M. Zakkar et al. / Interactive CardioVascular and Thoracic Surgery
CLINICAL BOTTOM LINE The risk of BPF development post-lung resection can be multifactorial. There is actually very little objective evidence of the superiority of manual stump closure over mechanical stapling closure in anatomical lung resection. Furthermore, there is very little objective evidence regarding the superiority of either technique in terms of training opportunities. Further studies are needed to assess safety, effectiveness and training variation between the two approaches. Conflict of interest: none declared.
REFERENCES [1] Dunning J, Prendergast B, Kway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003; 2:405–9. [2] Asamura H, Kondo H, Tsuchiya R. Management of the bronchial stump in pulmonary resections: a review of 533 consecutive recent bronchial closures. Eur J Cardiothorac Surg 2000;17:106–10. [3] Sonobe M, Nakagawa M, Ichinose M, Ikegami N, Nagasawa M, Shindo T. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer. Eur J Cardiothorac Surg 2000;18:519–23. [4] Sirbu H, Busch T, Aleksic I, Schreiner W, Oster O, Dalichau H. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001;7:330–6.
[5] Uçvet A, Gursoy S, Sirzai S, Erbaycu AE, Ozturk AA, Ceylan KC et al. Bronchial closure methods and risks for bronchopleural fistula in pulmonary resections: how a surgeon may choose the optimum method?. Interact CardioVasc Thorac Surg 2011;12:558–62. [6] Al-Kattan K, Cattelani L, Goldstraw P. Bronchopleural fistula after pneumonectomy for lung cancer. Eur J Cardiothorac Surg 1995;9:479–82. [7] Deschamps C, Bernard A, Nichols FC III, Allen MS, Miller DL, Trastek VF et al. Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence. Ann Thorac Surg 2001;72:243–7. [8] Wright CD, Wain JC, Mathisen DJ, Grillo HC. Postpneumonectomy bronchopleural fistula after sutured bronchial closure: incidence, risk factors, and management. J Thorac Cardiovasc Surg 1996;112:1367–71. [9] Panagopoulos ND, Apostolakis E, Koletsis E, Prokakis C, Hountis P, Sakellaropoulos G et al. Low incidence of bronchopleural fistula after pneumonectomy for lung cancer. Interact CardioVasc Thorac Surg 2009;9: 571–5.
eComment. Bronchial stump closure techniques: experimental and histological diversity Authors: Eleftherios Spartalis, Antonios Athanasiou, Vaios Kaminiotis and Periklis Tomos 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens, Greece doi: 10.1093/icvts/ivt556 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We read with great interest the article entitled ‘No evidence that manual closure of the bronchial stump has a lower failure rate than mechanical stapler closure following anatomical lung resection’ by Zakkar et al. [1]. This thorough and well-designed review showed that there is a lack of clinical evidence to either support or counter the superiority of one technique over the other regarding lower failure rates after lung resection. There are, however, several experimental studies that report an interesting variety of results. Two of the major advantages of animal trials are the resistance test and histological examination of the bronchial stump after euthanasia, which allow detailed investigation of the morphological aspects. It has been demonstrated that the sutured bronchial stump heals primarily through secondary closure [2]. Therefore, it is speculated that the level of attachment between the stump and surrounding tissues, and the magnitude of granulation tissue formation at the bronchial stump, should be important factors in stump healing or broncho-pleural fistula formation. In order to investigate the healing process, Izumi et al. [2] examined the bronchial stump one week after right upper lobectomy in dogs, and compared the morphology between stapler and manual suture closure. The incidence of adhesion formation between the surrounding tissues, the thickness of granulation tissue over the stump and its vessel density were significantly reduced in the stapler group in comparison to the suture group. Other studies aimed to determine the resistance to pressure of a bronchial stump depending upon the closure technique. Bof et al. [3] concluded that mechanical suture of the bronchial stump, submitted to pressure immediately after closure, is more resistant than manual suture in dogs submitted to pneumonectomy. Two years before, Ludwig et al. [4] conducted a similar study using sheep as an animal model. A statistically significant difference existed between the two groups, demonstrating that the resistance to pressure of the mechanical suture was better than that of the manual suture. In contrast to the results obtained in this study on freshly slaughtered pig tracheae, the same research team reported that 14 days after pneumonectomy, under ideal conditions, there was no longer any difference in favour of the automatic stapling device. The higher stability and therefore the increased resistance to pressure of the mechanical suture disappears once the bronchial stump has healed, becoming equal to that of the manual suture [4]. It is a fact that experimental studies show diverse results. Bronchial stump closure techniques, their histological healing patterns and possible bronchial stump complications after pneumonectomy need further experimental and clinical investigation. The new strategy should also aim to enhance and promote the tissue healing cascade by introducing an efficient and cost-effective adhesive substance for intraoperative application to the bronchial stump [5], regardless of the closure technique. Conflict of interest: none declared
BEST EVIDENCE TOPIC
characteristics. This has to be assessed carefully, especially in pneumonectomy and co-factors. The manual closure seems to be the more preferable method in high-risk patients. An additive support suture following stapling on the bronchial stump did not decrease the risk of BPF. Deschamps et al. [7] analysed factors affecting the incidence of empyema and BPF after pneumonectomy in 713 patients who underwent pneumonectomy for different conditions. Univariate analysis demonstrated that the development of BPF was significantly associated with bronchial stump reinforcement (P = 0.03). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (P = 0.009). The group concluded that multiple perioperative factors were associated with an increased incidence of BPF after pneumonectomy including the prophylactic reinforcement of the bronchial stump with viable tissue; however, mechanical stump closure had a protective effect against the development of BPFs. It is important to note, however, that although this study did not demonstrate a reduced incidence of BPFs with tissue reinforcement, the group practice included the routine reinforcement of stumps in patients deemed most likely to develop BPFs and therefore represent a selection bias. AI-Kattan et al. [6] studied the outcomes in 471 pneumonectomies that were performed by one surgical team for primary lung cancer. In this study, all operations were performed using a uniform hand suture technique. There were 7 cases of BPF (incidence of 1.5%). This study demonstrated clearly the importance of surgeons’ experience as the senior author performed 374 pneumonectomies with 2 fistulas (0.5%), while other surgeons in training performed 97 pneumonectomies with 5 fistulas (5.1%). The group concluded that suture closure to the bronchial stump after pneumonectomy provides a cheap and reliable technique that is applicable in all situations and can be taught to surgeons in training with an acceptable risk.
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M. Zakkar et al. / Interactive CardioVascular and Thoracic Surgery
References [1] Zakkar M, Kanagasabay R, Hunt I. No evidence that manual closure of the bronchial stump has a lower failure rate than mechanical stapler closure following anatomical lung resection. Interact CardioVasc Thorac Surg 2014;18:488–94. [2] Izumi Y, Kawamura M, Gika M, Nomori H. Granulation tissue formation at the bronchial stump is reduced after stapler closure in comparison to suture closure in dogs. Interact CardioVasc Thorac Surg 2010;10:356–9. [3] Bof AM, Rapoport A, Paulo DN, Leiro LC, Gomes MR, Pando-Serrano RR. Comparative study of the resistance of manual and mechanical sutures in the
bronchial stump of dogs submitted to left pneumonectomy. J Bras Pneumol 2007;33:141–7. [4] Ludwig C, Hoffarth U, Haberstroh J, Schuttler W, Passlick B, Stoelben E. Resistance to pressure of the stump after mechanical stapling or manual suture. An experimental study on sheep main bronchus. Eur J Cardiothorac Surg 2005;27:693–6. [5] Spartalis E, Tomos P, Konofaos P, Karagkiouzis G, Levidou G, Kavantzas N et al. The effect of autologous platelet-rich plasma on bronchial stump tissue granulation after pneumonectomy: experimental study. ISRN Surg 2013;doi.org/ 10.1155/2013/864350.
CLINICAL BOTTOM LINE The risk of BPF development post-lung resection can be multifactorial. There is actually very little objective evidence of the superiority of manual stump closure over mechanical stapling closure in anatomical lung resection. Furthermore, there is very little objective evidence regarding the superiority of either technique in terms of training opportunities. Further studies are needed to assess safety, effectiveness and training variation between the two approaches. Conflict of interest: none declared.
REFERENCES [1] Dunning J, Prendergast B, Kway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003; 2:405–9. [2] Asamura H, Kondo H, Tsuchiya R. Management of the bronchial stump in pulmonary resections: a review of 533 consecutive recent bronchial closures. Eur J Cardiothorac Surg 2000;17:106–10. [3] Sonobe M, Nakagawa M, Ichinose M, Ikegami N, Nagasawa M, Shindo T. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer. Eur J Cardiothorac Surg 2000;18:519–23. [4] Sirbu H, Busch T, Aleksic I, Schreiner W, Oster O, Dalichau H. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001;7:330–6.
[5] Uçvet A, Gursoy S, Sirzai S, Erbaycu AE, Ozturk AA, Ceylan KC et al. Bronchial closure methods and risks for bronchopleural fistula in pulmonary resections: how a surgeon may choose the optimum method?. Interact CardioVasc Thorac Surg 2011;12:558–62. [6] Al-Kattan K, Cattelani L, Goldstraw P. Bronchopleural fistula after pneumonectomy for lung cancer. Eur J Cardiothorac Surg 1995;9:479–82. [7] Deschamps C, Bernard A, Nichols FC III, Allen MS, Miller DL, Trastek VF et al. Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence. Ann Thorac Surg 2001;72:243–7. [8] Wright CD, Wain JC, Mathisen DJ, Grillo HC. Postpneumonectomy bronchopleural fistula after sutured bronchial closure: incidence, risk factors, and management. J Thorac Cardiovasc Surg 1996;112:1367–71. [9] Panagopoulos ND, Apostolakis E, Koletsis E, Prokakis C, Hountis P, Sakellaropoulos G et al. Low incidence of bronchopleural fistula after pneumonectomy for lung cancer. Interact CardioVasc Thorac Surg 2009;9: 571–5.
eComment. Bronchial stump closure techniques: experimental and histological diversity Authors: Eleftherios Spartalis, Antonios Athanasiou, Vaios Kaminiotis and Periklis Tomos 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens, Greece doi: 10.1093/icvts/ivt556 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We read with great interest the article entitled ‘No evidence that manual closure of the bronchial stump has a lower failure rate than mechanical stapler closure following anatomical lung resection’ by Zakkar et al. [1]. This thorough and well-designed review showed that there is a lack of clinical evidence to either support or counter the superiority of one technique over the other regarding lower failure rates after lung resection. There are, however, several experimental studies that report an interesting variety of results. Two of the major advantages of animal trials are the resistance test and histological examination of the bronchial stump after euthanasia, which allow detailed investigation of the morphological aspects. It has been demonstrated that the sutured bronchial stump heals primarily through secondary closure [2]. Therefore, it is speculated that the level of attachment between the stump and surrounding tissues, and the magnitude of granulation tissue formation at the bronchial stump, should be important factors in stump healing or broncho-pleural fistula formation. In order to investigate the healing process, Izumi et al. [2] examined the bronchial stump one week after right upper lobectomy in dogs, and compared the morphology between stapler and manual suture closure. The incidence of adhesion formation between the surrounding tissues, the thickness of granulation tissue over the stump and its vessel density were significantly reduced in the stapler group in comparison to the suture group. Other studies aimed to determine the resistance to pressure of a bronchial stump depending upon the closure technique. Bof et al. [3] concluded that mechanical suture of the bronchial stump, submitted to pressure immediately after closure, is more resistant than manual suture in dogs submitted to pneumonectomy. Two years before, Ludwig et al. [4] conducted a similar study using sheep as an animal model. A statistically significant difference existed between the two groups, demonstrating that the resistance to pressure of the mechanical suture was better than that of the manual suture. In contrast to the results obtained in this study on freshly slaughtered pig tracheae, the same research team reported that 14 days after pneumonectomy, under ideal conditions, there was no longer any difference in favour of the automatic stapling device. The higher stability and therefore the increased resistance to pressure of the mechanical suture disappears once the bronchial stump has healed, becoming equal to that of the manual suture [4]. It is a fact that experimental studies show diverse results. Bronchial stump closure techniques, their histological healing patterns and possible bronchial stump complications after pneumonectomy need further experimental and clinical investigation. The new strategy should also aim to enhance and promote the tissue healing cascade by introducing an efficient and cost-effective adhesive substance for intraoperative application to the bronchial stump [5], regardless of the closure technique. Conflict of interest: none declared
BEST EVIDENCE TOPIC
characteristics. This has to be assessed carefully, especially in pneumonectomy and co-factors. The manual closure seems to be the more preferable method in high-risk patients. An additive support suture following stapling on the bronchial stump did not decrease the risk of BPF. Deschamps et al. [7] analysed factors affecting the incidence of empyema and BPF after pneumonectomy in 713 patients who underwent pneumonectomy for different conditions. Univariate analysis demonstrated that the development of BPF was significantly associated with bronchial stump reinforcement (P = 0.03). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (P = 0.009). The group concluded that multiple perioperative factors were associated with an increased incidence of BPF after pneumonectomy including the prophylactic reinforcement of the bronchial stump with viable tissue; however, mechanical stump closure had a protective effect against the development of BPFs. It is important to note, however, that although this study did not demonstrate a reduced incidence of BPFs with tissue reinforcement, the group practice included the routine reinforcement of stumps in patients deemed most likely to develop BPFs and therefore represent a selection bias. AI-Kattan et al. [6] studied the outcomes in 471 pneumonectomies that were performed by one surgical team for primary lung cancer. In this study, all operations were performed using a uniform hand suture technique. There were 7 cases of BPF (incidence of 1.5%). This study demonstrated clearly the importance of surgeons’ experience as the senior author performed 374 pneumonectomies with 2 fistulas (0.5%), while other surgeons in training performed 97 pneumonectomies with 5 fistulas (5.1%). The group concluded that suture closure to the bronchial stump after pneumonectomy provides a cheap and reliable technique that is applicable in all situations and can be taught to surgeons in training with an acceptable risk.
493
494
M. Zakkar et al. / Interactive CardioVascular and Thoracic Surgery
References [1] Zakkar M, Kanagasabay R, Hunt I. No evidence that manual closure of the bronchial stump has a lower failure rate than mechanical stapler closure following anatomical lung resection. Interact CardioVasc Thorac Surg 2014;18:488–94. [2] Izumi Y, Kawamura M, Gika M, Nomori H. Granulation tissue formation at the bronchial stump is reduced after stapler closure in comparison to suture closure in dogs. Interact CardioVasc Thorac Surg 2010;10:356–9. [3] Bof AM, Rapoport A, Paulo DN, Leiro LC, Gomes MR, Pando-Serrano RR. Comparative study of the resistance of manual and mechanical sutures in the
bronchial stump of dogs submitted to left pneumonectomy. J Bras Pneumol 2007;33:141–7. [4] Ludwig C, Hoffarth U, Haberstroh J, Schuttler W, Passlick B, Stoelben E. Resistance to pressure of the stump after mechanical stapling or manual suture. An experimental study on sheep main bronchus. Eur J Cardiothorac Surg 2005;27:693–6. [5] Spartalis E, Tomos P, Konofaos P, Karagkiouzis G, Levidou G, Kavantzas N et al. The effect of autologous platelet-rich plasma on bronchial stump tissue granulation after pneumonectomy: experimental study. ISRN Surg 2013;doi.org/ 10.1155/2013/864350.
