Effectiveness of surgical sealants in reducing prolonged air leaks after pulmonary resection: A systematic review

OBJECTIVES: Prolonged air leak (PAL) is the most common complication following pulmonary resection, leading to increased morbidity, hospital stay, and healthcare costs. Although staplers are currently the standard for lung parenchymal closure, air leaks remain frequent. Surgical sealants have been introduced as adjuncts to staplers to reduce PAL, but evidence remains inconsistent. Prior systematic reviews frequently pooled together stapled and sutured resections, limiting applicability to contemporary practice. This review specifically evaluates whether surgical sealants reduce the incidence and duration of PAL when used with staplers in adult patients. METHODS: This systematic review followed PRISMA guidelines and was registered on PROSPERO (CRD420251064592). A literature search was conducted in PubMed, Ovid MEDLINE, and Cochrane Library for studies published between 2005 and June 2025. Eligible studies included adult patients undergoing stapler-based pulmonary resection comparing sealants plus staplers versus staplers alone. Risk of bias was assessed using the RoB 2 and ROBINS-I tools. RESULTS: Eight studies were included. Surgical sealants studied included fibrin-based (autologous fibrin sealant, fibrin sealant patch, human fibrin Sealant) and synthetic polymers (polyethylene glycol hydrogel sealant, cyanoacrylate-based sealant). Most studies reported a statistically significant reduction in PAL incidence and/or duration with sealant use. Some also showed reduced chest tube duration and hospital stay, though not always statistically significant. One study showed worse outcomes in the sealant group. No study reported increased complications. Subgroup analyses were limited. CONCLUSIONS: Sealants used with staplers may reduce PAL incidence and duration, particularly in high-risk patients, without increased complications. However, variability in study design and limited subgroup data weaken current evidence. Larger, standardised randomized controlled trials are needed to confirm clinical benefit and inform routine use.