Scandinavian Journal of Thoracic and Cardiovascular Surgery
ISSN: 0036-5580 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/icdv19
Mechanical and Conventional Manual Sutures of the Bronchial Stump. A Comparative Study of 298 Surgical Patients Árpád Péterffy & Emilio Calabrese To cite this article: Árpád Péterffy & Emilio Calabrese (1979) Mechanical and Conventional Manual Sutures of the Bronchial Stump. A Comparative Study of 298 Surgical Patients, Scandinavian Journal of Thoracic and Cardiovascular Surgery, 13:1, 87-91 To link to this article: http://dx.doi.org/10.3109/14017437909101793
Published online: 12 Jul 2009.
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Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=icdv19 Download by: [University of Sydney Library]
Date: 30 November 2015, At: 06:53
Scand J Thor Cardiovasc Surg 13: 87-91, 1979
MECHANICAL AND CONVENTIONAL MANUAL SUTURES OF THE BRONCHIAL STUMP A Cornpurativr S t d y of 298 Surgicul Patients
Arpad Peterffy and Emilio Calabrese From the Thoracic Surgical Clinic. Karolinsha Sjirkhuset , Stockholm, Sweden
(Submitted for publication October 23, 1978)
Downloaded by [University of Sydney Library] at 06:53 30 November 2015
This paper is dedicated to Professor Viking Olof Bjork on the occasion of his sixtieth birthday, December 3, 1978 Abstract. A U.S.-made TA-30 model stapling device was
utilized to close the bronchial stump in 146 patients, while conventional manual suturing with chromic catgut was performed for the same purpose in 152 patients. The two groups were comparable in respect of pre-operative status and operative diagnosis. Patients, in whom the stapler was utilized, showed a decreased incidence of bronchial fistula ( I 96 vs. 3 % ) and empyema without fistula ( I % vs. 3%). The stapler, compared with conventional manual sutures, allows a simpler and swifter suture of the bronchial stump, reduces the contamination of the operative field, achieves uniform and tighter closure of the bronchus, leaves a better preserved terminal blood perfusion of the stump and utilizes a more tolerated sewing material with less resultant tissue inflammation.
The first automatic sewing machine for stomach sutures was presented by Hiittl in Budapest in 1908. Petz (1924) presented a new model, which is still in use in some countries. The Russians improved stapling devices and began to use them in abdominal, thoracic and vascular surgery. They developed UKB staplers, that placed a single row of staples parallel to the bronchial lumen and later, in 1957, they designed and introduced into clinical practice the UKL-40 and UKL60 models (Amosov & Berezovsky 1961). These mechanical devices, which enjoy widespread use today, place two parallel rows of tantalium staples perpendicularly to the bronchus lumen. In 1960, U.S.-made stapling devices (Auto Suture@)'were introduced and one of them, the TA-30 model, is actually employed at this Clinic for bronchial sutures. In order to study the advantages of the mechanical suture over the conventional hand-made sutures in bronchial stump closure, a series of 298 surgical patients were analyzed and the results are presented in this paper.
CLINICAL MATERIAL During the period 1976-78, 298 patients who underwent lung resection at the Thoracic Surgical Clinic, Karolinska Sjukhuset, Stockholm, were reviewed and divided into two groups. N o sleeve or transsegmental resections were included in these series. One group included 146 patients, in whom the bronchial stump suture had been performed with an automatic TA30 stapler (TA = thoracic-abdominal with a 30 mm long row of staples). The other group of 152 patients had the bronchial suture made with chromic catgut, using the conventional manual sewing procedure (Sweet's method). The groups were comparable regarding pre-operative status and operative diagnosis. Malignant tumours comprised about 80% of the cases in both series. Tuberculosis accounted for 10%. while benign tumours, non-specific inflammations and other lesions made up the remainder (Table I). More pneumonectomies (35%) were performed in the TA-30 group than in the catgut group (29%), the remainder were lobectomies and few segmental resections (Table 11). These operations were performed by 15 surgeons. More than 80% of the patients were operated on by 9 surgeons who had employed both methods. The remaining 6 surgeons had never used the stapler. The operations, 72% in the TA-30 group and 67% in the catgut group, were performed by thoracic surgeons with five years or more experience.
METHODS An automatic stapling device for bronchial stump closure was utilized in 146 patients. This is a U.S.-made TA-30 stapler that places two rows of staggered stainless steel staples. The staples are supplied in sterile kits with a preloaded cartridge and a "safety pin". Three different kinds of cartridges are available: a green one with 4 mm large, 4.8 mm deep staples, that are 2 mm deep in closed
' United States Surgical Corporation. General agent for Scandinavia: Stille-Werner Company, Stockholm, Sweden.
88
A . Plterj’
arid E . Culahrew
Table I. Diagnosis oj298 patients undergoing lung resection
Downloaded by [University of Sydney Library] at 06:53 30 November 2015
TA-30 stapler Diagnosis
I1
Primary malignant tumour Metastatic tumour Benign tumour Tuberculosis Non-specific inflammation Others Total
109
Chromic catgut
%
I2
%
n
75
116 4
76
225
3
16
12 30 13 2 298
12
n
5 14 6
3
7
5
10 4
16
10
7 2 152
5 1
-
-
146
100
position, a blue one with 4 mm large, 3.5 mm deep staples, that are 1.5 mm deep in closed position and a third white cartridge with 3 mm large, 2.5 mm deep staples, that are 1 mm deep in closed position and is used for suture of pulmonary vessels. The green cartridge (4.8 mm) is generally used for the main bronchus in pneumonectomies and medio-inferior bilobectomies, while the blue one (3.5 mm) is utilized to suture the lober and segmental bronchi. The pulmonary vessels were ligated and divided separately in both groups in the same manner. The stapler is applied to the bronchus in order to achieve as short a stump as possible, with the ideal suture line parallel to the nearest remaining bronchus (Fig. I ) . The stapler is then carefully closed until a light resistance is met due to the compression of the bronchial tissue. Care is taken to avoid crushing the bronchus, closing the instrument with the minimum space needed to enter the “safety zone” marked by black lines on the edges of the instrument. The staples are then inserted by a single squeeze of the handles and the bronchus is cut with a scalpel distally to the sewing line. The stapler is then opened and removed. The bronchial stump is inspected under water for the presence of possible air leakage that can be controlled by a single catgut suture. In the other 152 patients, a 00 or 000 slowly reabsorbable (30 day) chromic catgut was utilized, closing the bronchus by Sweet’s technique after inspection of the bronchial lumen.
Total
100
o/o 76 5 4 10 4
1 100
13/108 of the patients (12%) required the same procedure in the catgut group OBSERVATIONS When studying the mechanics of the different sutures, we found that the conventional manual sutures, due to their irregularity, have many disadvantages in comparison with mechanical sutures.
RESULTS Three patients in each group died within 30 days after operation, representing an operative mortality of 2 % . The causes of the early deaths were not related to the type of bronchial closure. Non-fatal complications were 14% in the TA-30 group and 21 95 in the catgut group. They are presented in detail in Table 111. In both groups of patients 5 % underwent acute re-operations for these complications without mortality. In the TA-30 group 4/95 of the patients (4%) with partial lung resection required late insertion of a new thoracic drain because of recurrent pneumothorax, while
Fig. 1 . Diagrammatic view of the ideal suture line in differ-
ent kinds of lung resections (pneumonectomy and lobectomy). T , trachea; RMB, right main bronchus; L M B , left main bronchus; RULB, right upper lobe bronchus; RMLB, right middle lobe bronchus; RLLB, right lower lobe bronchus; LULB. left upper lobe bronchus; LLLB, left lower lobe bronchus.
Sutures o f t h e bronchial stirmp
89
Table 11. TJipeof operutions on 298 patients undergoing lung resection TA-30 stapler
Chromic catgut
Total
Operat ion
n
9%
n
%
n
9%
Pneumonectomy Lobectomy Segmentectomy
52 89 6
35 61 4
45 99 9
29 65 6
97 188 15
32 63 5
147"
100
153"
100
300"
100
Total "
In both series one patient was operated upon twice because of tumour recurrence after an interval of 4-6 months.
Downloaded by [University of Sydney Library] at 06:53 30 November 2015
Table 111. Postoperative non-futul complications und durution of hospitalization following lung resection
Postoperative complications Bronchial fistula Empyema without fistula Air leakage (more than 10 days) Bleeding Sterile wound rupture Pneumonia or atelectasis Other non-surgical complication Total Without complication 'I
TA-30 stapler
Chromic catgut
Total
n
n
%
n
5 4 10 2 1 7 3 32 117
3 3 96 1 1 5 2 21 77
7 5 16 5 2 10 8 53 239
2 1 6 3 1 3 5 21 122
%
1 1 7b 2 1 2 4 14 84
Duration of hospitalization (days)" %
2 2 8b 2 1 3 3 18 80
Stapler
Catgut
30.0 42.0 18.5 12.7 21 .o 18.7 23.8 21 .o 10.3
43.3 41.0 19.0 18.0 18.0 20.3 19.3 25.8 11.6
At the Thoracic Surgical Clinic, Karolinska sjukhuset, Stockholm. Refers to the incidence of long-term air leakage in patients undergoing partial lung resection.
Our model studies were performed on flexible sheets to stimulate t h e behaviour of bronchial tissue. It is sufficient that only one section on each sheet is delineated on the diagrams, as the situation is identical on the other section. Fig. 2 shows that the stitches (in points 1 to 6) of the hand-made suture are placed in the tissue-model at different distances from the cut border and they are tied with
varying strength of the applied forces ( F is not constant). These irregularities of manual sutures cause varying elongations, which lead to deformation of the edge illustrated by the broken line. Fig. 3 illustrates that this deformation results in a different pressure distribution (Pis not constant) on the contacting surfaces of the tissue that have been sutured. These disproportions in the suture line are
Fig. 2 . Diagrammatic illustration of a manual suture model. Distances between the edge and stitches in points 1 to 6 are different. The sutures are tied with varying forces ( F
Fig. 3 . Diagrammatic illustration of pressure distribution
= constant) and cause deformation on the suture line
illustrated by broken line.
in manual suture model. Due to the irregularity and deformation of the suture line, the pressure distribution is not equal (P = constant) on the contacting surfaces.
F=constant
Downloaded by [University of Sydney Library] at 06:53 30 November 2015
P=constant Fig. 4 . Diagrammatic illustration of a mechanical suture model. The applied forces ( F =constant) and pressure distribution ( P = constant) are uniform. The distances between the edge and the acting points of forces is mini-
mal. Hence, the deformation of the suture line is eliminated.
unfavorable conditions for the wound healing. Fig. 4 illustrates the uniform suture line permitted by mechanical suturing. The applied forces and pressure distribution are constant, the points of application of such forces are disposed regularly and near to the border, thus assuring elimination of the edge’s deformation. In their study of the role of inflammation i n bronchial stump healing, Scott et al. (1975) observed that in canine bronchi closed with silk there was a dense inflammatory infiltrate after 14 days. while in stumps closed with catgut there was a moderate infiltrate with disintegration of the suture material, but that in bronchi closed with stainless steel staples the best healing and the minimal degree of inflammation were observed. The same authors observed that if air was forced through the bronchus at increasing pressures 14 days after bronchial suture, leakage was achieved at much lower pressures in silk closed bronchi, while staples allowed a much tighter closure. Goldman (1964) observed that the typical ”B” shape of the staples in closed position allowed the passage of small vessels about 1 mm in diameter. Keszler (1969) pointed out that the stapler suture avoid haematoma formation around the suture line. These two observations are important in respect of adequate circulation of the bronchial edge. DISCUSSION Even with the improved technique and the various new antibiotic agents now available to prevent infection, bronchopleural fistula is still a problem, S
ISSN: 0036-5580 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/icdv19
Mechanical and Conventional Manual Sutures of the Bronchial Stump. A Comparative Study of 298 Surgical Patients Árpád Péterffy & Emilio Calabrese To cite this article: Árpád Péterffy & Emilio Calabrese (1979) Mechanical and Conventional Manual Sutures of the Bronchial Stump. A Comparative Study of 298 Surgical Patients, Scandinavian Journal of Thoracic and Cardiovascular Surgery, 13:1, 87-91 To link to this article: http://dx.doi.org/10.3109/14017437909101793
Published online: 12 Jul 2009.
Submit your article to this journal
Article views: 3
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=icdv19 Download by: [University of Sydney Library]
Date: 30 November 2015, At: 06:53
Scand J Thor Cardiovasc Surg 13: 87-91, 1979
MECHANICAL AND CONVENTIONAL MANUAL SUTURES OF THE BRONCHIAL STUMP A Cornpurativr S t d y of 298 Surgicul Patients
Arpad Peterffy and Emilio Calabrese From the Thoracic Surgical Clinic. Karolinsha Sjirkhuset , Stockholm, Sweden
(Submitted for publication October 23, 1978)
Downloaded by [University of Sydney Library] at 06:53 30 November 2015
This paper is dedicated to Professor Viking Olof Bjork on the occasion of his sixtieth birthday, December 3, 1978 Abstract. A U.S.-made TA-30 model stapling device was
utilized to close the bronchial stump in 146 patients, while conventional manual suturing with chromic catgut was performed for the same purpose in 152 patients. The two groups were comparable in respect of pre-operative status and operative diagnosis. Patients, in whom the stapler was utilized, showed a decreased incidence of bronchial fistula ( I 96 vs. 3 % ) and empyema without fistula ( I % vs. 3%). The stapler, compared with conventional manual sutures, allows a simpler and swifter suture of the bronchial stump, reduces the contamination of the operative field, achieves uniform and tighter closure of the bronchus, leaves a better preserved terminal blood perfusion of the stump and utilizes a more tolerated sewing material with less resultant tissue inflammation.
The first automatic sewing machine for stomach sutures was presented by Hiittl in Budapest in 1908. Petz (1924) presented a new model, which is still in use in some countries. The Russians improved stapling devices and began to use them in abdominal, thoracic and vascular surgery. They developed UKB staplers, that placed a single row of staples parallel to the bronchial lumen and later, in 1957, they designed and introduced into clinical practice the UKL-40 and UKL60 models (Amosov & Berezovsky 1961). These mechanical devices, which enjoy widespread use today, place two parallel rows of tantalium staples perpendicularly to the bronchus lumen. In 1960, U.S.-made stapling devices (Auto Suture@)'were introduced and one of them, the TA-30 model, is actually employed at this Clinic for bronchial sutures. In order to study the advantages of the mechanical suture over the conventional hand-made sutures in bronchial stump closure, a series of 298 surgical patients were analyzed and the results are presented in this paper.
CLINICAL MATERIAL During the period 1976-78, 298 patients who underwent lung resection at the Thoracic Surgical Clinic, Karolinska Sjukhuset, Stockholm, were reviewed and divided into two groups. N o sleeve or transsegmental resections were included in these series. One group included 146 patients, in whom the bronchial stump suture had been performed with an automatic TA30 stapler (TA = thoracic-abdominal with a 30 mm long row of staples). The other group of 152 patients had the bronchial suture made with chromic catgut, using the conventional manual sewing procedure (Sweet's method). The groups were comparable regarding pre-operative status and operative diagnosis. Malignant tumours comprised about 80% of the cases in both series. Tuberculosis accounted for 10%. while benign tumours, non-specific inflammations and other lesions made up the remainder (Table I). More pneumonectomies (35%) were performed in the TA-30 group than in the catgut group (29%), the remainder were lobectomies and few segmental resections (Table 11). These operations were performed by 15 surgeons. More than 80% of the patients were operated on by 9 surgeons who had employed both methods. The remaining 6 surgeons had never used the stapler. The operations, 72% in the TA-30 group and 67% in the catgut group, were performed by thoracic surgeons with five years or more experience.
METHODS An automatic stapling device for bronchial stump closure was utilized in 146 patients. This is a U.S.-made TA-30 stapler that places two rows of staggered stainless steel staples. The staples are supplied in sterile kits with a preloaded cartridge and a "safety pin". Three different kinds of cartridges are available: a green one with 4 mm large, 4.8 mm deep staples, that are 2 mm deep in closed
' United States Surgical Corporation. General agent for Scandinavia: Stille-Werner Company, Stockholm, Sweden.
88
A . Plterj’
arid E . Culahrew
Table I. Diagnosis oj298 patients undergoing lung resection
Downloaded by [University of Sydney Library] at 06:53 30 November 2015
TA-30 stapler Diagnosis
I1
Primary malignant tumour Metastatic tumour Benign tumour Tuberculosis Non-specific inflammation Others Total
109
Chromic catgut
%
I2
%
n
75
116 4
76
225
3
16
12 30 13 2 298
12
n
5 14 6
3
7
5
10 4
16
10
7 2 152
5 1
-
-
146
100
position, a blue one with 4 mm large, 3.5 mm deep staples, that are 1.5 mm deep in closed position and a third white cartridge with 3 mm large, 2.5 mm deep staples, that are 1 mm deep in closed position and is used for suture of pulmonary vessels. The green cartridge (4.8 mm) is generally used for the main bronchus in pneumonectomies and medio-inferior bilobectomies, while the blue one (3.5 mm) is utilized to suture the lober and segmental bronchi. The pulmonary vessels were ligated and divided separately in both groups in the same manner. The stapler is applied to the bronchus in order to achieve as short a stump as possible, with the ideal suture line parallel to the nearest remaining bronchus (Fig. I ) . The stapler is then carefully closed until a light resistance is met due to the compression of the bronchial tissue. Care is taken to avoid crushing the bronchus, closing the instrument with the minimum space needed to enter the “safety zone” marked by black lines on the edges of the instrument. The staples are then inserted by a single squeeze of the handles and the bronchus is cut with a scalpel distally to the sewing line. The stapler is then opened and removed. The bronchial stump is inspected under water for the presence of possible air leakage that can be controlled by a single catgut suture. In the other 152 patients, a 00 or 000 slowly reabsorbable (30 day) chromic catgut was utilized, closing the bronchus by Sweet’s technique after inspection of the bronchial lumen.
Total
100
o/o 76 5 4 10 4
1 100
13/108 of the patients (12%) required the same procedure in the catgut group OBSERVATIONS When studying the mechanics of the different sutures, we found that the conventional manual sutures, due to their irregularity, have many disadvantages in comparison with mechanical sutures.
RESULTS Three patients in each group died within 30 days after operation, representing an operative mortality of 2 % . The causes of the early deaths were not related to the type of bronchial closure. Non-fatal complications were 14% in the TA-30 group and 21 95 in the catgut group. They are presented in detail in Table 111. In both groups of patients 5 % underwent acute re-operations for these complications without mortality. In the TA-30 group 4/95 of the patients (4%) with partial lung resection required late insertion of a new thoracic drain because of recurrent pneumothorax, while
Fig. 1 . Diagrammatic view of the ideal suture line in differ-
ent kinds of lung resections (pneumonectomy and lobectomy). T , trachea; RMB, right main bronchus; L M B , left main bronchus; RULB, right upper lobe bronchus; RMLB, right middle lobe bronchus; RLLB, right lower lobe bronchus; LULB. left upper lobe bronchus; LLLB, left lower lobe bronchus.
Sutures o f t h e bronchial stirmp
89
Table 11. TJipeof operutions on 298 patients undergoing lung resection TA-30 stapler
Chromic catgut
Total
Operat ion
n
9%
n
%
n
9%
Pneumonectomy Lobectomy Segmentectomy
52 89 6
35 61 4
45 99 9
29 65 6
97 188 15
32 63 5
147"
100
153"
100
300"
100
Total "
In both series one patient was operated upon twice because of tumour recurrence after an interval of 4-6 months.
Downloaded by [University of Sydney Library] at 06:53 30 November 2015
Table 111. Postoperative non-futul complications und durution of hospitalization following lung resection
Postoperative complications Bronchial fistula Empyema without fistula Air leakage (more than 10 days) Bleeding Sterile wound rupture Pneumonia or atelectasis Other non-surgical complication Total Without complication 'I
TA-30 stapler
Chromic catgut
Total
n
n
%
n
5 4 10 2 1 7 3 32 117
3 3 96 1 1 5 2 21 77
7 5 16 5 2 10 8 53 239
2 1 6 3 1 3 5 21 122
%
1 1 7b 2 1 2 4 14 84
Duration of hospitalization (days)" %
2 2 8b 2 1 3 3 18 80
Stapler
Catgut
30.0 42.0 18.5 12.7 21 .o 18.7 23.8 21 .o 10.3
43.3 41.0 19.0 18.0 18.0 20.3 19.3 25.8 11.6
At the Thoracic Surgical Clinic, Karolinska sjukhuset, Stockholm. Refers to the incidence of long-term air leakage in patients undergoing partial lung resection.
Our model studies were performed on flexible sheets to stimulate t h e behaviour of bronchial tissue. It is sufficient that only one section on each sheet is delineated on the diagrams, as the situation is identical on the other section. Fig. 2 shows that the stitches (in points 1 to 6) of the hand-made suture are placed in the tissue-model at different distances from the cut border and they are tied with
varying strength of the applied forces ( F is not constant). These irregularities of manual sutures cause varying elongations, which lead to deformation of the edge illustrated by the broken line. Fig. 3 illustrates that this deformation results in a different pressure distribution (Pis not constant) on the contacting surfaces of the tissue that have been sutured. These disproportions in the suture line are
Fig. 2 . Diagrammatic illustration of a manual suture model. Distances between the edge and stitches in points 1 to 6 are different. The sutures are tied with varying forces ( F
Fig. 3 . Diagrammatic illustration of pressure distribution
= constant) and cause deformation on the suture line
illustrated by broken line.
in manual suture model. Due to the irregularity and deformation of the suture line, the pressure distribution is not equal (P = constant) on the contacting surfaces.
F=constant
Downloaded by [University of Sydney Library] at 06:53 30 November 2015
P=constant Fig. 4 . Diagrammatic illustration of a mechanical suture model. The applied forces ( F =constant) and pressure distribution ( P = constant) are uniform. The distances between the edge and the acting points of forces is mini-
mal. Hence, the deformation of the suture line is eliminated.
unfavorable conditions for the wound healing. Fig. 4 illustrates the uniform suture line permitted by mechanical suturing. The applied forces and pressure distribution are constant, the points of application of such forces are disposed regularly and near to the border, thus assuring elimination of the edge’s deformation. In their study of the role of inflammation i n bronchial stump healing, Scott et al. (1975) observed that in canine bronchi closed with silk there was a dense inflammatory infiltrate after 14 days. while in stumps closed with catgut there was a moderate infiltrate with disintegration of the suture material, but that in bronchi closed with stainless steel staples the best healing and the minimal degree of inflammation were observed. The same authors observed that if air was forced through the bronchus at increasing pressures 14 days after bronchial suture, leakage was achieved at much lower pressures in silk closed bronchi, while staples allowed a much tighter closure. Goldman (1964) observed that the typical ”B” shape of the staples in closed position allowed the passage of small vessels about 1 mm in diameter. Keszler (1969) pointed out that the stapler suture avoid haematoma formation around the suture line. These two observations are important in respect of adequate circulation of the bronchial edge. DISCUSSION Even with the improved technique and the various new antibiotic agents now available to prevent infection, bronchopleural fistula is still a problem, S
