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Ann Thorac Surg 1997;63:864-866
© 1997 The Society of Thoracic Surgeons

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How To Do It

Prevention of Air Leaks After Pulmonary Wedge Resection

Department of Thoracic Surgery, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Cardiac and Thoracic Surgery, Allgemeines Krankenhaus, Vienna, Austria; Service de Chirurgie Thoracique, Hôpital Purpan, Toulouse, France; IMM Porte de Choisy, Paris, France; and Phoenix Integrated Surgical Residency, Phoenix, Arizona

Accepted for publication October 2, 1996.

	Abstract

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
Prolonged air leak after a lung volume reduction operation for pulmonary emphysema is a major cause of morbidity and prolonged hospital stay. Staple line reinforcement is recognized as an effective adjunctive technique for decreasing the occurrence of air leaks after pulmonary wedge resection. Numerous materials have been used for staple-line reinforcement. We use expanded polytetrafluoroethylene sleeves that fit over the arms of surgical staplers to facilitate staple-line reinforcement in both thoracoscopic and open lung volume reduction procedures. The expanded polytetrafluoroethylene sleeves do not require rinsing or special handling; they are easy to use and effective in preventing air leaks. We had no prolonged air leaks or infections in any of the cases in which we used the sleeves.

	Introduction

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
With the resurgence of bilateral nonanatomic wedge resection of the lung for treatment of pulmonary emphysema [1], a major concern is the reduction of air leaks after the procedure. Prolonged air leaks increase morbidity and hospital stay. Air leaks may occur because of tearing of the lung caused by excessive surface tension between two parallel staple lines that are too close together. Faulty stapler application or the use of staples that are not long enough may result in an inadequate seal and staple pull-out. The friable, "cotton candy" consistency of emphysematous lung tissue makes it especially susceptible to tearing.

A variety of surgical techniques and materials have been used in attempts to decrease the occurrence of air leaks after pulmonary wedge resection by reinforcing the staple lines. Reinforcement materials that have been employed include everted walls of bullae [2, 3], fibrin glue [3], blood patches [3], polydioxane ribbon [4], polyglycolic acid fabric [5], and, most commonly, bovine pericardial strips [3]. Recently, we have used expanded polytetrafluoroethylene (ePTFE) sleeves (Seamguard Staple Line Reinforcement Material; W.L. Gore & Associates, Inc, Flagstaff, AZ; product received United States Food and Drug Administration clearance via 510(k) in February 1996) for staple-line reinforcement in lung volume reduction operations.

The ePTFE sleeves are 0.35-mm–thick quadrangular tubes (Fig 1) about 8 cm in length, with tear lines and grasping flaps at each end to facilitate removal of excess ePTFE after firing of the stapler. The sleeves are supplied in pairs, with one sleeve having a larger circumference so that it will fit on the cartridge of the stapler and the other having a smaller circumference to fit on the anvil. The sterile sleeves can be placed directly on the stapler after removal from their packaging; no soaking, rinsing, or disposal of liquids is required. The sleeves slip easily and snugly onto the legs of the stapler, which is then locked into position until ready for use.

View larger version (154K): [in this window] [in a new window]   Fig 1. . Expanded polytetrafluoroethylene quadrangular sleeves being placed over the arms of a surgical stapler; tear lines are visible at the corners of the material.

	Technique

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

The target areas in the lung are grasped with a lung forceps. The stapler is appropriately positioned and fired. Before the stapler is released, the excess ePTFE from the three panels of the quadrangular tube that have not been stapled through is removed by peeling it from the stapler arms along the tear lines (Fig 2). The stapler is then released. Repeated applications of the stapler are made as needed to resect the targeted portion of the lung. We have experienced no problems in stapling across previously placed staple lines reinforced with ePTFE.

View larger version (111K): [in this window] [in a new window]   Fig 2. . Removal of excess expanded polytetrafluoroethylene after firing of the stapler.

The staple lines are checked for air leaks by submerging them in water and inflating the lung to 20 to 25 cm of water pressure. Overinflation is avoided. Any residual air leaks are identified and repaired, ideally by reapplication of the stapler sheathed with the ePTFE reinforcement material. We rarely use pledgeted sutures to repair perihilar air leaks. Such leaks are best avoided by judicious selection of target areas away from the hilum.

	Comment

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
We have used the ePTFE staple-line reinforcement material in 26 patients. Three had a thoracoscopic procedure and 23 had an open operation (median sternotomy or thoracotomy). Chest tubes were usually removed on the second or third postoperative day. There were no pneumothoraces or prolonged air leaks (more than 72 hours), and no patient required reoperation for control of air leaks. Patients have been followed up for up to 9 months. No deaths, infections, or other complications related to use of the ePTFE occurred.

The material used for reinforcement of staple lines in pulmonary wedge resection should be flexible, sufficiently thin to allow placement of overlapping staple lines, and easily cut by the blade of the stapler. At the same time, it must be strong enough so that tension on the material will not result in expansion of the staple holes, and it should not allow air to pass through it. Ease of handling would be a clear advantage. We believe that ePTFE meets all these criteria. Staple-line reinforcement with ePTFE has also provided good hemostasis in our patients. We have not found it necessary to reapply the stapler or to suture any staple line because of bleeding.

One of us (C.C.V.) previously used bovine pericardium for staple-line reinforcement in lung-volume reduction. Because this material is treated with glutaraldehyde, it must be soaked in saline solution for 3 minutes and then rinsed carefully to avoid an inflammatory reaction in host tissue. The product must also be kept moist. Thus, use of bovine pericardial strips requires considerable time and effort by operating-room staff.

Bovine pericardial strips come in containers holding two or five pairs, and once the container has been opened the strips must either be used or discarded. Each strip is attached with sutures to a polyethylene backing. Care must be taken not to staple through either the sutures or the backing because both must be removed after the stapler has been fired but before it is unlocked.

In contrast to the pericardial strips, the ePTFE sleeves require no rinsing or disposal of liquids. Thus, delays resulting from waiting for the rinsing process to be completed are avoided, and one surgical nurse can easily keep up with having the sheathed stapler ready. Because the sleeves come one pair to a package, there is no waste of reinforcement material that is not needed for a case. Moreover, after the surgical stapler has been fired, the three unstapled panels of ePTFE are easily removed by grasping the flaps at either end and pulling along the tear lines. There are no sutures or backing material to remove.

The issue of biocompatibility must be considered when any prosthetic material is used. Little information is available on host reaction to prosthetics used in lung-resection procedures, although bovine pericardium has been associated with calcification, extensive inflammatory reactions, and formation of fibrous tissue in cardiac applications [6]. Expanded polytetrafluoroethylene has a long history of safe use in many parts of the body. It produces a minimal inflammatory reaction and appears to be resistant to infection [7]. Studies are needed to determine whether ePTFE suture-line reinforcement material is superior to bovine pericardium with respect to prevention of air leaks and minimization of complications. We believe, however, that the use of ePTFE in pulmonary wedge resection is safe and effective.

	Acknowledgments

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
Funding for this work was provided by W.L. Gore & Associates, Inc, Flagstaff, AZ.

We thank Fred Walburn and Renée Robillard, W.L. Gore & Associates, Inc, for assistance in the preparation of the manuscript.

	Footnotes

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
Address reprint requests to Dr Cecil C. Vaughn, Cardiothoracic & Vascular Surgeons, Ltd, 6036 N 19th Ave, Suite 405, Phoenix, AZ 85015.

Cecil C. Vaughn, MD, is a consultant to W.L. Gore & Associates, Inc.

	References

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 

1. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106–19.[Abstract/Free Full Text]
2. Brantigan OC, Kress MB, Mueller EA. The surgical approach to pulmonary emphysema. Dis Chest 1961;39:485–501.
3. Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038–9.[Abstract]
4. Juettner F-M, Kohek P, Pinter H, Klepp G, Friehs G. Reinforced staple line in severely emphysematous lungs. J Thorac Cardiovasc Surg 1989;97:362–3.[Abstract]
5. Nakamura T, Shimizu Y, Mizuno H, Hitomi S, Kitano M, Matsunobe S. Clinical study of bioabsorbable PGA sheets for suture reinforcement and use as artificial pleura. Jpn Lung Surg J 1992;40:1828–31.
6. Dahn M, Lyman WD, Schwell AB, Factor SM, Frater RW. Immunogenicity of glutaraldehyde-tanned bovine pericardium. J Thorac Cardiovasc Surg 1990;99:1082–90.[Abstract]
7. Brewster DC. Prosthetic grafts. In: Rutherford RB, ed. Vascular surgery. 4th ed. Philadelphia: Saunders, 1995;492–521.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Cecil C. Vaughn Ernst Wolner Marcel Dahan Dominique Grunenwald Cecil C. Vaughn, III Walter Klepetko Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vaughn, C. C. Articles by Baratz, R. A. Search for Related Content PubMed PubMed Citation Articles by Vaughn, C. C. Articles by Baratz, R. A.