Masato Kanzakireviewed the manuscript. All authors read and approved thefinal manuscript.Acknowledgments: The authors would like to thank NorioUeno, MD and Editage ( www. editage. com ) for excellentEnglish language editing.References1．De Giacomo T, Rendina EA, Venuta F, et al. Bullectomyis comparable to lung volume reduction in patients withend-stage emphysema. Eur J Cardiothorac Surg. 2002;22(3):357―62.2．Naclerio E, Langer L. Pulmonary cysts: Special refer-ence to surgical treatment of emphysematous blebs andbullae. Surgery. 1947;22(3):516―24.3．Goldberg M. Thoracic Surgery. 2 nd ed. Philadelphia( USA ) : Churchill Livingstone ; 2002. Chapter 26,Bullous disease; p. 697―715.4．Ceonzo K, Gaynor A, Shaffer L, et al. Polyglycolic acidinduced inflammation: Role of hydrolysis and resultingcomplement activation. Tissue Eng. 2006;12(2):301―8.5．Takahashi M, Matsukura T, Hirai T, et al. Recurrentcatamenial hemopneumothorax treated by coverage withpolyglycolic acid sheets. J Thorac Cardiovasc Surg.2013;145(1):300―2.6．Kanzaki M. Technological Advances in Surgery, Traumaand Critical Care. New York (USA): Springer Science+Business Media; 2015. Chapter 23, Advanced Thora-coscopic Surgery to Modern Pulmonary Disease : TheJapanese Approach; p. 249―60.

A Successful Case of an Implanted Polyglycolic-Acid Sheet Inside the Bulla for Preventing the Residual Cavity After Video-Assisted Thoracoscopic Bullectomy

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A Successful Case of an Implanted Polyglycolic-Acid Sheet Inside the Bulla for Preventing the Residual Cavity After Video-Assisted Thoracoscopic Bullectomy

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