Ann Thorac Surg 1998;65:1800-1801
© 1998 The Society of Thoracic Surgeons
How to Do It
Cartilage Folding Method for Main Bronchial Stapling
Teruhiro Aoki, MDa,
Yuichi Ozeki, MDa,
Masazumi Watanabe, MDa,
Susumu Tanaka, MDa
a Department of Surgery II, National Defense Medical College, Saitama, Japan
Accepted for publication December 4, 1997.
Address reprint requests to Dr Aoki, Department of Surgery, Saiseikai Kanagawaken Hospital, 6-6 Tomiya-cho, Kanagawa-ku, Yokohama 221, Japan
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Abstract
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Bronchopleural fistula is one of the most severe complications of lung operations. To prevent bronchopleural fistula, we modified the stapling technique to include folding of both sides of the cartilaginous main bronchus. This reduces the tension at the center of the membranous portion of the airway. From 1991 to 1994, this technique was performed in 7 patients. Despite the fact that 4 of these patients received adjuvant therapy, none had development of a bronchopleural fistula.
Bronchopleural fistula (BPF) is one of the most severe complications of lung operations. The incidence, which is higher after pneumonectomy than after lobectomy, is related to the technique of main bronchial closure. After pneumonectomy, the incidence of BPF with stapling has been reported to be 2.0% to 5.2%, whereas after hand suturing it has been shown to be as high as 6.6% to 18.2% [1–4]. Because BPF still occurs after stapling, refinements are required.
In earlier cases, we have stapled the main bronchus using the conventional technique. Bronchoscopy revealed that BPF often occurred in the center of the stump (Fig 1). At this point, the membranous portion of the bronchus is stretched, resulting in increased tension. Recently, when stapling the main bronchus, we folded both sides of the cartilaginous wall (Fig 2). This takes the tension off the center point and is easy to perform because the lateral cartilage is readily folded (Fig 3). The suture line can be slanted toward the trachea. After stapling, the stump is not covered (Fig 4).
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Fig 1. Bronchoscopic photograph showing a bronchopleural fistula in a patient who underwent pneumonectomy with the conventional stapling method. Note the two pinhole fistulas in the center of the main bronchus where the membranous portion was stretched.
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Fig 2. Schematic diagram showing the conventional treatment of the stump and our cartilage folding method. In the cartilage folding method, the membranous portion is not stretched.
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Fig 3. Schema of the folding technique. With the fingers of both hands, the surgeon folds both sides of the cartilaginous wall and controls the position of the stapler.
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Fig 4. Bronchoscopic photograph of a patient who underwent pneumonectomy using our stapling method. Note the folded cartilage and the lack of stretch in the membranous portion.
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From 1991 to 1994, we used this technique with a TA-45 stapler in 7 patients undergoing pneumonectomy. All stapling procedures were performed by one of us (T.A.). Two of these patients had an invasive thymoma and underwent pleuropneumonectomy. One received methylprednisolone pulse therapy for concomitant pure red cell aplasia, and the other received preoperative and postoperative chemotherapy and radiotherapy. Of the 5 patients with lung cancer, 2 received adjuvant chemotherapy (cisplatin, vindesine, and mitomycin). None of these patients had development of a BPF. Because the number of patients treated with this method is small, further study is required.
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References
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- Forrester-Wood C.P. Bronchopleural fistula following pneumonectomy for carcinoma of the bronchus. Mechanical stapling versus hand suturing. J Thorac Cardiovasc Surg 1980;80:406-409.[Abstract]
- Junginger T., Walgenbach S., Pichlmaier H. Stapler and manual bronchial anastomosis. Results of a consecutive trial series. Langenbecks Arch Chir 1989;374:323-328.[Medline]
- Brewer L.A., III, King E.L., Lilly L.J., Bai A.F. Bronchial closure in pulmonary resection: a clinical and experimental study using a pedicled pericardial fat graft reinforcement. J Thorac Surg 1953;26:507-532.
- Vester S.R., Faber L.P., Kittle C.F., Warren W.H., Jensik R.J. Bronchopleural fistula after stapled closure of bronchus. Ann Thorac Surg 1991;52:1253-1257.[Abstract/Free Full Text]
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