Comparison of Different Synthesis Methods After Partial Pulmonary Lobectomy in Dogs

Comparison of Different Synthesis Methods After Partial Pulmonary Lobectomy in Dogs | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Different Synthesis Methods After Partial Pulmonary Lobectomy in Dogs Paloma Helena Sanches da Silva, Carlos Eduardo Bastos Lopes, Larissa Bueno Stallmach, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1965208/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Pulmonary loborraphy can be performed using manual sutures and staples, although other methods such as tissue adhesives are also cited in the veterinary literature. However, despite the wide availability, no efficient suture material has yet been recognized that is completely safe in preventing any air leakage, a complication that is heavily investigated in medicine and not uncommon in veterinary medicine, despite the few studies and reports in dogs. Although the surgery is well tolerated in the canine species, failure in pulmonary aerostasis is still a reality, since all the methods described so far eventually lead to air leakage after the use of the partial lobectomy technique in the lungs. Within this context, the aim of this research was to compare the effectiveness of different hermetic sealing methods after partial lobectomy of the right caudal lung lobe (RCLL) in dogs. Using 30 cadaver models of canine lungs obtained immediately after death. The 30 cadavers models were divided in 6 groups: G1 - cobbler suture associated with simple continuous; G2 - overlapping continuous suture associated with simple continuous suture; G3 - Ford interlocking suture ; G4 - Stapling device; G5 - Tissue glue (cyanoacrylate). After performing the sealing techniques, the lungs were submerged in water, inflated with oxygen at positive ventilatory pressures at physiological (20 cmH 2 O) and supraphysiological levels (above 20 cmH 2 O) to evaluate the performance of the sealing methods and to asses the level of ventilatory pressures at which air leakage occur. Results: At physiological ventilatory pressure levels there was no difference between groups. However, when evaluating such methods at ventilation pressure levels above 20 cmH 2 O, it was found a superiority of G5 over G3 and G4. Conclusion: Manual sutures, as well as staples and synthetic tissue glue were able to promote aerostasis after partial lobectomy of the RCLL at physiological ventilatory pressures. Sealing with surgical glue was superior to Ford interlocking suture and stapling device at supraphysiological levels of ventilatory pressure. This study supports the efficay of all manual, mechanical sutures and synthetic glue sealant when used after partial lobectomy in dogs. Cyanoacrylates Lungs Pneumostasis Surgical technique Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Pulmonary lobectomy is a surgical tecnique occasionally performed in dogs to resect pulmonary tumours, bullae and damaged lung lobes 1 . This procedure consists of partial or total lobar resection, depending on the extention of the lesion in the parenchyma 2 , 3 . Although the surgical procedure using manual suture or stapling devices is usually safe, failures, including air leakage and consequent pneumothorax can occur. Postoperative mild pneumothorax can resolve spontaneously or with the use of thoracic drains. However when not treated, severe pneumothorax can result in severe complications and even death 2 – 4 . Various sealing tecniques have been developed to increase the safety of the procedure. Specific tissue glue, as well as the use of different types of staplers, pre tied loop ligatures and vascular sealing devices are now used in veterinary medicine 5 . Howeverit is not completely known, which sealing method is the safest. Air leaking post lung lobectomy is still a complication reported in dogs with most suture tecniques and sealing devices 6 – 12 . The aim of this study was to investigate the airtigh sealing property and efficacy of the most common suture tecniques and sealing devices after pulmonary lobectomy against physiological and supraphysiological ventilatory pressures. Methods Specimens Thirty dogs cadavers were obtained after euthanasia, following the diagnosis of leishmaniasis at the Zoonosis Control Center. Criteria for inclusion were: mixed breed dogs; weight between 5 and 10 kg; variable body condition score; macroscopically normal respiratory tract during necroscopy. The respiratory tract was removed en block including the larynx, trachea, bronchi and lungs. The experiment was carried out within 12 hours after macroscopic collection of the respiratory block. An appropriately sized endotracheal tube was inserted into the trachea and secured with a nylon seal. Tracheal tube was connected to a calibrated manometer and oxygen gas for positive pressure. All lungs were initially pressurized slowly to 10 mmHg, and then deflated, to check for pre-existing atelectasis and/or previous air leakage before performing the experiment. The RCLL was chosen and the partial lobectomy was performed, followed by tissue sealing and aerostasis assesment. Pulmonary lobectomy sealing methods The five experimental groups are listed in the table 1. Table 1 Different methods of pulmonary synthesis organized into five experimental groups. Groups Total n: 30 Pulmonary lobar sealing methods 1 n=6 Loborrhaphy with cobbler or Vachetta suture pattern, followed by simple continuous suture 2 n=6 Loborrhaphy with overlapping continuous suture associated with simple continuous suture 3 n=6 Loborrhaphy with Ford interlocking suture pattern 4 n=6 Loborraphy with metal staples by TA linear stapler (Covidien ® ) (2 units 45mm reload inserted in opposite directions in to the lobe) 5 n=6 Loborraphy with 1mL of Glubran-2 ® (n-butyl cyanoacrylate - NBCA and methacryloisofolane – MS) synthetic adhesive The width and height of the parenchyma in the middle third of the resected RCLL were measured with a calliper. For manual sutures, surgical threads of Polyglactin 910 (coated Vicryl®) of size 4-0 and cylindrical needle were used. Pulmonary aerostasis test After performing the sealing tecniques, the lungs were placed into a transparent plastic container and submerged in water. The lungs were then inflated and all models were filmed to allow for accurate monitoring and recording of any potential air leak. A leakage was considered only when air bubbles were visualized at the level of the suture line or on the surface of the cut. Any occurrence of air leakage was recorded at physiological pressure (up to 20 cmH 2 O or 14.7 mmHg) or supraphysiological if above 15 mmHg. The value of air pressure at which any leakage occurred was also recorded. Statistical analysis For statistical analysis, the software GraphPadPrism v. 6.02 was used. Differences with a p value less than 0.05 (p < 0.05) were considered significant. The cadavers were randomized into five groups of six. The Kolmogorov-Smirnov test was used to assess the normality of the variables studied. The homogeneity of the groups was evaluated by comparing body weight, body score, height and width of the RCLL. The comparison of the means between the groups, of the parametric variable with normal distribution (body weight), was performed by ANOVA and Fisher's ad-hocTukey test. The comparison of the medians for the non-parametric variable (body score) and for those with non-normal distribution (height and width of the lobe) was performed using the Kruskall-Wallis ad-hocDunns test. The pressure related to the air leaks also showed a non-normal distribution and, therefore, the medians between the groups were compared by the same test. Furthermore, the groups were compared regarding the aerostatic variable, that is, whether or not there is air leakage, under physiological ventilatory pressures considered up to 20 cmH 2 O, using the Kurskall-Wallis ad-hocDunns test. Fisher's exact test was also used to evaluate the frequency of distribution in relation to leakage under physiological pressure, according to the sealing methods. Results All the five groups analyzed were homogeneous in terms of body weight (p=0.1901) and lung lobe width (p=0.0637). However, they differed in the median for the body condition score (p=0.0202) and lung lobe height (p=0.0347). Regarding the body condition score of the animals used in this study, there was a statistical difference only between the medians of groups G1 (cobbler suture followed by simple continuous suture) and G3 (Ford interlocking suture ). Lung lobe height differed only between groups G4 (surgical staplers) and G5 (synthetic glue) (Figure 1). The pressure in mmHg needed to cause lung lobe air leakage varied according to the type of sealing tecniques, as shown in Table 2. Table 2 Values referring to extravasation pressures in mmHg by type of lobar synthesis (mmHg). Cobbler suture + simple continuous suture G1 Overlapping continuous suture + simple continuous suture G2 Ford interlocking suture G3 Staples G4 Synthetic glue G5 Lung lobe 1 20 18 15 10 60 Lung lobe 2 20 20 24 22 40 Lung lobe 3 18 20 14 19 20 Lung lobe 4 30 23 19 14 40 Lung lobe 5 14 16 14 18 40 Lung lobe 6 20 20 21 20 80 Although some experimental units demonstrated a rupture in physiological pressures in groups G1, G3 and G4, there was no difference between the groups (p = 0.3263). The pressure needed to cause air leakage in the lung lobe sutured with Ford interlocking suture (G3) and TA stapler (G4) was lower than the synthetic glue (G5), with p=0.0164 (Table 3) (Figure 2). There were not statistical significant difference (p=0.2873) in the sealing methods efficacy against physiological pressure (up to 20 cmH 2 O or 15 mmHg). However while the G2 (overlapping continuous suture) and G5 (synthetic glue) did not have any air leakage at phisiological air pressure, aerostasis failure was observed in 1/6 in s G1 (cobbler suture + continuous simple suture 2/6 in G3 (Ford interlocking suture ), and 2/6 in G4 (stapling device). Table 3 Values of the mean, median, standard deviation and 95% confidence interval for the values of the groups analyzed regarding the variable extravasation pressure. Groups Mean Median Standard deviation Confidence interval 95% Low Higher G1 (Cobbler suture + simple continuous suture) 20.33 20.00 5.279 14.79 25.87 G2 (Overlapping continuous suture + simple continuous suture) 19.50 20.00 2.345 17.04 21.96 G3 (Ford interlocking suture ) 17.83 17.00 b 4.167 13.46 22.21 G4 (Staples) 17.17 18.50 c 4.401 12.55 21.78 G5 (Synthetic glue) 46.67 40.00 a 20.66 24.99 68.34 There was a difference between G5 in relation to G3 and G4, with p = 0.0164. Medians followed by distinct letters differ from each other at a 5% significance level. Discussion The physiological ventilatory pressure considered in this study was 20 cmH 2 O (15 mmHg). According veterinary guidelines, pressure levels on lung tissue from 15 to 25 cmH 2 O can be considered physiological 13 . However, pressure values ​​of 15 to 20 cmH 2 O are considered more accurate for small animals under normal respiratory mechanics conditions 14 . In one study, aerostasis was considered safe when air leakage occurr at ventilatory pressures greater than 20 cmH 2 O after a lung biopsy in anesthetised dogs 11 . In another experimental study evaluating different types of surgical staplers, air leakage at a ventilatory pressure equal to or less than 20 cmH 2 O was considered not safe and the sealing device inadequate 12 . Sealing methods probably should withstand a ventilatory pressure of the airways of up to 20 cmH 2 O to be considered safe. All the methods used for sealing that were investigated in this study were effective against established physiological ventilatory pressure. The canine lung model used wasmacroscopically normal butit was obtained from dogs with leishmaniasis. Most of the dogs were clinically unwell which resulted in different body conditions score between the groups. The body condition score values 15 ​​of G3 were lower (1–3), compared to G1 (3–7). However, there was not a statistical difference in the aerostatic property of these groups. Despite difference between median lung lobe height of G4 (Md = 12.12 cm) and G5 (Md = 19.47 cm), G5 showed superiority sealing property under supraphysiological pressures compared to the median obtained by G4, which proves that even with a larger surface area to be sealed, the synthetic glue was still able to withstand against high pressures ventilation, ensuring greater aerostatic safety than the staples device. One of the manual sutures used and analyzed in this study was the cobbler suture 16 (Fig. 3 A) which ensured good sealing in almost all the lung lobes (Fig. 3 B). However one developed air leakage, at the pressure of 14 mmHg (= 19.03 cmH 2 O). The punctual air leak detected in the place where the suture was contained, possibly corroborates the observation described by other authors when evaluating the double-layer mattress suture in sheep lungs after partial resection of one of the lobes 10 . The authors observed minimal air leakage along the parenchyma when the lungs were inflated to 40 mmHg and explained that this was due to the portion of the parenchyma along the needle incisions. Thus, the small leak detected in 1/6 model after cobbler suture probably occurred when the needle passed through the tissue. However, there were no statistical differences between the models analyzed in the present study. The successful aerostasis observed in this group can be attributed to the increase in tissue contact surface caused by this suture pattern, which ensured sufficient sealing against physiological ventilatory pressures. The overlapping continuous suture (Fig. 4 A) used in G2 has been described for lung sealing after partial lobectomy in dogs and cats 17 , 18 . This is a manual suture pattern defined as a pneumostatic suture, once it results in additional compression of the parenchyma 17 . The results found in this study confirm the efficacy of this suture patternin maintain aerostasis against physiological ventilatory pressures (Fig. 4 B). The third manual suture investigated (G3) was the Ford interlocking suture pattern (Fig. 5 A), characterized by a modified continuous suture and frequently used in soft tissue surgeries in order to withstand some degree of tissue tension 19 . Such sealing suture also demonstrated a good aerostasis, although two of the models showed air leakage at physiological ventilatory pressures. It is worth mentioning that so far, there are no references in the veterinary literature regarding the use of the Ford interlocking suture pattern in loborraphy after partial lung lobectomy in dogs. This suture pattern is indicated for the correction of lacerations of the lung parenchyma in humans, since it promotes good adhesion of its edges, and therefore hemostasis 20 . This suture brings the margins closer providing an effective seal. Despite the lack of studies with the Ford interlocking suture technique in dogs in vivo, this sealing tecnique could be a safe option after partial pulmonary lobectomy in dogs. Two out of six cadaver models in the Ford interlocking suture group failed to achieve aerostasis when the ventilatory pressure reached a value of 19.03 cmH 2 O (Fig. 5 B). In both cases, along the suture line, there was no leakage, except for a single laceration point lateral to the suture line. When the ventilatory pressure wasincreased, the tissue tension in the lobe was probably higher in certain points, which may have caused a punctual laceration, and consequent leakage of air 19 , 21 , 22 . In the group of lung lobes in which the mechanical suture was performed with metal staples using the TA linear surgical stapler, the results showed a good response in terms of aerostasis, with no difference compared to the other groups. However two out of six cases failed due to air leakage laterally to the staple line, at physiological ventilatory pressures of 13.59 cmH 2 O and 19.03 cmH 2 O. The effective aerostasis with mechanical stapling sealing devices and observed in the present experimental study was also reported by other authors 2 , 23 . The safe use of staples has been previously demonstrated in nearly 40 dogs and cats undergoing pulmonary lobectomy for the treatment of different conditions 2 . In this study only two patients developed pneumothorax in the postoperative period 2 . In an ex vivo study with lung biopsy in dogs, airway leakage occurred at pressure of 28 cmH 2 O. However this was achieved using an EndoGIA 45 mm endoscope stapler 11 . In another study, also using a stapler during thoracoscopy, eight dogs were submitted to partial and total pulmonary lobectomies, and although the pulmonary inflation pressure was not mentioned, all animals were discharged without intraoperative complications after loborraphy with surgical staples 24 . In a clinical study two main conventional methods of pulmonary sealing were compared after partial lobectomy in eight dogs. It was found that the mechanical suture with staplers was superior over manual suture with non-absorbable material 23 . The authors concluded that staples could be superior as it achieves an equal distribution along the parenchyma, while manual suture, are more likley to depend on the surgeons tecnique which may lead to variability in tissues sealing distribution 23 . Furthermore, the efficacy of surgical staples over manual sutures has been proven in humans undergoing pulmonary lobectomy 25 . The authors also believe that manual suturing depends on the surgeon's experience and skills, and manual suturing could cause more air leakage caused by the passage of the needle throughout the pulmonary parenchyma 25 . However, in the present study, there was no statistical difference regarding the efficacy of aerostasis between manual and mechanical sutures. However, in the present study, aerostasis promoted by mechanical suturing was achieved by ensuring the insertion of staples for all the lenght of the sectioned parenchyma 6 . To avoid air leakage due to failure of inserted staples, two blue cartridges with a total width of 45 mm each were used, containing a double row of staples (Fig. 6 A). The width x height dimension of each of these staples when opened was 4.0 x 3.5 mm. Both cartridges were inserted in opposite directions in the lobe, in order to ensure that the lateral ends of the parenchyma to be stapled were all completely covered by staples, thus avoiding air leakage from uncovered areas. The presence of a wider cartridge, such as the 60 mm one, could haved replaced the use of the two cartridges used in the study. An interesting observation is that the leg length of the staple in mm did not match the thickness of the tissue to which it was inserted. According to the type of surgical stapler used in this study, the blue cartridge of the TA linear stapler has a leg length of 3.5 mm when open, with a staple height of 1.5 mm when closed 26 . The veterinary literature recommends that when surgical staples are used in the lung parenchyma, the selection of the height of the staples to be used depends upon the compressed thickness of the tissue 6 . The discrepancy of the height in vivo should be taken in consideration before deciding the type of staple to apply. However in our study lung lobes with different values ​​of height or parenchyma thickness were used. In the stapling device group, the thinnest parenchyma was 10.89 mm and the largest was 14.33 mm, which means that these values were higher than the standardized heights of the staples used in the study. Despite an incomplete cover of the staple over all the parenchyma to be sealed, air leakage did not occur, since the six lobes of G4 did not show differences at physiological pressures. Probably, the reduced length of the staple when closed, should consider only the diameter of the bronchioles and not the all thickness of the tissue to ensure aerostasis 6 . However, the use of staples in pulmonary loborrhaphy in dogs, although considered safe, does not rule out completely the risk of air leakage during intraoperative positive pulmonary ventilation as observed in the two out of six models in the staples group. Air leakage has been documented at the staples site under physiological ventilatory pressures, in other studies with dog’s lung 12 . In a study evaluating three different models of surgical staplers used in the pulmonary loborrhaphy of canine cadavers, the rupture pressure at the stapling line seldom occurred at values equal to or less than 20 cmH 2 O 1 2 . Air leakage along the stapling line was reported by other authors when using an EndoGia 45 mm endoscopic stapler. When performing lung lobe biopsy in vivo in dogs and comparing Endo Gia 45 mm with vascular sealing devices and sutures, air leak was found at the stapler site and possibly caused by staple trauma to the parenchyma. The authour concluded that the stapler device was considered safe because the median pressure values of air leakage was not less than 20 cmH 2 O 1 1 . At high positive pressure he inserted staples can lacerate the lung tissue, resulting in wider orifices and consequent air leakage 9 even at pressures around 20 to 25 cmH 2 O. This is the likely explanation for what may have caused air leackage in the two models in the staples group (Fig. 6 B). Although the superiority of mechanical suturing has been reported, an additional manual suture over the staple line used for partial pulmonary loborrhaphy may be necessary to control parenchymal leakage and bleeding 23 . This suture reinforcement in the stapling line is also recommended by other authors, and can be performed with additional stapling or with manual suturing over the area of air leakage 6 , 26 . Complementing the staple line with other surgical suture or devices could guarantee better resistance at supraphysiological levels of ventilatory pressure 8 , 27 . However this was not evaluated in our study. The effective sealing property provided by the Glubran-2® surgical sealant (G5) did not result in aerostasis failure in any of the six lungs when challenged by physiological ventilatory pressure. Air leakage occurred only at very high ventilatory pressure, with a minimum of 20 mmHg (or 27.19 cmH 2 O) and a maximum of 80 mmHg (or 108.76 cmH 2 O) (Figs. 7AB). Similar results were achieved in an experimental study using rabbit lungs and sealant that contains NBCA, one of the monomers present in Glubran-2®. In such study with rabbits the authors demonstrated that of the 12 lung lobes resection, air leakage developed only at supraphysiological ventilatory pressures, ranging from 18.38 to 40.45 mmHg (25 to 55 cmH 2 O) 28 . Similarly to our study sealing failure occurred only at pressure above 27 cmH 2 O, demonstrating greater safety after pulmonary loborrhaphy in dogs. In the present study, two of the six lobes in the glue group had aerostasis failure, at 60 and 80 mmHg, 4–5,.4 times higher than the physiological pressure, and above the maximum pressure recorded in the study with rabbit lungs 28 . Other similar result was reported in an experimental study that used the same type of sealant in 20 sheeps lungs against supraphysiological pressures of 40, 60 and 80 mmHg 10 . The authors noted that most of the lobes did not present air leakage in the region sealed by the glue, except for a smaller percentage of 20% of the lobes that resulted in minimal degree of air leackage. The Glubran-2® sealant is one of the commercial names of NBCA, an important synthetic biodegradable surgical glue, which is modified by the addition of MS monomer. It has been widely used in medicine, such as in urological, gynecological, digestive, neurological, cardiovascular and thoracic surgeries because it demonstrates adhesive, hemostatic and aerostatic properties when applied to diferent tissues 29− 31 . Safety and efficacy of this synthetic glue has been reported in cats, swine, rabbits, sheeps and humans 10,28,32− 35 . However, so far, no reports have been described or published using the cyanoacrylate co-monomer Glubran-2® in surgeries involving lobectomy in dog’s lungs. In a study with six healthy cats after performing partial pulmonary lobectomy, NBCA has effective hemostatic and aerostatic property 32 . The results were satisfactory, although the ventilatory pressure used to assess aerostasis was not reported, nor the extent of resected parenchyma. However, due to the absence of clinical significant post-surgical complications and the histopathological evaluation of the patches containing the glue three weeks after surgery, it was concluded that this type of cyanoacrylate would be a safe alternative method for pulmonary loborrhaphy in cats 32 . From radiographic examinations, mild asymptomatic pneumothorax was observed only in 4 patients soon after surgery and in 1 patient two days post surgery 32 . The sealing property of the glue is due to the formation of a thin elastic film of high strength that molds itself over the tissue, and makes the tissue region firm within 60 to 90 seconds. This is the result of the glue exothermic polymerization after interacting with tissue surface, forming strong bonds with tissue proteins and ensuring strong sealing to the lung tissue at the place where it is applied 29 , 34 , 36 . In the experimental study with rabbit lungs local and systemic effects were investigated after the use of the synthetic cyanoacrylate sealant. It was macroscopically observed that the portion of the lung parenchyma that was glued had an altered texture and hardened consistency for almost a month after being applied. This highlights the efficacy of the sealing property of this product for pulmonary aerostasis 36 . In the current study, although no difference was observed between the groups regarding rupture under physiological pressure, the sealing promoted by the synthetic glue containing NBCA was able to ensure an efficient aerostasis also at supraphysiological ventilation pressures. The median pressure of rupture in G5 (Glubran-2®) was superior to observed in G3 (Ford interlocking suture) and G4 (staples). In the present study, the canine lung lobes of the 3 groups that received the different manual sutures made with the same type of surgical material, were not able to achieve aerostasis at pressure levels of 40 mmHg,. Similarly, as demonstrated in the study carried out with sheeps lungs after partial lobectomy, all lobes that received manual sutures failed aerostasis after applyng this pressure 10 . However, among the manual sutures analyzed in the current study, only the group that received the Ford interlocking suture showed a significantly lower difference compared to the group that received the synthetic glue. The air leak observed in the manual suture line proved to come from the place where the needle passed in the parenchyma 10 . Similar to our study, the authors concluded that the aerostasis promoted by the sealing performed by the manual suture, was inferior to the sealing performed by the synthetic glue, in all 20 sheeps lungs evaluated at high ventilatory pressure 10 . In our study synthetic cyanoacrylate adhesive was significantly superior to the manual Ford interlocking suture, and to mechanical suturing by staples. The excellent seal maintained by the synthetic glue can be explained by the low viscosity of the sealant when in liquid phase filling the small gaps and creating better sealing between the cutting surfaces of the lung than other sealing methods 29 . The glue also does not create physical injury to the lung parenchyma, as the tissue trauma caused by the needle and staples 10 , 11 , 25 . The main limitation of this study is the experimental model. The lungs were evaluated outside the thoracic cavity, a condition that prevents adequate lung distension and retraction during the respiratory cycle 37 . Under laboratory conditions accurate assessment of the sealing methods against physiological variations of ventilatory pressures is not completely possible. On post mortem examination the lungs appeared macroscopically normal and the experiment carried out within a few hours after death. However this is not completely comparable to a lung in a physiological condition. Therefore, the safety and eficacy data of aerostasis in all the methods evaluatedin this experimental model, should not be completely and safely extrapolated for dogs in vivo. Another limitation regards the collection of lungs from patients, diagnosed with leishmaniasis. It is possible that microscopic lung lesions could be present at the time of the study, without being macroscopically visible. Leishmania sp is known to cause histological changes including mild to severe peribronchial inflammatory infiltration, fibroblast proliferation in lung tissues, edema and congestion in the alveolar wall, but histological examination of the lungs in this study were not performed 38 . Microscopic changes, whether caused by Leishmania sp or some subclinical respiratory disease, could interfere with lung compliance and adequate sealing, resulting in rupture at lower pressures, and could justify some results of this study 7 , 11 , 38 . Conclusions The result of this study proved the safety and efficacy of all investigated sealing methods after partial lobectomy in the middle third of the right caudal lung lobe of dogs. There was no difference at physiological ventilatory pressures (20 cmH 2 O). However, greater efficacy was achieved by the surgical tissue glue Glubran-2® at supraphysiological ventilatory pressures (greater than 20 cmH 2 O). Glubran-2® was superior to the Ford interlocking suture and the TA 45 mm linear surgical stapler, but no difference was found between Glubran-2 and cobbler suture associated with simple continuous and overlapping continuous with simple continuous suture. Abbreviations RCLL: Partial lobectomy of the right caudal lung lobe NBCA: n-butyl cyanoacrylate MS: Methacryloisofolane Declarations Acknowledgements We thank CAPES for all the financial support. Authors' contributions All authors contributed to the study conception. Horta RS., DVM, MS, PhD conceived the idea presented, being complemented by Freitas PMC., DVM, MS, PhD and Silva, PHS., DVM, MS.Freitas PMC., DVM, MS, PhD and Horta RS., DVM, MS, PhD supervised the experiment. Silva, PHS., DVM, MS carried out the experiment with Lopes CEB., DVM; Stallmach LB., DVM; Ferreira LO., DVM and Pimentel PAB., DVM. Silva, PHS., DVM, MS wrote the manuscript, with the help of Giuliano A., DVM, MS, PhD; Freitas PMC., DVM, MS, PhD and Horta RS., DVM, MS, PhD. All authors read and approved the final manuscript. Funding This work was supported by funds from Coordination for the Improvement of Higher Education Personnel (CAPES). Availability of data and materials All data generated or analysed during this study are included in this published article [and its supplementary information files]. Ethics approval and consent to participate This study was approved by the Ethical Committee on Animal Use (CEUA) of the Federal University of Minas Gerais (UFMG), under protocol number 236/2020. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Bleakley S, Duncan CG, Monnet E. Thoracoscopic Lung Lobectomy for Primary Lung Tumors in 13 Dogs. Vet Surg. 2015;44(8):1029-1035. doi: 10.1111/vsu.12411 LaRue SM, Withrow SJ, Wykes PM. Lung resection using surgical staples in dogs and cats. Vet Surg. 1987;16(3):238-240. doi: 10.1111/j.1532-950x.1987.tb00945.x Bleakley S, Phipps K, Petrovsky B, Monnet E. Median sternotomy versus intercostal thoracotomy for lung lobectomy: A comparison of short-term outcome in 134 dogs. 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Pulmonary and Bronchotracheal Trauma. In: Velmahos G, Degiannis E, Doll D. Penetrating Trauma: A Practical Guide on Operative Technique and Peri-Operative Management. Verlag Berlin Heidelberg: Springer; 2012. p. 259-267. https://www.springer.com/gp/book/9783662498576. Accessed Jun 2020. Latona J, Tannouri S. Fundamentals of Sutures, Needles, Knot Tying, and Suturing Technique. In: Palazzo F, Pucci M. Fundamentals of General Surgery. USA: Springer; 2018. p. 39-63. http://doi.org/10.1007/978-3-319-75656-1. Accessed Apr 2020. Szkudlarek A, Sincero P, Sousa R, Fogaça R. Adesivo cirúrgico de etil-2-cianoacrilato em lobectomia parcial em ratos. J Bras Pneumol. 2011,37(6):729-734. https://doi.org/10.1590/S1806-37132011000600005 Ferreira Filho J, Junior N, Tortelly R, et al. Comparação entre sutura convencional com fio de poliéster e sutura com grampos de aço inoxidáveis na lobectomia parcial pulmonar. Estudo experimental em cães (Canis familiaris). R. bras. Ci. Vet. 1997;4(3);127-130. Wormser C, Singhal S, Holt DE, Runge JJ. Thoracoscopic-assisted pulmonary surgery for partial and complete lung lobectomy in dogs and cats: 11 cases (2008-2013). J Am Vet Med Assoc. 2014;245(9):1036-1041. doi: 10.2460/javma.245.9.1036. Tantraworasin A, Seateang S, Bunchungmongkol N. Staplers versus hand-sewing for pulmonary lobectomy: randomized controlled trial. Asian Cardiovasc Thorac Ann. 2014;22(3):309-314. doi: 10.1177/0218492313491754. Tobias K. Surgical Stapling Devices in Veterinary Medicine: A Review. Vet Surg. 2007;36(4)341–349. doi: 10.1111/j.1532-950X.2007.00275.x. Roberson LD, Netherland DE, Dhillon R, Heath BJ. Air leaks after surgical stapling in lung resection: a comparison between stapling alone and stapling with staple-line reinforcement materials in a canine model. J Thorac Cardiovasc Surg. 1998;116(2):353-354. doi: 10.1016/s0022-5223(98)70138-2. Cagirici U, Cetin Y, Cakan A, Samancilar O, Veral A, Askar FZ. Experimental use of N-butyl cyanoacrylate tissue adhesive on lung parenchyma after pulmonary resection. Thorac Cardiovasc Surg. 2007;55(3):180-181. doi: 10.1055/s-2006-924579. Kull S, Martinelli I, Briganti E, et al. Glubran2 surgical glue: in vitro evaluation of adhesive and mechanical properties. J Surg Res. 2009;157(1):e15-e21. doi:10.1016/j.jss.2009.01.034 Ayyıldız SN, Ayyıldız A. Cyanoacrylic tissue glues: Biochemical properties and their usage in urology. Turk J Urol. 2017;43(1):14-24. doi: 10.5152/tud.2017.09465. Valentim Filho J, Pardinho L, Avena K, Felzemburgh V. Uso da cola de cianoacrilato como alternativa em procedimentos cirúrgicos: uma revisão integrativa. Res Soc Dev. 2021;10(2); e28310212592.doi: http://dx.doi.org/10.33448/rsd-v10i2.12592 Ishizaki M, Reis A, Salomão Júnior E, Júnior A. O n-butil cianoacrilato na lobectomia pulmonar parcial em felinos. Estudo experimental. Cienc Rural. 2005; 35(1);109-115. https://doi.org/10.1590/S0103-84782005000100017 Petter-Puchner AH, Simunek M, Redl H, Puchner KU, Van Griensven M. A comparison of a cyanoacrylate [corrected] glue (Glubran) vs. fibrin sealant (Tisseel) in experimental models of partial pulmonary resection and lung incision [corrected] in rabbits [published correction appears in J Invest Surg. 2010;23(2):124]. J Invest Surg. 2010;23(1):40-47. doi: 10.3109/08941930903469383. Davoli F, Sellitri F, Brandolini J, et al. Use of coagulant spray glue (Glubran 2) for aerostatic purposes in pulmonary parenchyma resections in pigs: a preliminary study. Eur Surg Res. 2009;43(4):360-364. doi: 10.1159/000248334. Allama AM, Abd Elaziz ME. Using tissue glues for decreasing alveolar air leak in thoracic surgery. Asian Cardiovasc Thorac Ann. 2019;27(5):369-373. doi: 10.1177/0218492319841734. Carvalho MVH, Marchi E, Fruchi AJ, et al. Local and systemic effects of fibrin and cyanoacrylate adhesives on lung lesions in rabbits. Clinics (Sao Paulo). 2017;72(10):624-628. doi: 10.6061/clinics/2017(10)06. Wilson W, Benumof J. Physiology of the Airway. In: Hagberg C. Benumof and Hagberg's Airway Management. USA: Saunders; 2013. p. 118-158. https://clinicalgate.com/physiology-of-the-airway/Accessed Dec 2021. Alves GB, Pinho FA, Silva SM, Cruz MS, Costa FA. Cardiac and pulmonary alterations in symptomatic and asymptomatic dogs infected naturally with Leishmania (Leishmania) chagasi. Braz J Med Biol Res. 2010;43(3):310-315. doi: 10.1590/s0100-879x2009007500037. Supplementary Files ANNEXSFILES.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 28 Sep, 2022 Editor invited by journal 07 Sep, 2022 Editor assigned by journal 16 Aug, 2022 First submitted to journal 15 Aug, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1965208","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":140308713,"identity":"04c9bf65-f68a-4267-a52d-fb96043f1482","order_by":0,"name":"Paloma Helena Sanches da Silva","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-4301-5822","institution":"UFMG: Universidade Federal de Minas Gerais","correspondingAuthor":true,"prefix":"","firstName":"Paloma","middleName":"Helena Sanches da","lastName":"Silva","suffix":""},{"id":140308714,"identity":"3e11db2e-798e-478c-bd75-d6c17636ef5e","order_by":1,"name":"Carlos Eduardo Bastos Lopes","email":"","orcid":"","institution":"UFMG: Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"Eduardo Bastos","lastName":"Lopes","suffix":""},{"id":140308715,"identity":"9302dc37-edfd-438a-a381-00163506682c","order_by":2,"name":"Larissa Bueno Stallmach","email":"","orcid":"","institution":"UFMG: Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Larissa","middleName":"Bueno","lastName":"Stallmach","suffix":""},{"id":140308716,"identity":"3f411a7c-fdc1-4eea-91fe-1bf132d7accd","order_by":3,"name":"Lucas de Oliveira Ferreira","email":"","orcid":"","institution":"UFMG: Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Lucas","middleName":"de Oliveira","lastName":"Ferreira","suffix":""},{"id":140308717,"identity":"b1e4ad51-6e01-4541-8999-a984098fc04a","order_by":4,"name":"Pedro Antônio Bronhara Pimentel","email":"","orcid":"","institution":"UFMG: Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Pedro","middleName":"Antônio Bronhara","lastName":"Pimentel","suffix":""},{"id":140308718,"identity":"976d3873-845c-455d-81d1-280afef018ac","order_by":5,"name":"Antonio Giuliano","email":"","orcid":"","institution":"Hong Kong Jockey Club","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Giuliano","suffix":""},{"id":140308719,"identity":"2d514cc6-9c4f-4685-b172-4bdeb16d7b9c","order_by":6,"name":"Patrícia Maria Coletto Freitas","email":"","orcid":"","institution":"UFMG: Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Patrícia","middleName":"Maria Coletto","lastName":"Freitas","suffix":""},{"id":140308720,"identity":"61fef663-9e77-4821-92ca-94c8e677442c","order_by":7,"name":"Rodrigo dos Santos Horta","email":"","orcid":"","institution":"UFMG: Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Rodrigo","middleName":"dos Santos","lastName":"Horta","suffix":""}],"badges":[],"createdAt":"2022-08-15 22:16:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1965208/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1965208/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":27321181,"identity":"9e730b85-4761-40d0-b7d3-acc903e8a832","added_by":"auto","created_at":"2022-10-04 13:52:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":125220,"visible":true,"origin":"","legend":"\u003cp\u003eMean and median values of the variables analyzed in the different groups (G1= cobbler + simple continuous; G2= overlapping continuous + simple continuous; G3= Ford \u003cem\u003einterlocking suture;\u003c/em\u003eG4= staples; G5= synthetic adhesive). Mean for the variable body weight (Kg), p = 0.1901. Medians for the variable lung lobe width (cm), p = 0.0637. Medians for variable body score of the animals, with statistical difference between G1 and G3, p = 0.0202. Medians for the variable lung lobe height (cm), with statistical differences between G5 and G4, p = 0.0347.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-1965208/v1/083b107eed6e28f9910af769.png"},{"id":27321855,"identity":"378dfc2a-3721-4de7-87a0-a0a502776ae4","added_by":"auto","created_at":"2022-10-04 14:02:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":77286,"visible":true,"origin":"","legend":"\u003cp\u003eMedian burst pressures (mmHg) referring to the types of synthesis in which there was loss of pulmonary aerostasis, p = 0.0164. G1= cobbler + simple continuous; G2= overlapping continuous + simple continuous; G3= Ford \u003cem\u003einterlocking;\u003c/em\u003eG4= staples; G5= synthetic glue.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-1965208/v1/ab9515bf56f05ead823eb824.png"},{"id":27322014,"identity":"54dd9224-a3ce-4c74-a0e7-792bc00c1361","added_by":"auto","created_at":"2022-10-04 14:07:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":732751,"visible":true,"origin":"","legend":"\u003cp\u003eA: Photographic image of the cobbler and simple continuous suture in lung lobe. B: Photographic image of the RCLL (G1) showing air leakage (arrow) laterally to the suture line at supraphysiological pressure at 18 mmHg (24.47 cmH\u003csub\u003e2\u003c/sub\u003eO).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-1965208/v1/6c4894d50a3c8b04a3d72a77.png"},{"id":27321445,"identity":"ca751c42-8511-42b9-abc5-74461d4c8bf6","added_by":"auto","created_at":"2022-10-04 13:57:47","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":656137,"visible":true,"origin":"","legend":"\u003cp\u003eA: Photographic image of the overlapping continuous and simple continuous suture in lung lobe. B: Photographic image of the RCLL (G2) showing air leakage (arrow) at supraphysiological pressure at 20 mmHg (27.19 cmH2O).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-1965208/v1/2c58f7cd2dcd2fbc398ab7f7.png"},{"id":27321447,"identity":"ad0d256b-cbb4-4eb1-9c5e-a286ca30d932","added_by":"auto","created_at":"2022-10-04 13:57:47","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":678563,"visible":true,"origin":"","legend":"\u003cp\u003eA: Photographic image of the Ford \u003cem\u003einterlocking suture\u003c/em\u003ein lung lobe. B: Photographic image of the RCLL (G3) showing air leakage (arrow) at supraphysiological pressure at 14 mmHg (19.03 cmH2O).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-1965208/v1/36ff406ed2c65e25e6e5ef4f.png"},{"id":27321185,"identity":"8ba06ebd-6888-4c4a-abea-46cc8be3a823","added_by":"auto","created_at":"2022-10-04 13:52:47","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":613881,"visible":true,"origin":"","legend":"\u003cp\u003eA: Photographic image of the double row of staples (arrow) in lung lobe lung. B: Photographic image of the RCLL (G4) showing air leakage (arrow) at supraphysiological pressure at 19 mmHg (25.83 cmH2O).\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-1965208/v1/047d2551299bdb1afac64a7f.png"},{"id":27321449,"identity":"11c1e587-71fd-4bad-9347-4f676af2e842","added_by":"auto","created_at":"2022-10-04 13:57:47","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":500785,"visible":true,"origin":"","legend":"\u003cp\u003eA: Photographic image of the Glubran-2 adhesive in lung lobe. Note the sealant in bronchioles (arrow). B: Photographic image of the RCLL (G5) showing air leakage (arrow) at supraphysiological pressure at 80 mmHg (108.76 cmH2O) in a resected area during aerostasis test.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-1965208/v1/1fde6525e4fb689c1fef34e6.png"},{"id":27322125,"identity":"c614a18e-9ad9-4c14-8dd1-b641e276ff89","added_by":"auto","created_at":"2022-10-04 14:12:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5301940,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1965208/v1/25881670-82ab-4f09-b262-cc69dc2ee30a.pdf"},{"id":27321187,"identity":"a4c1e4ae-3d29-4e4f-84ca-57ae9142ba38","added_by":"auto","created_at":"2022-10-04 13:52:47","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":641771,"visible":true,"origin":"","legend":"","description":"","filename":"ANNEXSFILES.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1965208/v1/80f1aa87654e611aa626fe32.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eComparison of Different Synthesis Methods After Partial Pulmonary Lobectomy in Dogs\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003ePulmonary lobectomy is a surgical tecnique occasionally performed in dogs to resect pulmonary tumours, bullae and damaged lung lobes\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. This procedure consists of partial or total lobar resection, depending on the extention of the lesion in the parenchyma\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Although the surgical procedure using manual suture or stapling devices is usually safe, failures, including air leakage and consequent pneumothorax can occur. Postoperative mild pneumothorax can resolve spontaneously or with the use of thoracic drains. However when not treated, severe pneumothorax can result in severe complications and even death\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Various sealing tecniques have been developed to increase the safety of the procedure. Specific tissue glue, as well as the use of different types of staplers, pre tied loop ligatures and vascular sealing devices are now used in veterinary medicine\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Howeverit is not completely known, which sealing method is the safest. Air leaking post lung lobectomy is still a complication reported in dogs with most suture tecniques and sealing devices\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The aim of this study was to investigate the airtigh sealing property and efficacy of the most common suture tecniques and sealing devices after pulmonary lobectomy against physiological and supraphysiological ventilatory pressures.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eSpecimens\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirty dogs cadavers were obtained after euthanasia, following the diagnosis of leishmaniasis at the Zoonosis Control Center. Criteria for inclusion were: mixed breed dogs; weight between 5 and 10 kg; variable body condition score; macroscopically normal respiratory tract during necroscopy. The respiratory tract was removed en block including the larynx, trachea, bronchi and lungs. The experiment was carried out within 12 hours after macroscopic collection of the respiratory block. An appropriately sized endotracheal tube was inserted into the trachea and secured with a nylon seal. Tracheal tube was connected to a calibrated manometer and oxygen gas for positive pressure. All lungs were initially pressurized slowly to 10 mmHg, and then deflated, to check for pre-existing atelectasis and/or previous air leakage before performing the experiment. The RCLL was chosen and the partial lobectomy was performed, followed by tissue sealing and aerostasis assesment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePulmonary lobectomy sealing methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe five experimental groups are listed in the table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eTable 1\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eDifferent methods of pulmonary synthesis organized into five experimental groups.\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.87612208258528%\"\u003e\n \u003cp\u003eGroups\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eTotal n: 30\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.12387791741472%\"\u003e\n \u003cp\u003ePulmonary lobar sealing methods\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.87612208258528%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;n=6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.12387791741472%\"\u003e\n \u003cp\u003eLoborrhaphy with cobbler or Vachetta suture pattern, followed by simple continuous suture\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.87612208258528%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003en=6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.12387791741472%\"\u003e\n \u003cp\u003eLoborrhaphy with overlapping continuous suture associated with simple continuous suture\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.87612208258528%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003en=6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.12387791741472%\"\u003e\n \u003cp\u003eLoborrhaphy with Ford \u003cem\u003einterlocking suture\u003c/em\u003e pattern\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.87612208258528%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003en=6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.12387791741472%\"\u003e\n \u003cp\u003eLoborraphy with metal staples by TA linear stapler (Covidien\u003csup\u003e\u0026reg;\u003c/sup\u003e) (2 units 45mm reload inserted in opposite directions in to the lobe)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.87612208258528%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003en=6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.12387791741472%\"\u003e\n \u003cp\u003eLoborraphy with 1mL of Glubran-2\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003e(n-butyl cyanoacrylate - NBCA and methacryloisofolane \u0026ndash; MS) synthetic adhesive\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe width and height of the parenchyma in the middle third of the resected RCLL were measured with a calliper. For manual sutures, surgical threads of Polyglactin 910 (coated Vicryl\u0026reg;) of size 4-0 and cylindrical needle were used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePulmonary aerostasis test\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter performing the sealing tecniques, the lungs were placed into a transparent plastic container and submerged in water. The lungs were then inflated and all models were filmed to allow for accurate monitoring and recording of any potential air leak. A leakage was considered only when air bubbles were visualized at the level of the suture line or on the surface of the cut. Any occurrence of air leakage was recorded at physiological pressure (up to 20 cmH\u003csub\u003e2\u003c/sub\u003eO or 14.7 mmHg) or supraphysiological if above 15 mmHg. The value of air pressure at which any leakage occurred was also recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor statistical analysis, the software GraphPadPrism v. 6.02 was used. Differences with a p value less than 0.05 (p \u0026lt; 0.05) were considered significant. The cadavers were randomized into five groups of six. The Kolmogorov-Smirnov test was used to assess the normality of the variables studied. The homogeneity of the groups was evaluated by comparing body weight, body score, height and width of the RCLL. The comparison of the means between the groups, of the parametric variable with normal distribution (body weight), was performed by ANOVA and Fisher\u0026apos;s ad-hocTukey test. The comparison of the medians for the non-parametric variable (body score) and for those with non-normal distribution (height and width of the lobe) was performed using the Kruskall-Wallis ad-hocDunns test. The pressure related to the air leaks also showed a non-normal distribution and, therefore, the medians between the groups were compared by the same test. Furthermore, the groups were compared regarding the aerostatic variable, that is, whether or not there is air leakage, under physiological ventilatory pressures considered up to 20 cmH\u003csub\u003e2\u003c/sub\u003eO, using the Kurskall-Wallis ad-hocDunns test. Fisher\u0026apos;s exact test was also used to evaluate the frequency of distribution in relation to leakage \u0026nbsp;under physiological pressure, according to the sealing methods.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll the five groups analyzed were homogeneous in terms of body weight (p=0.1901) and lung lobe width (p=0.0637). However, they differed in the median for the body condition score (p=0.0202) and lung lobe height (p=0.0347). Regarding the body condition score of the animals used in this study, there was a statistical difference only between the medians of groups G1 (cobbler suture followed by simple continuous suture) and G3 (Ford \u003cem\u003einterlocking suture\u003c/em\u003e). Lung lobe height differed only between groups G4 (surgical staplers) and G5 (synthetic glue) (Figure 1).\u003c/p\u003e\n\u003cp\u003eThe pressure in mmHg needed to cause lung lobe air leakage varied according to the type of sealing tecniques, as shown in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eTable 2\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eValues referring to extravasation pressures in mmHg by type of lobar synthesis (mmHg).\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"11.838440111420613%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.384401114206128%\"\u003e\n \u003cp\u003eCobbler suture + simple continuous suture\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eG1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"25.069637883008358%\"\u003e\n \u003cp\u003eOverlapping continuous suture + simple continuous suture\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eG2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.384401114206128%\"\u003e\n \u003cp\u003eFord \u003cem\u003einterlocking suture\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eG3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.192200557103064%\"\u003e\n \u003cp\u003eStaples\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eG4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.13091922005571%\"\u003e\n \u003cp\u003eSynthetic\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eglue\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eG5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"11.838440111420613%\"\u003e\n \u003cp\u003eLung lobe 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.676880222841227%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.77715877437326%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.384401114206128%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.192200557103064%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.13091922005571%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"11.838440111420613%\"\u003e\n \u003cp\u003eLung lobe 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.676880222841227%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.77715877437326%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.384401114206128%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.192200557103064%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.13091922005571%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"11.838440111420613%\"\u003e\n \u003cp\u003eLung lobe 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.676880222841227%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.77715877437326%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.384401114206128%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.192200557103064%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.13091922005571%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"11.838440111420613%\"\u003e\n \u003cp\u003eLung lobe 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.676880222841227%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.77715877437326%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.384401114206128%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.192200557103064%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.13091922005571%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"11.838440111420613%\"\u003e\n \u003cp\u003eLung lobe 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.676880222841227%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.77715877437326%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.384401114206128%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.192200557103064%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.13091922005571%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"11.838440111420613%\"\u003e\n \u003cp\u003eLung lobe 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.676880222841227%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.77715877437326%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.384401114206128%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.192200557103064%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.13091922005571%\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAlthough some experimental units demonstrated a rupture in physiological pressures in groups G1, G3 and G4, there was no difference between the groups (p = 0.3263).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The pressure needed to cause air leakage in the lung lobe sutured with Ford \u003cem\u003einterlocking suture\u003c/em\u003e (G3) and TA stapler (G4) was lower than the synthetic glue (G5), with p=0.0164 (Table 3) (Figure 2). There were not statistical significant difference (p=0.2873) in the sealing methods efficacy against physiological pressure (up to 20 cmH\u003csub\u003e2\u003c/sub\u003eO or 15 mmHg). However while the G2 (overlapping continuous suture) and G5 (synthetic glue) did not have any air leakage at phisiological air pressure, aerostasis failure was observed in 1/6 in s G1 (cobbler suture + continuous simple suture 2/6 in G3 (Ford \u003cem\u003einterlocking suture\u003c/em\u003e), and 2/6 in G4 (stapling device).\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eTable 3\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eValues of the mean, median, standard deviation and 95% confidence interval for the values of the groups analyzed regarding the variable extravasation pressure.\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"26.286509040333797%\"\u003e\n \u003cp\u003eGroups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"11.821974965229485%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.21279554937413%\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.46453407510431%\"\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"34.21418636995828%\"\u003e\n \u003cp\u003eConfidence interval 95%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.441295546558706%\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.15384615384615%\"\u003e\n \u003cp\u003eHigher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.4048582995951417%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.25%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; G1 (Cobbler suture + simple continuous suture)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.805555555555555%\"\u003e\n \u003cp\u003e20.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.194444444444445%\"\u003e\n \u003cp\u003e20.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.444444444444445%\"\u003e\n \u003cp\u003e5.279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.333333333333332%\"\u003e\n \u003cp\u003e14.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.833333333333334%\"\u003e\n \u003cp\u003e25.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.1388888888888889%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.25%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eG2 (Overlapping continuous suture + simple continuous suture)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.805555555555555%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.194444444444445%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.444444444444445%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.345\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.333333333333332%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.833333333333334%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.1388888888888889%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.25%\"\u003e\n \u003cp\u003e\u0026nbsp; G3 (Ford \u003cem\u003einterlocking suture\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.805555555555555%\"\u003e\n \u003cp\u003e17.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.194444444444445%\"\u003e\n \u003cp\u003e17.00\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.444444444444445%\"\u003e\n \u003cp\u003e4.167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.333333333333332%\"\u003e\n \u003cp\u003e13.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.833333333333334%\"\u003e\n \u003cp\u003e22.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.1388888888888889%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.25%\"\u003e\n \u003cp\u003eG4 (Staples)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.805555555555555%\"\u003e\n \u003cp\u003e17.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.194444444444445%\"\u003e\n \u003cp\u003e18.50\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.444444444444445%\"\u003e\n \u003cp\u003e4.401\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.333333333333332%\"\u003e\n \u003cp\u003e12.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.833333333333334%\"\u003e\n \u003cp\u003e21.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.1388888888888889%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"26.25%\"\u003e\n \u003cp\u003e\u0026nbsp;G5 (Synthetic\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eglue)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.805555555555555%\"\u003e\n \u003cp\u003e46.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.194444444444445%\"\u003e\n \u003cp\u003e40.00\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.444444444444445%\"\u003e\n \u003cp\u003e20.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.333333333333332%\"\u003e\n \u003cp\u003e24.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.833333333333334%\"\u003e\n \u003cp\u003e68.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.1388888888888889%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThere was a difference between G5 in relation to G3 and G4, with p = 0.0164. Medians followed by distinct letters differ from each other at a 5% significance level.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe physiological ventilatory pressure considered in this study was 20 cmH\u003csub\u003e2\u003c/sub\u003eO (15 mmHg). According veterinary guidelines, pressure levels on lung tissue from 15 to 25 cmH\u003csub\u003e2\u003c/sub\u003eO can be considered physiological\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. However, pressure values ​​of 15 to 20 cmH\u003csub\u003e2\u003c/sub\u003eO are considered more accurate for small animals under normal respiratory mechanics conditions\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. In one study, aerostasis was considered safe when air leakage occurr at ventilatory pressures greater than 20 cmH\u003csub\u003e2\u003c/sub\u003eO after a lung biopsy in anesthetised dogs\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In another experimental study evaluating different types of surgical staplers, air leakage at a ventilatory pressure equal to or less than 20 cmH\u003csub\u003e2\u003c/sub\u003eO was considered not safe and the sealing device inadequate\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Sealing methods probably should withstand a ventilatory pressure of the airways of up to 20 cmH\u003csub\u003e2\u003c/sub\u003eO to be considered safe. All the methods used for sealing that were investigated in this study were effective against established physiological ventilatory pressure.\u003c/p\u003e \u003cp\u003eThe canine lung model used wasmacroscopically normal butit was obtained from dogs with leishmaniasis. Most of the dogs were clinically unwell which resulted in different body conditions score between the groups. The body condition score values\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e ​​of G3 were lower (1\u0026ndash;3), compared to G1 (3\u0026ndash;7). However, there was not a statistical difference in the aerostatic property of these groups. Despite difference between median lung lobe height of G4 (Md\u0026thinsp;=\u0026thinsp;12.12 cm) and G5 (Md\u0026thinsp;=\u0026thinsp;19.47 cm), G5 showed superiority sealing property under supraphysiological pressures compared to the median obtained by G4, which proves that even with a larger surface area to be sealed, the synthetic glue was still able to withstand against high pressures ventilation, ensuring greater aerostatic safety than the staples device.\u003c/p\u003e \u003cp\u003eOne of the manual sutures used and analyzed in this study was the cobbler suture\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA) which ensured good sealing in almost all the lung lobes (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). However one developed air leakage, at the pressure of 14 mmHg (=\u0026thinsp;19.03 cmH\u003csub\u003e2\u003c/sub\u003eO). The punctual air leak detected in the place where the suture was contained, possibly corroborates the observation described by other authors when evaluating the double-layer mattress suture in sheep lungs after partial resection of one of the lobes\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The authors observed minimal air leakage along the parenchyma when the lungs were inflated to 40 mmHg and explained that this was due to the portion of the parenchyma along the needle incisions. Thus, the small leak detected in 1/6 model after cobbler suture probably occurred when the needle passed through the tissue. However, there were no statistical differences between the models analyzed in the present study. The successful aerostasis observed in this group can be attributed to the increase in tissue contact surface caused by this suture pattern, which ensured sufficient sealing against physiological ventilatory pressures.\u003c/p\u003e \u003cp\u003eThe overlapping continuous suture (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA) used in G2 has been described for lung sealing after partial lobectomy in dogs and cats\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. This is a manual suture pattern defined as a pneumostatic suture, once it results in additional compression of the parenchyma \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The results found in this study confirm the efficacy of this suture patternin maintain aerostasis against physiological ventilatory pressures (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003eThe third manual suture investigated (G3) was the Ford interlocking suture pattern (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA), characterized by a modified continuous suture and frequently used in soft tissue surgeries in order to withstand some degree of tissue tension\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Such sealing suture also demonstrated a good aerostasis, although two of the models showed air leakage at physiological ventilatory pressures. It is worth mentioning that so far, there are no references in the veterinary literature regarding the use of the Ford interlocking suture pattern in loborraphy after partial lung lobectomy in dogs. This suture pattern is indicated for the correction of lacerations of the lung parenchyma in humans, since it promotes good adhesion of its edges, and therefore hemostasis\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. This suture brings the margins closer providing an effective seal. Despite the lack of studies with the Ford interlocking suture technique in dogs in vivo, this sealing tecnique could be a safe option after partial pulmonary lobectomy in dogs. Two out of six cadaver models in the Ford interlocking suture group failed to achieve aerostasis when the ventilatory pressure reached a value of 19.03 cmH\u003csub\u003e2\u003c/sub\u003eO (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eB). In both cases, along the suture line, there was no leakage, except for a single laceration point lateral to the suture line. When the ventilatory pressure wasincreased, the tissue tension in the lobe was probably higher in certain points, which may have caused a punctual laceration, and consequent leakage of air\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the group of lung lobes in which the mechanical suture was performed with metal staples using the TA linear surgical stapler, the results showed a good response in terms of aerostasis, with no difference compared to the other groups. However two out of six cases failed due to air leakage laterally to the staple line, at physiological ventilatory pressures of 13.59 cmH\u003csub\u003e2\u003c/sub\u003eO and 19.03 cmH\u003csub\u003e2\u003c/sub\u003eO. The effective aerostasis with mechanical stapling sealing devices and observed in the present experimental study was also reported by other authors\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The safe use of staples has been previously demonstrated in nearly 40 dogs and cats undergoing pulmonary lobectomy for the treatment of different conditions\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. In this study only two patients developed pneumothorax in the postoperative period\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. In an \u003cem\u003eex vivo\u003c/em\u003e study with lung biopsy in dogs, airway leakage occurred at pressure of 28 cmH\u003csub\u003e2\u003c/sub\u003eO. However this was achieved using an EndoGIA 45 mm endoscope stapler\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In another study, also using a stapler during thoracoscopy, eight dogs were submitted to partial and total pulmonary lobectomies, and although the pulmonary inflation pressure was not mentioned, all animals were discharged without intraoperative complications after loborraphy with surgical staples\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. In a clinical study two main conventional methods of pulmonary sealing were compared after partial lobectomy in eight dogs. It was found that the mechanical suture with staplers was superior over manual suture with non-absorbable material\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The authors concluded that staples could be superior as it achieves an equal distribution along the parenchyma, while manual suture, are more likley to depend on the surgeons tecnique which may lead to variability in tissues sealing distribution\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Furthermore, the efficacy of surgical staples over manual sutures has been proven in humans undergoing pulmonary lobectomy\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. The authors also believe that manual suturing depends on the surgeon's experience and skills, and manual suturing could cause more air leakage caused by the passage of the needle throughout the pulmonary parenchyma\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. However, in the present study, there was no statistical difference regarding the efficacy of aerostasis between manual and mechanical sutures. However, in the present study, aerostasis promoted by mechanical suturing was achieved by ensuring the insertion of staples for all the lenght of the sectioned parenchyma \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. To avoid air leakage due to failure of inserted staples, two blue cartridges with a total width of 45 mm each were used, containing a double row of staples (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eA). The width x height dimension of each of these staples when opened was 4.0 x 3.5 mm. Both cartridges were inserted in opposite directions in the lobe, in order to ensure that the lateral ends of the parenchyma to be stapled were all completely covered by staples, thus avoiding air leakage from uncovered areas. The presence of a wider cartridge, such as the 60 mm one, could haved replaced the use of the two cartridges used in the study.\u003c/p\u003e \u003cp\u003eAn interesting observation is that the leg length of the staple in \u003cem\u003emm\u003c/em\u003e did not match the thickness of the tissue to which it was inserted. According to the type of surgical stapler used in this study, the blue cartridge of the TA linear stapler has a leg length of 3.5 mm when open, with a staple height of 1.5 mm when closed\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The veterinary literature recommends that when surgical staples are used in the lung parenchyma, the selection of the height of the staples to be used depends upon the compressed thickness of the tissue\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The discrepancy of the height in vivo should be taken in consideration before deciding the type of staple to apply. However in our study lung lobes with different values ​​of height or parenchyma thickness were used. In the stapling device group, the thinnest parenchyma was 10.89 mm and the largest was 14.33 mm, which means that these values were higher than the standardized heights of the staples used in the study. Despite an incomplete cover of the staple over all the parenchyma to be sealed, air leakage did not occur, since the six lobes of G4 did not show differences at physiological pressures. Probably, the reduced length of the staple when closed, should consider only the diameter of the bronchioles and not the all thickness of the tissue to ensure aerostasis\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. However, the use of staples in pulmonary loborrhaphy in dogs, although considered safe, does not rule out completely the risk of air leakage during intraoperative positive pulmonary ventilation as observed in the two out of six models in the staples group. Air leakage has been documented at the staples site under physiological ventilatory pressures, in other studies with dog\u0026rsquo;s lung\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In a study evaluating three different models of surgical staplers used in the pulmonary loborrhaphy of canine cadavers, the rupture pressure at the stapling line seldom occurred at values equal to or less than 20 cmH\u003csub\u003e2\u003c/sub\u003eO\u003csup\u003e1\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Air leakage along the stapling line was reported by other authors when using an EndoGia 45 mm endoscopic stapler. When performing lung lobe biopsy in vivo in dogs and comparing Endo Gia 45 mm with vascular sealing devices and sutures, air leak was found at the stapler site and possibly caused by staple trauma to the parenchyma. The authour concluded that the stapler device was considered safe because the median pressure values of air leakage was not less than 20 cmH\u003csub\u003e2\u003c/sub\u003eO\u003csup\u003e1\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. At high positive pressure he inserted staples can lacerate the lung tissue, resulting in wider orifices and consequent air leakage\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e even at pressures around 20 to 25 cmH\u003csub\u003e2\u003c/sub\u003eO. This is the likely explanation for what may have caused air leackage in the two models in the staples group (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eB). Although the superiority of mechanical suturing has been reported, an additional manual suture over the staple line used for partial pulmonary loborrhaphy may be necessary to control parenchymal leakage and bleeding\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. This suture reinforcement in the stapling line is also recommended by other authors, and can be performed with additional stapling or with manual suturing over the area of air leakage\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Complementing the staple line with other surgical suture or devices could guarantee better resistance at supraphysiological levels of ventilatory pressure\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. However this was not evaluated in our study.\u003c/p\u003e \u003cp\u003eThe effective sealing property provided by the Glubran-2\u0026reg; surgical sealant (G5) did not result in aerostasis failure in any of the six lungs when challenged by physiological ventilatory pressure. Air leakage occurred only at very high ventilatory pressure, with a minimum of 20 mmHg (or 27.19 cmH\u003csub\u003e2\u003c/sub\u003eO) and a maximum of 80 mmHg (or 108.76 cmH\u003csub\u003e2\u003c/sub\u003eO) (Figs.\u0026nbsp;7AB). Similar results were achieved in an experimental study using rabbit lungs and sealant that contains NBCA, one of the monomers present in Glubran-2\u0026reg;. In such study with rabbits the authors demonstrated that of the 12 lung lobes resection, air leakage developed only at supraphysiological ventilatory pressures, ranging from 18.38 to 40.45 mmHg (25 to 55 cmH\u003csub\u003e2\u003c/sub\u003eO)\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Similarly to our study sealing failure occurred only at pressure above 27 cmH\u003csub\u003e2\u003c/sub\u003eO, demonstrating greater safety after pulmonary loborrhaphy in dogs. In the present study, two of the six lobes in the glue group had aerostasis failure, at 60 and 80 mmHg, 4\u0026ndash;5,.4 times higher than the physiological pressure, and above the maximum pressure recorded in the study with rabbit lungs\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Other similar result was reported in an experimental study that used the same type of sealant in 20 sheeps lungs against supraphysiological pressures of 40, 60 and 80 mmHg\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The authors noted that most of the lobes did not present air leakage in the region sealed by the glue, except for a smaller percentage of 20% of the lobes that resulted in minimal degree of air leackage.\u003c/p\u003e \u003cp\u003eThe Glubran-2\u0026reg; sealant is one of the commercial names of NBCA, an important synthetic biodegradable surgical glue, which is modified by the addition of MS monomer. It has been widely used in medicine, such as in urological, gynecological, digestive, neurological, cardiovascular and thoracic surgeries because it demonstrates adhesive, hemostatic and aerostatic properties when applied to diferent tissues\u003csup\u003e29\u0026minus;\u0026thinsp;31\u003c/sup\u003e. Safety and efficacy of this synthetic glue has been reported in cats, swine, rabbits, sheeps and humans\u003csup\u003e10,28,32\u0026minus;\u0026thinsp;35\u003c/sup\u003e. However, so far, no reports have been described or published using the cyanoacrylate co-monomer Glubran-2\u0026reg; in surgeries involving lobectomy in dog\u0026rsquo;s lungs. In a study with six healthy cats after performing partial pulmonary lobectomy, NBCA has effective hemostatic and aerostatic property\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. The results were satisfactory, although the ventilatory pressure used to assess aerostasis was not reported, nor the extent of resected parenchyma. However, due to the absence of clinical significant post-surgical complications and the histopathological evaluation of the patches containing the glue three weeks after surgery, it was concluded that this type of cyanoacrylate would be a safe alternative method for pulmonary loborrhaphy in cats\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. From radiographic examinations, mild asymptomatic pneumothorax was observed only in 4 patients soon after surgery and in 1 patient two days post surgery \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. The sealing property of the glue is due to the formation of a thin elastic film of high strength that molds itself over the tissue, and makes the tissue region firm within 60 to 90 seconds. This is the result of the glue exothermic polymerization after interacting with tissue surface, forming strong bonds with tissue proteins and ensuring strong sealing to the lung tissue at the place where it is applied\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. In the experimental study with rabbit lungs local and systemic effects were investigated after the use of the synthetic cyanoacrylate sealant. It was macroscopically observed that the portion of the lung parenchyma that was glued had an altered texture and hardened consistency for almost a month after being applied. This highlights the efficacy of the sealing property of this product for pulmonary aerostasis\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. In the current study, although no difference was observed between the groups regarding rupture under physiological pressure, the sealing promoted by the synthetic glue containing NBCA was able to ensure an efficient aerostasis also at supraphysiological ventilation pressures. The median pressure of rupture in G5 (Glubran-2\u0026reg;) was superior to observed in G3 (Ford interlocking suture) and G4 (staples).\u003c/p\u003e \u003cp\u003eIn the present study, the canine lung lobes of the 3 groups that received the different manual sutures made with the same type of surgical material, were not able to achieve aerostasis at pressure levels of 40 mmHg,. Similarly, as demonstrated in the study carried out with sheeps lungs after partial lobectomy, all lobes that received manual sutures failed aerostasis after applyng this pressure\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. However, among the manual sutures analyzed in the current study, only the group that received the Ford interlocking suture showed a significantly lower difference compared to the group that received the synthetic glue. The air leak observed in the manual suture line proved to come from the place where the needle passed in the parenchyma\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Similar to our study, the authors concluded that the aerostasis promoted by the sealing performed by the manual suture, was inferior to the sealing performed by the synthetic glue, in all 20 sheeps lungs evaluated at high ventilatory pressure\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study synthetic cyanoacrylate adhesive was significantly superior to the manual Ford interlocking suture, and to mechanical suturing by staples. The excellent seal maintained by the synthetic glue can be explained by the low viscosity of the sealant when in liquid phase filling the small gaps and creating better sealing between the cutting surfaces of the lung than other sealing methods\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. The glue also does not create physical injury to the lung parenchyma, as the tissue trauma caused by the needle and staples\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe main limitation of this study is the experimental model. The lungs were evaluated outside the thoracic cavity, a condition that prevents adequate lung distension and retraction during the respiratory cycle\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Under laboratory conditions accurate assessment of the sealing methods against physiological variations of ventilatory pressures is not completely possible. On post mortem examination the lungs appeared macroscopically normal and the experiment carried out within a few hours after death. However this is not completely comparable to a lung in a physiological condition. Therefore, the safety and eficacy data of aerostasis in all the methods evaluatedin this experimental model, should not be completely and safely extrapolated for dogs in vivo. Another limitation regards the collection of lungs from patients, diagnosed with leishmaniasis. It is possible that microscopic lung lesions could be present at the time of the study, without being macroscopically visible. \u003cem\u003eLeishmania sp\u003c/em\u003e is known to cause histological changes including mild to severe peribronchial inflammatory infiltration, fibroblast proliferation in lung tissues, edema and congestion in the alveolar wall, but histological examination of the lungs in this study were not performed\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. Microscopic changes, whether caused by \u003cem\u003eLeishmania sp\u003c/em\u003e or some subclinical respiratory disease, could interfere with lung compliance and adequate sealing, resulting in rupture at lower pressures, and could justify some results of this study\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe result of this study proved the safety and efficacy of all investigated sealing methods after partial lobectomy in the middle third of the right caudal lung lobe of dogs. There was no difference at physiological ventilatory pressures (20 cmH\u003csub\u003e2\u003c/sub\u003eO). However, greater efficacy was achieved by the surgical tissue glue Glubran-2\u0026reg; at supraphysiological ventilatory pressures (greater than 20 cmH\u003csub\u003e2\u003c/sub\u003eO). Glubran-2\u0026reg; was superior to the Ford interlocking suture and the TA 45 mm linear surgical stapler, but no difference was found between Glubran-2 and cobbler suture associated with simple continuous and overlapping continuous with simple continuous suture.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eRCLL: Partial lobectomy of the right caudal lung lobe\u003c/p\u003e\n\u003cp\u003eNBCA: n-butyl cyanoacrylate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMS: Methacryloisofolane \u003c/p\u003e"},{"header":"Declarations","content":"\u003ch4\u003eAcknowledgements\u003c/h4\u003e\n\u003cp\u003eWe thank CAPES for all the financial support.\u003c/p\u003e\n\u003ch4\u003eAuthors\u0026apos; contributions\u003c/h4\u003e\n\u003cp\u003eAll authors contributed to the study conception. Horta RS., DVM, MS, PhD conceived the idea presented, being complemented by Freitas PMC., DVM, MS, PhD and Silva, PHS., DVM, MS.Freitas PMC., DVM, MS, PhD and Horta RS., DVM, MS, PhD supervised the experiment. Silva, PHS., DVM, MS carried out the experiment with Lopes CEB., DVM; Stallmach LB., DVM; Ferreira LO., DVM and Pimentel PAB., DVM. Silva, PHS., DVM, MS wrote the manuscript, with the help of Giuliano A., DVM, MS, PhD; Freitas PMC., DVM, MS, PhD and Horta RS., DVM, MS, PhD. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch4\u003eFunding\u003c/h4\u003e\n\u003cp\u003eThis work was supported by funds from Coordination for the Improvement of Higher Education Personnel (CAPES).\u003c/p\u003e\n\u003ch4\u003eAvailability of data and materials\u003c/h4\u003e\n\u003ch4\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/h4\u003e\n\u003ch4\u003eEthics approval and consent to participate\u003c/h4\u003e\n\u003cp\u003eThis study was approved by the Ethical Committee on Animal Use (CEUA) of the Federal University of Minas Gerais (UFMG), under protocol number 236/2020.\u003c/p\u003e\n\u003ch4\u003eConsent for publication\u003c/h4\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch4\u003eCompeting interests\u003c/h4\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBleakley S, Duncan CG, Monnet E. 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A comparison of a cyanoacrylate [corrected] glue (Glubran) vs. fibrin sealant (Tisseel) in experimental models of partial pulmonary resection and lung incision [corrected] in rabbits [published correction appears in J Invest Surg. 2010;23(2):124]. J Invest Surg. 2010;23(1):40-47. doi: 10.3109/08941930903469383.\u003c/li\u003e\n \u003cli\u003eDavoli F, Sellitri F, Brandolini J, et al. Use of coagulant spray glue (Glubran 2) for aerostatic purposes in pulmonary parenchyma resections in pigs: a preliminary study. Eur Surg Res. 2009;43(4):360-364. doi: 10.1159/000248334.\u003c/li\u003e\n \u003cli\u003eAllama AM, Abd Elaziz ME. Using tissue glues for decreasing alveolar air leak in thoracic surgery. Asian Cardiovasc Thorac Ann. 2019;27(5):369-373. doi: 10.1177/0218492319841734.\u003c/li\u003e\n \u003cli\u003eCarvalho MVH, Marchi E, Fruchi AJ, et al. Local and systemic effects of fibrin and cyanoacrylate adhesives on lung lesions in rabbits. Clinics (Sao Paulo). 2017;72(10):624-628. doi: 10.6061/clinics/2017(10)06.\u003c/li\u003e\n \u003cli\u003eWilson W, Benumof J. Physiology of the Airway. In: Hagberg C. Benumof and Hagberg\u0026apos;s Airway Management. USA: Saunders; 2013. p. 118-158. https://clinicalgate.com/physiology-of-the-airway/Accessed Dec 2021.\u003c/li\u003e\n \u003cli\u003eAlves GB, Pinho FA, Silva SM, Cruz MS, Costa FA. Cardiac and pulmonary alterations in symptomatic and asymptomatic dogs infected naturally with Leishmania (Leishmania) chagasi. Braz J Med Biol Res. 2010;43(3):310-315. doi: 10.1590/s0100-879x2009007500037.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-veterinary-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Veterinary Research](http://bmcvetres.biomedcentral.com/)","snPcode":"12917","submissionUrl":"https://submission.nature.com/new-submission/12917/3?","title":"BMC Veterinary Research","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cyanoacrylates, Lungs, Pneumostasis, Surgical technique","lastPublishedDoi":"10.21203/rs.3.rs-1965208/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1965208/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Pulmonary loborraphy can be performed using manual sutures and staples, although other methods such as tissue adhesives are also cited in the veterinary literature. However, despite the wide availability, no efficient suture material has yet been recognized that is completely safe in preventing any air leakage, a complication that is heavily investigated in medicine and not uncommon in veterinary medicine, despite the few studies and reports in dogs. Although the surgery is well tolerated in the canine species, failure in pulmonary aerostasis is still a reality, since all the methods described so far eventually lead to air leakage after the use of the partial lobectomy technique in the lungs. Within this context, the aim of this research was to compare the effectiveness of different hermetic sealing methods after partial lobectomy of the right caudal lung lobe (RCLL) in dogs. Using 30 cadaver models of canine lungs obtained immediately after death. The 30 cadavers models were divided in 6 groups: G1 - cobbler suture associated with simple continuous; G2 - overlapping continuous suture associated with simple continuous suture; G3 - Ford\u0026nbsp;\u003cem\u003einterlocking suture\u003c/em\u003e; G4 - Stapling device; G5 - Tissue glue (cyanoacrylate). After performing the sealing techniques, the lungs were submerged in water, inflated with oxygen at positive ventilatory pressures at physiological (20 cmH\u003csub\u003e2\u003c/sub\u003eO) and supraphysiological levels (above 20 cmH\u003csub\u003e2\u003c/sub\u003eO) to evaluate the performance of the sealing methods and to asses the level of ventilatory pressures at which air leakage occur.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e At physiological ventilatory pressure levels there was no difference between groups. However, when evaluating such methods at ventilation pressure levels above 20 cmH\u003csub\u003e2\u003c/sub\u003eO, it was found a superiority of G5 over G3 and G4. \u003cstrong\u003eConclusion:\u003c/strong\u003e Manual sutures, as well as staples and synthetic tissue glue were able to promote aerostasis after partial lobectomy of the RCLL at physiological ventilatory pressures. Sealing with surgical glue was superior to Ford\u0026nbsp;\u003cem\u003einterlocking suture\u003c/em\u003e and stapling device at supraphysiological levels of ventilatory pressure. This study supports the efficay of all manual, mechanical sutures and synthetic glue sealant when used after partial lobectomy in dogs.\u003c/p\u003e","manuscriptTitle":"Comparison of Different Synthesis Methods After Partial Pulmonary Lobectomy in Dogs","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-10-04 13:52:44","doi":"10.21203/rs.3.rs-1965208/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2022-09-28T13:00:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"BMC Veterinary Research","date":"2022-09-07T13:54:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-08-16T06:42:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Veterinary Research","date":"2022-08-16T00:56:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-veterinary-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Veterinary Research](http://bmcvetres.biomedcentral.com/)","snPcode":"12917","submissionUrl":"https://submission.nature.com/new-submission/12917/3?","title":"BMC Veterinary Research","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3ca0b84f-6232-4d4d-b1b0-5db4943ac932","owner":[],"postedDate":"October 4th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-10-04T13:52:45+00:00","versionOfRecord":[],"versionCreatedAt":"2022-10-04 13:52:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1965208","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1965208","identity":"rs-1965208","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}