Polyglycolic Acid-Reinforced Sutures for Alveolar-Bronchiole Level Fistula Closure During Acute Empyema Surgery

Closure of alveolar-bronchiole level fistulas encountered during surgery for acute empyema is challenging due to compromised lung tissue, increasing the risk of persistent air leaks and infection. The use of polyglycolic acid (PGA)-reinforced sutures offers potential, but their application in infected fields is debated. This study evaluates the safety and efficacy of this technique for managing such intraoperative fistulas during video-assisted thoracoscopic (VATS) decortication.

This single-centre retrospective study between 2017 and 2023 compared outcomes in patients undergoing VATS decortication for acute empyema. Patients requiring intraoperative closure of alveolar-bronchiole fistulas using PGA-reinforced sutures (Suture group, N = 7) were compared to those without identified fistulas (Control group, N = 14). Patients with post-resection empyema were excluded. The primary end-point was postoperative complications.

The Suture group had longer surgical durations (mean 139.3 vs 103.5 min, P < 0.01) and greater intraoperative blood loss (mean 192.0 vs 58.1 g, P = 0.04) compared to Controls. All identified air leaks in the Suture group were successfully sealed intraoperatively, confirmed by water-seal test and intraoperative confirmation test. Crucially, the Suture group experienced significantly fewer postoperative complications (Clavien-Dindo ≥ Grade 2) (0/7 [0%] vs 8/14 [57.1%], P = 0.01). No re-exacerbations or re-operations occurred in the Suture group, compared to 4 each in controls. Postoperative inflammatory markers decreased similarly in both groups (P > 0.05).

PGA-reinforced suturing for alveolar-bronchiole fistulas during acute empyema surgery appears feasible and safe. While fewer complications were noted in the Suture group, this small, non-randomized study precludes definitive conclusions on efficacy. Larger prospective studies are warranted.