Polyglactin mesh in preventing recurrent pneumothorax in primary spontaneous pneumothorax: a retrospective efficacy study
Highlight box
Key findings
• Pleurodesis using polyglactin mesh benefits in reduce hospital stay, operative time, and intra-operative blood loss.
What is known and what is new?
• Surgical pleurodesis during surgical lung bullectomy has been a gold standard as an adjunct in treating patient with primary spontaneous pneumothorax (PSP).
• Using polyglactin mesh coverage is a novel option that facilitates shorter hospital stay, reduce intraoperative blood loss and operative time.
What is the implication, and what should change now?
• Polyglactin mesh coverage is another option in treating PSP patient.
Introduction
Primary spontaneous pneumothorax (PSP) is one of the most common pulmonary diseases affecting young age patient with thin and tall stature which has an annual incidence about 14 per 100,000 population (1). Notably, PSP is more often in men rather than women in a ratio of 1:3 (2) and has high recurrence ranging from 25% to 54% (2). According to British Thoracic Society guideline 2023 (3), if the patient is first episode tension pneumothorax, high risk occupation, second ipsilateral, or first contralateral recurrence, he or she should receive surgical lung bullectomy and pleurodesis. Pleurodesis is a type of surgery performed to reduce the chance of recurrence after the index surgery and to prevent future pneumothorax. The goal of pleurodesis is to adhere parietal pleura on the chest wall and visceral pleura on the lung side to form a severe adhesion that can obliterate pleural space, hence prevent accumulation of air or fluid inside the pleural space as called pleural symphysis (4). There are several types and methods of pleurodesis performing in PSP such as surgical pleural abrasion, pleurectomy, talc pleurodesis which all achieving excellent result in preventing recurrence above 95% at 10 years follow-up (5). However, the former twos create wound on the chest wall causing blood loss, and longer operative time (6) and the latter has been criticized by a myth of causing long-term mesothelioma even it has been proven as no risk in a large cohort with 40 years follow-up (7). Polyglactin mesh, a short-term absorbable mesh, has been recognized as a candidate for pleurodesis as its property to resolve 50% within 3 weeks and complete between 60–90 days (8). Sakamoto et al. in 2004 showed that in PSP patient, polyglactin mesh has benefits in shorter postoperative chest tube duration, no prolonged air leak, and less recurrence at 25 months (9). Furthermore, a randomized controlled trial by Hsu et al. in 2021 comparing between Vicryl mesh coverage at the staple line and surgical pleural abrasion showed that mesh group had lower recurrence at 1 year after operation and comparable postoperative outcomes (10). Recently, a meta-analysis of 23 studies conducted by Yeo et al. in 2023 showed that using mesh coverage facilitates significant lower recurrence, shorter duration of chest tube (11).
From our experience, we have used polyglactin mesh to cover not only staple line but the entire lung to prevent recurrent pneumothorax. In this study, we aim to evaluate the efficacy of polyglactin mesh covering the entire lung compared to conventional surgical pleurodesis in term of perioperative period and mid-term follow up. We present this article in accordance with the STROBE reporting checklist (available at https://atm.amegroups.com/article/view/10.21037/atm-25-91/rc).
Methods
This study was approved by the Ethical Committee at Vajira Hospital (No. COA 001/2567). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Informed consent was waived for this retrospective study. This study retrospectively collected the PSP who underwent pulmonary bullectomy and pleurodesis between January 2016 and August 2023 at our institute. The patients were classified into two groups regarding their method of pleurodesis. The patients who underwent surgical pleurodesis and polyglactin mesh coverage were classified as non-mesh group and mesh group respectively. Type of pleurodesis technique will depend on surgeon preference.
The demographic data including age, gender, height, weight, and body mass index (BMI), smoking status, indication for surgery, comorbidities, left side involved, and approach type [open vs. video-assisted thoracic surgery (VATS)] were evaluated. The operative data were measured such as operation time, intraoperative blood loss, and complications during surgery. Finally, the following postoperative data were assessed, including the post-operative complication, length of hospital stay, chest tube duration, and recurrence.
Inclusion criteria
- PSP who underwent bullectomy with pleurodesis;
- Age 15 to 50 years.
Exclusion criteria
- Redo-surgery;
- Underlying pulmonary disease such as chronic obstructive pulmonary disease (COPD), or interstitial lung disease;
- Missing data or unclear classification of type of spontaneous pneumothorax;
- History of recent trauma before episode of pneumothorax;
- Requiring bilateral bullectomy;
- Bleeding tendency [platelet <100,000/µL, prolong prothrombin time (PT), partial thromboplastin time (PTT), and international normalized ratio (INR)];
- Other techniques of pleurodesis (e.g., talc, pleurectomy).
Surgical technique
Mesh group
Our routine procedure in mesh group was done in a uni-portal VATS approach. In some patients with pronounced adhesions or the current chest tube hole was located too close to the diaphragm, a bi-portal VATS approach was employed instead. After creating a hole either uni-portal or bi-portal, soft tissue retractor was placed at surgical site and 10-mm, 30-degree endoscope was placed in the port. All visible blebs were systematically identified and resected using endo-stapler leaving 10 to 20 mm end at the base of the lesion. Subsequently, polyglactin mesh 30 cm × 30 cm in size, in which pre-created the hole 2 cm in the upper 1/3, was inserted into the thoracic cavity. The rest of the lesion was pulled to pass the pre-created hole. After that, the hole of the mesh was resected together with the rest of the lesion aiming to fix the mesh at the apex and complete covering the staple line. All rims of the mesh were placed carefully to cover the entire pulmonary tissue. Finally, the 24 Fr chest tube was placed, the lung was re-expanded with intentionally holding the edge of the mesh to ensure fully coverage over the entire lung tissue.
Non-mesh group
The bullectomy process was done in the same fashion as mesh group. On the other hand, the pleurodesis was achieved by surgical abrasion technique. We used the cautery scratch pad to scratch the entire parietal pleura starting from apex down to 5th or 6th intercostal space.
Postoperative care
After surgery, the patient was transferred to general ward. The chest tube was routinely connected to a thoracic suction device setting at −10 mmHg. Non-steroid anti-inflammatory drugs was given if there was no contraindication. Rehabilitation program was established as soon as possible at postoperative day 0. When there was no air leakage and the fluid drainage was below 300 mL per day, the chest tube would be removed and the patient would.
Follow-up and recurrence
After discharge, the patients were routinely assigned to visit in the outpatient department at 2 weeks, 2 months, 6 months, 12 months and then annually together with chest X-ray examination. All of them were acknowledged the symptoms of recurrence and how to revisit whenever they had recurrent pneumothorax. Recurrent pneumothorax was defined as recurrence in the side that underwent the surgery. This was judged by two examiners including a thoracic surgeon at the clinic and a report from radiologist.
Statistical analysis
The statistical analysis was performed using STATA v. 16.0 software (StataCorp, College Stata, TX, USA). Categorical variables are presented as frequencies and percentages, and continuous variables are presented as median and interquartile range (P25–P75). To reduce the selection bias between mesh and non-mesh group, we performed a one-to-one propensity score matching by adjusting the baseline characteristics including age, gender, smoking status, comorbidities, weight, height, BMI, and approach type (VATS or open).
The Chi-squared test was used to compare categorical variables and differences between two groups for dichotomous data. For continuous variables, normal distributed variables were analyzed using Student’s t-test and skewed variables were analyzed using Mann-Whitney U test. Univariate regression analysis was performed to assess the risk factor of recurrent pneumothorax in both groups. The rate of freedom from recurrence was analyzed as survival analysis using Kaplan-Meier method. A P value of below 0.05 was considered statistically significant.
Results
Between 2016 and 2023, there were 151 PSP patients underwent bullectomy at our institute, 84 of them were in mesh group and 67 in non-mesh group. Mesh group showed higher age, and higher proportion of VATS approach, but there was no difference in gender, smoking status, and indications for surgery. After 1:1 propensity score- matching analysis, there were 49 patients in each group (Figure 1). There was no difference in demographic variables between two groups as shown in Table 1. Intra-operatively, mesh group had shorter procedural time (45 vs. 60 minutes, P=0.01), and less intraoperative blood loss (10 vs. 20 mL, P<0.001). During postoperative period, polyglactin mesh coverage had benefits on decreasing length of hospital stay and chest tube duration for 2 (P=0.02) and 1 day (P=0.002) respectively (Table 2). There was no fever pattern during post-operative period in both groups. Kaplan-Meier analysis of freedom from recurrent pneumothorax as shown in Figure 2 depicted no difference in recurrence between two groups even though there was 0 recurrence in mesh group compared to 3 patients in non-mesh group. For regression analysis aiming to identify the risk of recurrent pneumothorax, prolong hospital stay and duration of chest tube were significant risk factors with hazard ratio of 1.2 (P=0.03) and 1.2 (P=0.02) respectively as shown in Table 3.
Table 1
| Demographic data | Before propensity score matching | After propensity score matching | |||||
|---|---|---|---|---|---|---|---|
| Mesh (n=84) | Non-mesh (n=67) | SMD | Mesh (n=49) | Non-mesh (n=49) | SMD | ||
| Age, years | 28 [23–41.5] | 40 [28–45] | 0.264 | 28 [23–43] | 38 [28–45] | 0.194 | |
| Sex | 0.223 | 0.093 | |||||
| Male | 67 (79.8) | 47 (70.1) | 35 (71.4) | 37 (75.5) | |||
| Female | 17 (20.2) | 20 (29.9) | 14 (28.6) | 12 (24.5) | |||
| Smoking status | 0.087 | <0.001 | |||||
| Non-smoker | 61 (72.6) | 46 (68.7) | 35 (71.4) | 35 (71.4) | |||
| Smoker | 23 (27.4) | 21 (31.3) | 14 (28.6) | 14 (28.6) | |||
| Indication for surgery (yes) | |||||||
| Persistent air leak | 26 (31.0) | 28 (41.8) | 0.227 | 20 (40.8) | 20 (40.8) | <0.001 | |
| Recurrent pneumothorax | 39 (46.4) | 29 (43.3) | 0.063 | 20 (40.8) | 21 (42.9) | 0.041 | |
| Large lung bleb | 7 (8.3) | 3 (4.5) | 0.158 | 1 (2.0) | 2 (4.1) | 0.119 | |
| Other | 15 (17.9) | 7 (10.4) | 0.214 | 8 (16.3) | 6 (12.2) | 0.117 | |
| Approach | 0.592 | <0.001 | |||||
| Open | 0 (0) | 10 (14.9) | 0 (0) | 0 (0) | |||
| VATS | 84 (100.0) | 57 (85.1) | 49 (100.0) | 49 (100.0) | |||
Data are presented as median [P25–P75] or n (%). SMD, standardized mean difference; VATS, video assisted thoracoscopic surgery.
Table 2
| Variables | Before propensity score matching | After propensity score matching | |||||
|---|---|---|---|---|---|---|---|
| Mesh (n=84) | Non-mesh (n=67) | P value | Mesh (n=49) | Non-mesh (n=49) | P value | ||
| Operation time, minutes | 50 [30–65] | 60 [50–150] | <0.001 | 45 [30–70] | 60 [40–120] | 0.01 | |
| Intra-operative blood loss, mL | 5 [10–20] | 20 [10–100] | <0.001 | 10 [5–20] | 20 [10–50] | <0.001 | |
| No blood transfusion | 84 (100.0) | 67 (100.0) | NA | 49 (100.0) | 49 (100.0) | NA | |
| Complication (yes) | |||||||
| Post-operative complication (bleeding) | 1 (1.2) | 3 (4.5) | 0.32 | 0 (0) | 3 (6.1) | 0.08 | |
| Pneumonia | 2 (2.4) | 1 (1.5) | >0.99 | 1 (2.0) | 0 (0) | 0.32 | |
| Length of stay, days | 3 [2–5] | 5 [3–8] | 0.001 | 3 [2–5] | 5 [3–6] | 0.02 | |
| Chest tube duration, days | 2 [1–3] | 2 [3–6] | <0.001 | 2 [1–3] | 3 [2–5] | 0.002 | |
| Recurrence | 0.09 | 0.08 | |||||
| No | 84 (100.0) | 64 (95.5) | 49 (100.0) | 46 (93.9) | |||
| Yes | 0 (0) | 3 (4.5) | 0 (0) | 3 (6.1) | |||
Data are presented as median [P25–P75] or n (%). NA, not applicable.
Table 3
| Factors | Univariable | ||
|---|---|---|---|
| HR | 95% CI | P value | |
| Age | 0.983 | 0.894–1.081 | 0.72 |
| Indication as persistent air leak | 0.802 | 0.073–8.861 | 0.86 |
| Indication as recurrent pneumothorax | 2.214 | 0.200–24.546 | 0.52 |
| Operation time | 0.993 | 0.964–1.023 | 0.64 |
| Estimate blood | 0.991 | 0.963–1.020 | 0.53 |
| Length of hospital stay | 1.158 | 1.018–1.319 | 0.03 |
| Tube duration stay | 1.168 | 1.024–1.332 | 0.02 |
| Mesh vs. non mesh | 1.000 | NA | >0.99 |
CI, confidence interval; HR, hazard ratio; NA, not applicable.
Discussion
In this study, there was no difference in recurrent pneumothorax between two groups which was the primary outcome. However, polyglactin mesh demonstrated faster operative time and less intra-operative blood loss. Notably, the patients in mesh group showed shorter duration of chest tube, therefore, shorter length of hospital stay.
In our study, polyglactin mesh cannot demonstrate benefit in preventing recurrent pneumothorax over the standard surgical pleurodesis. Even though, several studies (10,12-14) have shown that polyglactin mesh showed this benefit, most of them compared between mesh and without any type of pleurodesis. Only a single study with 102 patients in each group (mesh vs. pleural abrasion) showed less recurrence at 1 year after operation. Since our study had only 49 patients in each group, so the power may not be enough to demonstrate the difference.
We demonstrated significant shorter operative time in mesh group for 15 minutes. From many published studies (10,15-22), and one meta-analysis (11), usage of mesh cannot demonstrate faster in operative time. Since some studies performed no pleurodesis in a control group, so there would be no extra time after bullectomy in these patients. On the other hand, in our study putting mesh to cover the entire lung was a straight forward procedure whereas surgical pleural abrasion required procedure and meticulous inspection for bleeding which can add a bit of time.
In our study, mesh coverage depicted reduction in intra-operative blood loss for approximately 10 mL. However, other previous studies didn’t show this benefit (10). This can be explained by the surgical technique that some surgeons tend to ablate more than others which is subjective. Nevertheless, reduction of only 10 mL blood loss is not much clinically significant. We believe that deeper pleural abrasion should still benefit the patient because blood is one of the best options to generate intrapleural inflammation and showed to stop the air leak within 48 hours (23).
It is generally acknowledged that mesh coverage not only promotes adhesion (9) but also not cause any bleeding. Hence, these benefits can reduce the duration of chest tube by both stopping the air leak and less postoperative chest tube fluid. On the other hand, surgical pleural abrasion requires blood to create adhesion (4) which can cause more postoperative chest tube fluid resulting in delay removal of chest tube. As in our study, mesh coverage can significantly shorten both chest tube duration and length of hospital stay for 1 day.
Our study has several limitations; this was a retrospective study at a single institution, with some selection biases, number of patients and potential unmeasured confounding variables. In the past few years, polyglactin mesh technique had been introduced in our unit. We try reduce selection bias in this study by propensity match score. There was also a small sample size, missing data and limited long-term follow-up on outcomes. We believe a next our randomized control trial may help to further clarify the benefit of polyglactin mesh in spontaneous pneumothorax patients.
Conclusions
In PSP patients undergoing lung bullectomy with pleurodesis, using of polyglactin mesh coverage the entire lung facilitates less operative time, less intra-operative blood loss and shorter both length of stay and chest tube duration. Polyglactin mesh should be considered as an alternative option for surgical pleurodesis.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://atm.amegroups.com/article/view/10.21037/atm-25-91/rc
Data Sharing Statement: Available at https://atm.amegroups.com/article/view/10.21037/atm-25-91/dss
Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-25-91/prf
Funding: None.
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-25-91/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. This study was approved by the Ethical Committee at Vajira Hospital (No. COA 001/2567). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Informed consent was waived for this retrospective study.
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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