Scand J Thor Cardiovasc Surg 26: 125-127, 1992
SUTURE CLOSURE VERSUS STAPLING OF BRONCHIAL STUMP IN 304 LUNG CANCER OPERATIONS Dov Weissberg and Moritz Kaufman From the Department of Thoracic Surgery, Tel Aviu University Sackler School of Medicine, E. Wolf on Medical Center, Holon, Israel Scand Cardiovasc J Downloaded from informahealthcare.com by Chinese University of Hong Kong on 12/26/14 For personal use only.
(Accepted for publication February 11, 1991)
Abstract. Suture closure of the bronchial stump was compared with staple closure after 304 operations for bronchogenic carcinoma over an 8-year period. In 154 cases (112 lobectomies and 42 pneumonectomies) the bronchial stump was closed with interrupted sutures of 000 polyester, and in 150 cases (120 lobectomies and 30 pneumonectomies) an autosuture stapler was used. The time for suture closure ranged from 5-15 minutes, whereas stapling was accomplished uniformly in c. 90 seconds. Bronchopleural fistula developed after suture closure in seven cases (4.5%), but in none after stapling closure. Stapling of the bronchial stump after lobectomy or pneumonectomy for lung cancer is safer and quicker than suture closure, and is recommended as the method of choice. Key words: Bronchial stump closure, stapling of bronchus, suture of bronchus.
‘One ounce of prevention is better than a pound of treatment’ (William Osler). One of the direst complications of a major pulmonary resection is disruption of the bronchial stump with bronchopleural fistula, which often results in empyema, may lead to sepsis and death and is exceedingly difficult to treat. Secondary closure of the bronchial stump is difficult and hazardous, and failure is common (1). The method of closing the stump is almost certainly one of the factors influencing the development of this complication. Accordingly, in attempts to prevent fistula formation various methods of closing the bronchial stump have been devised, none of them absolutely safe (3, 4, 11, 12). Few studies have compared results of bronchial closure with staples vs suture (6, 9, 16). The conclusions were not unequivocal probably for several reasons which presumably included participation of many surgeons in multicenter
studies (9), variety of the diseases for which surgery was performed and possible presence of diseased tissue, e.g. cancer, at the suture line. During an 8-year period we compared standard suture closure with stapling of the bronchus in a homogeneous series of 304 patients who underwent pneumonectomy or lobectomy because of lung cancer. MATERIAL AND METHODS Major pulmonary resection was performed for bronchogenic cancer in 308 patients in 1980 through 1987. The tumors were squamous cell carcinoma (1 30), adenocarcinoma (99), bronchiolo-alveolar carcinoma ( 1 6), large-cell undifferentiated carcinoma ( 5 2 ) and small-cell carcinoma (1 1). There were 75 pneumonectomies and 233 lobectomies. Other operations such as segmentectomy and wedge resection were not included in this review, as we wished to study a homogeneous group with a minimum of variable factors, and we judged that in lesser resections the bronchi and bronchioles would be of insufficient size for meaningful comparison with larger bronchi. For further homogeneity, lung cancer was the only disease in the study. The patients were randomly allocated to bronchial closure with either sutures or staples. After 154 resections (1 12 lobectomies, 42 pneumonectomies) the bronchial stump was closed with interrupted sutures of 000 polyester. In the other group of 154 operations (1 21 lobectomies, 33 pneumonectomies) the Autosuture stapler (US. Surgical Corp, Norwalk, Connecticut, model TA-30) was used, though in the last 52 cases of this group we used the newer variant of stapler, the hinged-jaw ‘Premium’ model, manufactured by the same company. Blue-coded staples, size 3.5 mm, were used after lobectomy and green-coded staples, size 4.8 mm, after pneumonectomy. There were no intergroup differences in the technique of bronchial dissection or in other surgical details. The time for suture closure ranged from 5 to 15 minutes. Staple closure was accomplished in approximately 90 seconds. All survivors were regularly followed up at our out-patient department. Scand J Thoracic 26
126
D. Weissberg and M. Kaufman
Scand Cardiovasc J Downloaded from informahealthcare.com by Chinese University of Hong Kong on 12/26/14 For personal use only.
RESULTS Four patients. (1.3 O/o) died within 30 days of operation, three of them after pneumonectomy (2 squamous cell carcinomas, 1 adenocarcinoma) and one after lobectomy (large-cell undifferentiated carcinoma). All deaths were due to cardiovascular complications, and all occurred after staple closure of the bronchus, though none was related to the operative technique and none of the patients had bronchial leak at the time of death. These four cases were excluded from the series, leaving 304 for analysis. Follow-up ranged from 2 to 10 years. Following suture closure of the bronchus, bronchopleural fistula developed in seven (4.5%) of the 154 patients, always within 4 months of operation. There were five post-lobectomy fistulas, which were small and closed in response to conservative treatment. The two fistulas after pneumonectomy were large, complicated by empyema and required long treatment. One fistula was a contributory cause of death. There was no fistula following stapler closure of the bronchus. DISCUSSION Reported incidence of bronchopleural fistula following resection for lung cancer with sutureclosure of the bronchus ranges from 1.4 Yo (1 5 ) to 10% (2). After pulmonary resection for tuberculosis this incidence has been as high as 28% (5). Stapling of the bronchial stump following major pulmonary resection has been used for the past two decades, and in many centers it has become routine practice (8, 14). Two types of stapling device are available the older, in which the jaws are parallel, and the newer, hinged-jaw ‘Premium’ instrument. Although the ease of use and the overall results are impressive, some authors have reported disruption of the stapled bronchial stump, particularly when the Premium hinged-jaw stapler was used (7, 13, 16). In one report (7) the incidence of bronchopleural fistula was 15.2 Yo with Premium stapler, but only 4.2 % with the older instrument. Six cases of disruption among 36 successive pneumonectomies with Premium stapling bronchial closure led to the suggestion of an immediate moratorium on use of this instrument (1 6). Our comparisons between results of Scand J Thoracic 26
suture and of stapling indicates that the stapling method is safe and superior to suture closure. Although staplers of both types were used in our cases, we found no difference in outcome, contrary to reports critical of the Premium instrument. Both stapling devices gave equally good results. The discrepancy between our results and earlier reports (7, 16) is intriguing. One explanation may be use of different-sized staples. To close the bronchial stump after pneumonectomy we always used the larger, green-coded staples. We believe this to be necessary because of the larger bulk of tissue that has to be compressed on the pulmonary bronchus compared with the lobar bronchus. For effective compression and closure of the pulmonary bronchial stump the blue-coded staples may be too small and may become deformed or incompletely closed. Further, dissection of the bronchi must be very carefully performed, avoiding excessive trauma and devascularization that could impair healing. We believe that condemnation of Premium stapling is premature. Final settlement of this issue requires prospective, randomized studies designed to compare the use of various staples and staplers. Bronchopleural fistula cannot be totally prevented, and obviously the likelihood of complications will tend to increase with the volume of work undertaken. Very marked diminution of the complication rate, however, can be achieved by use of bronchial stump stapling. In our experience, both variants of stapler are safe and can be recommended for routine use. In 1982 Lawrence (10) stated: ‘My hunch is that 10 years from now, stapling will have succeeded suture, primarily with the use of the disposable stapler’. In our hospital that time has already come, and we recommend stapling as the preferable of the two methods. REFERENCES Barker WL, Faber LP, Ostermiller WE Jr, Langston HT. Management of persistent bronchopleural fistula. J Thorac Cardiovasc Surg 1971; 62: 393-401. Buchenberger R, Jenny RH. Ergebnisse der chirurgischen Behandlung beim Bronchus Karzinom. Med Klin 1965; 60: 629-632. Dahlback 0, Schuller H. Die operative Behand-
Suture us stapling of bronchial stump
4.
Scand Cardiovasc J Downloaded from informahealthcare.com by Chinese University of Hong Kong on 12/26/14 For personal use only.
5.
6.
7.
8.
lung der Bronchusstumpfinsufzienz nach Pneumonektomie. Thoraxchirurgie 1965; 13: 2 16-220. Eerola S. Treatment of postpneumonectomy empyema and associated mediastinal fistulae: A clinical study. Academic Dissertation, Medical Faculty of the University of Helsinki, Painoavain Oy, Helsinki, 1977. Floyd RD, Hollister WF, Sealy WC. Complications in 430 consecutive pulmonary resections for tuberculosis. Surg Gynecol Obstet 1959; 109: 467-472. Forrester-Wood CP. Bronchopleural fistula following pneumonectomy for carcinoma of the bronchus. Mechanical stapling versus hand suturing. J Thorac Cardiovasc Surg 1980; 80: 406-409. Hakim M, Milstein BB. Role of automatic staplers in the aetiology of bronchopleural fistula. Thorax 1985; 40: 27-31. Hood RM, Kirksey TD, Calhoon JH, Arnold HS, Tate RS. The use of automatic stapling devices in pulmonary resection. Ann Thorac Surg 1973; 16: 85-98.
127
9. Lawrence GH, Ristroph R, Wood JA, Starr A. Methods for avoiding a dire surgical complication: Bronchopleural fistula after pulmonary resection. Am J Surg 1982; 144: 136-140. 10. Lawrence GH. Discussion of reference 9. Am J Surg 1982; 144: 140. 1 1 . Maier HC, Loumanen RKJ. Pectoral myoplasty for closure of residual empyema cavity and bronchial fistula. Surgery 1949; 25: 621-624. 12. Monod 0, Weyl B. Uber Bronchialfisteln nach Lungenresektion. Thoraxchirurgie 1956; 4: 197-2 14. 13. Moritz E. Automatic staplers and bronchopleural fistulas. Chest 1988; 94: 222-223. 14. Ravitch MM, Steichen FM. Atlas of General Thoracic Surgery. Philadelphia, W. B. Saunders Co, 1988. 15. Sensening DM, Rossi NP, Ehrenhaft JL. Results of the surgical treatment of bronchogenic carcinoma. Surg Gynecol Obstet 1963; 1 16: 279-284. 16. Smiell J, Widmann WD. Bronchopleural fistulas after pneumonectomy. A problem with surgical stapling. Chest 1987; 92: 1056-1060.
Scand J Thoracic 26
SUTURE CLOSURE VERSUS STAPLING OF BRONCHIAL STUMP IN 304 LUNG CANCER OPERATIONS Dov Weissberg and Moritz Kaufman From the Department of Thoracic Surgery, Tel Aviu University Sackler School of Medicine, E. Wolf on Medical Center, Holon, Israel Scand Cardiovasc J Downloaded from informahealthcare.com by Chinese University of Hong Kong on 12/26/14 For personal use only.
(Accepted for publication February 11, 1991)
Abstract. Suture closure of the bronchial stump was compared with staple closure after 304 operations for bronchogenic carcinoma over an 8-year period. In 154 cases (112 lobectomies and 42 pneumonectomies) the bronchial stump was closed with interrupted sutures of 000 polyester, and in 150 cases (120 lobectomies and 30 pneumonectomies) an autosuture stapler was used. The time for suture closure ranged from 5-15 minutes, whereas stapling was accomplished uniformly in c. 90 seconds. Bronchopleural fistula developed after suture closure in seven cases (4.5%), but in none after stapling closure. Stapling of the bronchial stump after lobectomy or pneumonectomy for lung cancer is safer and quicker than suture closure, and is recommended as the method of choice. Key words: Bronchial stump closure, stapling of bronchus, suture of bronchus.
‘One ounce of prevention is better than a pound of treatment’ (William Osler). One of the direst complications of a major pulmonary resection is disruption of the bronchial stump with bronchopleural fistula, which often results in empyema, may lead to sepsis and death and is exceedingly difficult to treat. Secondary closure of the bronchial stump is difficult and hazardous, and failure is common (1). The method of closing the stump is almost certainly one of the factors influencing the development of this complication. Accordingly, in attempts to prevent fistula formation various methods of closing the bronchial stump have been devised, none of them absolutely safe (3, 4, 11, 12). Few studies have compared results of bronchial closure with staples vs suture (6, 9, 16). The conclusions were not unequivocal probably for several reasons which presumably included participation of many surgeons in multicenter
studies (9), variety of the diseases for which surgery was performed and possible presence of diseased tissue, e.g. cancer, at the suture line. During an 8-year period we compared standard suture closure with stapling of the bronchus in a homogeneous series of 304 patients who underwent pneumonectomy or lobectomy because of lung cancer. MATERIAL AND METHODS Major pulmonary resection was performed for bronchogenic cancer in 308 patients in 1980 through 1987. The tumors were squamous cell carcinoma (1 30), adenocarcinoma (99), bronchiolo-alveolar carcinoma ( 1 6), large-cell undifferentiated carcinoma ( 5 2 ) and small-cell carcinoma (1 1). There were 75 pneumonectomies and 233 lobectomies. Other operations such as segmentectomy and wedge resection were not included in this review, as we wished to study a homogeneous group with a minimum of variable factors, and we judged that in lesser resections the bronchi and bronchioles would be of insufficient size for meaningful comparison with larger bronchi. For further homogeneity, lung cancer was the only disease in the study. The patients were randomly allocated to bronchial closure with either sutures or staples. After 154 resections (1 12 lobectomies, 42 pneumonectomies) the bronchial stump was closed with interrupted sutures of 000 polyester. In the other group of 154 operations (1 21 lobectomies, 33 pneumonectomies) the Autosuture stapler (US. Surgical Corp, Norwalk, Connecticut, model TA-30) was used, though in the last 52 cases of this group we used the newer variant of stapler, the hinged-jaw ‘Premium’ model, manufactured by the same company. Blue-coded staples, size 3.5 mm, were used after lobectomy and green-coded staples, size 4.8 mm, after pneumonectomy. There were no intergroup differences in the technique of bronchial dissection or in other surgical details. The time for suture closure ranged from 5 to 15 minutes. Staple closure was accomplished in approximately 90 seconds. All survivors were regularly followed up at our out-patient department. Scand J Thoracic 26
126
D. Weissberg and M. Kaufman
Scand Cardiovasc J Downloaded from informahealthcare.com by Chinese University of Hong Kong on 12/26/14 For personal use only.
RESULTS Four patients. (1.3 O/o) died within 30 days of operation, three of them after pneumonectomy (2 squamous cell carcinomas, 1 adenocarcinoma) and one after lobectomy (large-cell undifferentiated carcinoma). All deaths were due to cardiovascular complications, and all occurred after staple closure of the bronchus, though none was related to the operative technique and none of the patients had bronchial leak at the time of death. These four cases were excluded from the series, leaving 304 for analysis. Follow-up ranged from 2 to 10 years. Following suture closure of the bronchus, bronchopleural fistula developed in seven (4.5%) of the 154 patients, always within 4 months of operation. There were five post-lobectomy fistulas, which were small and closed in response to conservative treatment. The two fistulas after pneumonectomy were large, complicated by empyema and required long treatment. One fistula was a contributory cause of death. There was no fistula following stapler closure of the bronchus. DISCUSSION Reported incidence of bronchopleural fistula following resection for lung cancer with sutureclosure of the bronchus ranges from 1.4 Yo (1 5 ) to 10% (2). After pulmonary resection for tuberculosis this incidence has been as high as 28% (5). Stapling of the bronchial stump following major pulmonary resection has been used for the past two decades, and in many centers it has become routine practice (8, 14). Two types of stapling device are available the older, in which the jaws are parallel, and the newer, hinged-jaw ‘Premium’ instrument. Although the ease of use and the overall results are impressive, some authors have reported disruption of the stapled bronchial stump, particularly when the Premium hinged-jaw stapler was used (7, 13, 16). In one report (7) the incidence of bronchopleural fistula was 15.2 Yo with Premium stapler, but only 4.2 % with the older instrument. Six cases of disruption among 36 successive pneumonectomies with Premium stapling bronchial closure led to the suggestion of an immediate moratorium on use of this instrument (1 6). Our comparisons between results of Scand J Thoracic 26
suture and of stapling indicates that the stapling method is safe and superior to suture closure. Although staplers of both types were used in our cases, we found no difference in outcome, contrary to reports critical of the Premium instrument. Both stapling devices gave equally good results. The discrepancy between our results and earlier reports (7, 16) is intriguing. One explanation may be use of different-sized staples. To close the bronchial stump after pneumonectomy we always used the larger, green-coded staples. We believe this to be necessary because of the larger bulk of tissue that has to be compressed on the pulmonary bronchus compared with the lobar bronchus. For effective compression and closure of the pulmonary bronchial stump the blue-coded staples may be too small and may become deformed or incompletely closed. Further, dissection of the bronchi must be very carefully performed, avoiding excessive trauma and devascularization that could impair healing. We believe that condemnation of Premium stapling is premature. Final settlement of this issue requires prospective, randomized studies designed to compare the use of various staples and staplers. Bronchopleural fistula cannot be totally prevented, and obviously the likelihood of complications will tend to increase with the volume of work undertaken. Very marked diminution of the complication rate, however, can be achieved by use of bronchial stump stapling. In our experience, both variants of stapler are safe and can be recommended for routine use. In 1982 Lawrence (10) stated: ‘My hunch is that 10 years from now, stapling will have succeeded suture, primarily with the use of the disposable stapler’. In our hospital that time has already come, and we recommend stapling as the preferable of the two methods. REFERENCES Barker WL, Faber LP, Ostermiller WE Jr, Langston HT. Management of persistent bronchopleural fistula. J Thorac Cardiovasc Surg 1971; 62: 393-401. Buchenberger R, Jenny RH. Ergebnisse der chirurgischen Behandlung beim Bronchus Karzinom. Med Klin 1965; 60: 629-632. Dahlback 0, Schuller H. Die operative Behand-
Suture us stapling of bronchial stump
4.
Scand Cardiovasc J Downloaded from informahealthcare.com by Chinese University of Hong Kong on 12/26/14 For personal use only.
5.
6.
7.
8.
lung der Bronchusstumpfinsufzienz nach Pneumonektomie. Thoraxchirurgie 1965; 13: 2 16-220. Eerola S. Treatment of postpneumonectomy empyema and associated mediastinal fistulae: A clinical study. Academic Dissertation, Medical Faculty of the University of Helsinki, Painoavain Oy, Helsinki, 1977. Floyd RD, Hollister WF, Sealy WC. Complications in 430 consecutive pulmonary resections for tuberculosis. Surg Gynecol Obstet 1959; 109: 467-472. Forrester-Wood CP. Bronchopleural fistula following pneumonectomy for carcinoma of the bronchus. Mechanical stapling versus hand suturing. J Thorac Cardiovasc Surg 1980; 80: 406-409. Hakim M, Milstein BB. Role of automatic staplers in the aetiology of bronchopleural fistula. Thorax 1985; 40: 27-31. Hood RM, Kirksey TD, Calhoon JH, Arnold HS, Tate RS. The use of automatic stapling devices in pulmonary resection. Ann Thorac Surg 1973; 16: 85-98.
127
9. Lawrence GH, Ristroph R, Wood JA, Starr A. Methods for avoiding a dire surgical complication: Bronchopleural fistula after pulmonary resection. Am J Surg 1982; 144: 136-140. 10. Lawrence GH. Discussion of reference 9. Am J Surg 1982; 144: 140. 1 1 . Maier HC, Loumanen RKJ. Pectoral myoplasty for closure of residual empyema cavity and bronchial fistula. Surgery 1949; 25: 621-624. 12. Monod 0, Weyl B. Uber Bronchialfisteln nach Lungenresektion. Thoraxchirurgie 1956; 4: 197-2 14. 13. Moritz E. Automatic staplers and bronchopleural fistulas. Chest 1988; 94: 222-223. 14. Ravitch MM, Steichen FM. Atlas of General Thoracic Surgery. Philadelphia, W. B. Saunders Co, 1988. 15. Sensening DM, Rossi NP, Ehrenhaft JL. Results of the surgical treatment of bronchogenic carcinoma. Surg Gynecol Obstet 1963; 1 16: 279-284. 16. Smiell J, Widmann WD. Bronchopleural fistulas after pneumonectomy. A problem with surgical stapling. Chest 1987; 92: 1056-1060.
Scand J Thoracic 26
