ARTICLE IN PRESS
Interactive CardioVascular and Thoracic Surgery 9 (2009) 1–3
? 2009 Published by European Association for Cardio-Thoracic Surgery
Editorial - Pulmonary
The use of sealants in modern thoracic surgery: a survey
Gaetano Rocco *, Erino Angelo Rendina , Federico Venuta , Michael Rolf Mueller , Semih Halezeroglu ,
Hendrik Dienemann , Dirk Van Raemdonck , Henrik Jessen Hansen
Division of Thoracic Surgery, Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation,
Via Semmola, 81, 80131, Naples, Italy
Division of Thoracic Surgery, University Hospital ‘S. Andrea’, Rome, Italy
Division of Thoracic Surgery, Policlinico Umberto I, University ‘La Sapienza’, Rome, Italy
Division of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria
Division of Thoracic Surgery, Istanbul Bilim University, Gayrettepe, Istanbul, Turkey
Division of Thoracic Surgery, Heidelberg Thoraxklinik, Heidelberg, Germany
Division of Thoracic Surgery, Department of Surgery, Catholic University, Leuven, Belgium
Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
Received 13 January 2009; received in revised form 18 March 2009; accepted 18 March 2009
Keywords: Sealants; Air leaks; Hemostasis; Lung surgery
The indications for the resort to sealants during thoracic
surgery are still controversial w1x. The multiplicity of com-
mercially available products, the lack of consistent, irre-
futable evidence for their efficacy and the delicate
relationship with industry call for a clarification of the
status quo within the thoracic surgical community. The
results of a survey conducted during the proceedings of a
Satellite Symposium taking place during the last 2006 joint
EACTS-ESTS meeting in Stockholm are hereafter reported.
Two hundred and forty participants to a Satellite Symposium
on the use of a specific, commercially available, sealant
were asked to anonymously respond through a power-vote
system to six multiple-choice questions aimed at establish-
ing the current standards of practice. No additional demo-
graphic data nor information on professional experience
were required to participate in the survey. The answers
were collected via an electronic (‘power vote’) system and
displayed by percentage at the end of the questionnaire
(see Figures). The analysis of the results was as follows
Question no. 1
How often do you use sealants in your practice?
The survey clarified that only a minority of surgeons use
sealants routinely in their practice (8%). Conversely, 54%
use these products only when indicated, while 21% prefer
to have sealants available in the hospital for an exceptional
use. Worthy of note is that 17% of the participants felt that
the use of sealants is limited by their cost.
*Corresponding author. Tel.: q39-0815903262; fax: q39-0815903823.
E-mail address: Gaetano.Rocco@btopenworld.com (G. Rocco).
Question no. 2
Which hemostatic method do you routinely use
on fragile vascular structures?
With regard to the technique of hemostasis of fragile
vascular structures, it was obvious that most surgeons
would resort to all necessary measures to ensure control
of the bleeder, including sealants. However, the traditional
methods of hemostasis represented a priority.
Question no. 3
Why should we use sealants?
Although 49% of the surgeons seemed convinced that
sealants do work and recognize that no definitive evidence
is available, 34% were uncertain as to their possible clinical
usefulness. Not surprisingly, 17% of the surgeons declared
their skepticism and their willingness to be guided in the
selection of these products by experts from industry.
Question no. 4
When should we use sealants?
Sealants are used to prevent air leaks in 49% of the
patients on fissures but also on bronchial stump after either
lobectomies or pneumonectomies. In addition, 13% of the
attendees reported to use sealants in an attempt at closing
bronchopleural fistulas. While 7% of the surgeons use seal-
ants also on other structures (i.e. pleura), almost one-third
of the total showed some degree of versatility by declaring
to use sealants for all the above indications.
Question no. 5
Which one do you use?
For all indications, fibrin glue (30%) and surgical patch
combining human fibrinogen and thrombin (46%) were the
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G. Rocco et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1–3
Fig. 1. (a) Answers to question no. 1: ‘How often do you use sealants in your
practice?’; (b) Answers to question no. 2: ‘Which hemostatic method do you
routinely use on fragile vascular structures?’.
Fig. 2. (a) Answers to question no. 3: ‘Why should we use sealants?’; (b)
Answers to question no. 4: ‘When should we use sealants?’.
Fig. 3. (a) Answers to question no. 5: ‘Which one do you use?’; (b) Answers
to question no. 6: ‘Do you envisage different sealants for different indica-
tions or a ‘one-fits-all’ situation?’.
most used sealants by our survey population. However, 17%
of the surgeons could only identify the products by their
brand names and not by their main chemical components.
Question no. 6
Do you envisage different sealants for different indications
or a ‘one-fits-all’ situation?
While half of the audience seemed to prefer specific
sealants for specific indications, the remaining surgeons
either expressed the willingness of deciding based on their
own experience (41%) or were not sure and confused by
the variety of commercially available sealants (9%).
Several randomized studies have been proposed for dif-
ferent, commercially available products, in an effort to
confer to the evaluation of the use of sealants the long
desired scientific rigorousness w2–9x. Recently, a meta-
anlysis has showed the absence of a definitive advantage
from using sealants in pulmonary surgery when the end-
points are the reduction of in-hospital length of stay and
postoperative morbidity w10x. In line with the conclusions
expressed by this literature source, only 8% of the respon-
dents to our survey have declared to use sealants routinely.
Major criticisms elicited by currently available studies
include the lack of a precise methodology, the usually
limited numerosity, the deficient information of the rela-
tionship between companies and surgeons testing a sealant,
and the presence of significant confounding factors (i.e.
postoperative air leak assessment). In addition, the defi-
nition of costs and reimbursement policies are often a
neglected, albeit crucial, point of discussion.
With the modern management protocols focused on fast-
tracking thoracic patients in order to decrease costs of
health care, one wonders whether the simple reduction of
hospitalization could still serve as a major clinical goal for
wedge resections. Rather, the clinical contribution of seal-
ants should be tested in contexts where the use of sealants
may undoubtedly make a difference in the clinical practice,
i.e. in association with a no-drain policy following video-
assisted sublobar pulmonary resections, such as for lung
biopsy, peripheral nodules or spontaneous pneumothorax.
A consistent ratio of the procedures commonly performed
in the routine in-patient clinical practice could then be
reserved for an outpatient setting. As a consequence, the
issue of the cost-effectiveness of sealants for preventative
air leak control could become less relevant for thoracic
surgeons. In fact, only 17% of the respondents to our survey
have claimed the costs of sealants to be a determining
factor in their clinical decisions.
Despite the obvious limitations intrinsic to any survey, this
study is meant to serve the purpose to clarify the approach
of contemporary thoracic surgeons towards the utilization
Firstly, a clear distinction is needed between hemostatic
agents and air leak sealants, particularly because more
than half of the respondents want to apply sealants only
when indicated and almost the same percentage feel these
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adjuncts actually work. While a persistent bleeding is seen
as a threatening intraoperative complication which calls
for all possible means to stop or control it, in the thoracic
surgeons’ mind the presence of air leakage seems far less
worrisome. Indeed, De Camp and co-workers have demon-
strated that the air-leak phenomenon in severely emphy-
sematous patients may not be related to the surgical
technique used w11x.
Secondly, according to the survey, there is still a signifi-
cant percentage of surgeons (17%) who are not aware of
the physiologic mechanisms of action of each single sealant.
Curiously, it is the same percentage of respondents who
would prefer to have guidance in theatre while using
Thirdly, despite the wide array of commercially available
products, the responders seemed to converge on the use
of fibrin glue andyor thrombin-fibrinogen patches, currently
the most studied sealants in thoracic surgery. Whether the
participants to a Symposium sponsored by a Company with
a definite interest in the field were somehow influenced
towards a product preference, it remains to be seen espe-
cially taking into account the anonymity of the reply
system. However, slightly more than one-third of the
respondents replied they used sealants according to their
own experience, irrespective of current knowledge in this
It is our opinion that this survey shows the need for taking
the subjectivity out of the assessment of sealants clinical
efficacy. When observational data are analyzed, propensity
score methods should be routinely used to reduce the so-
called ‘treatment-selection bias’ w12x. Alternatively, rigor-
represent the way forward but this may still not be enough.
As an example, given the latest technological advance-
ments utilized to objectively quantify air leakage, an
empiric determination of persistent air leaks in the setting
of randomized trials should not be accepted any longer
w13x. Commendable efforts are being made to approach the
issue of the use of sealants in thoracic surgery by profes-
sional organizations which have been able to produce
recently published guidelines aimed at establishing their
clinical value in specific clinical scenarios . However, it is
envisaged that, in the future, scientific societies may also
offer the intellectual structure and the network of institu-
tions necessary to ensure an impartial organization, per-
1Nycomed, Copenhagen, DK.
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