Modified enhanced pleural fixation: combined intra- and postoperative hypertonic glucose in elderly and high-risk pulmonary bullae patients — a retrospective cohort study

BACKGROUND: Although mechanical pleurectomy effectively prevents recurrent pneumothorax in elderly patients with diffuse emphysematous bullae, it entails substantial surgical trauma and postoperative pain. This study evaluates an enhanced pleurodesis technique-combining intraoperative hypertonic glucose spraying with three-day postoperative intrapleural perfusion-as a minimally invasive alternative. METHODS: A retrospective analysis included 155 patients who underwent thoracoscopic bullectomy: 72 in the glucose protocol group and 83 in the parietal pleurectomy control group. Following 1:1 propensity score matching, 72 well-balanced matched pairs were obtained. RESULTS: The glucose protocol group exhibited significantly improved perioperative outcomes compared with the parietal pleurectomy control group, including shorter operative duration (65.33 ± 2.43 vs. 84.92 ± 2.35 min), reduced intraoperative blood loss (50.00 ± 3.82 vs. 71.89 ± 4.62 mL), lower postoperative chest tube drainage volume (551.39 ± 27.76 vs. 785.42 ± 57.83 mL), shorter chest tube dwell time (4.42 ± 0.17 vs. 5.32 ± 0.21 days), lower pain scores on postoperative day 3 (0.93 ± 0.07 vs. 1.28 ± 0.06), and shorter length of hospital stay (5.04 ± 0.16 vs. 6.31 ± 0.24 days) (all P < 0.05). No significant differences were observed in postoperative complication rates (18.1% vs. 15.3%) or one-year pneumothorax recurrence rates (4.2% vs. 2.8%) between the two groups (both P > 0.05). CONCLUSION: In this retrospective, propensity-score matched cohort study involving elderly high-risk patients with recurrent diffuse pulmonary bullae, an enhanced pleurodesis protocol-comprising intraoperative hypertonic glucose spray followed by three-day postoperative intrapleural perfusion-was associated with significantly improved perioperative outcomes compared with parietal pleurectomy. No statistically significant difference was detected in 1-year recurrence; however, this finding should not be interpreted as evidence of equivalence or non-inferiority because the recurrence analysis was underpowered and no non-inferiority margin was prespecified. These results indicate that the glucose-based protocol may serve as a viable, less invasive alternative to mechanical pleurectomy in this vulnerable population; however, validation through prospective, randomized controlled trials remains essential to establish causality and generalizability.