Ann Thorac Surg 2009;87:975-976. doi:10.1016/j.athoracsur.2008.07.029
© 2009 The Society of Thoracic Surgeons
How To Do It
Multiple-Running Suture Technique for Bronchial Anastomosis in Difficult Sleeve Resection
Abdel-Mohsen Hamad, MD,
Giuseppe Marulli, MD,
Giovanna Rizzardi, MD,
Marco Schiavon, MD,
Andrea Zuin, MD*,
Cristiano Breda, MD,
Federico Rea, MD
Division of Thoracic Surgery, Department of Cardiothoracic and Vascular Sciences, University of Padua, Padua, Italy
Accepted for publication July 9, 2008.
* Address correspondence to Dr Rea, Division of Thoracic Surgery, University of Padua, Via Giustiniani, 2, Padua, 35128, Italy (Email: federico.rea{at}unipd.it).
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Abstract
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We present a simplified technique for bronchial anastomosis in difficult sleeve resection using multiple running sutures. During the last 5 years we used this technique in 11 patients. We recorded no anastomotic-related complications in all of them. We found this technique easier, faster, and effective; we consider it a potential routine bronchial anastomotic technique.
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Introduction
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In centers with large experience in tracheobronchoplasty, sleeve lobectomy is now considered the first option whenever the anatomy is suitable even for patients who can tolerate pneumonectomy. The major postoperative complications pertinent of sleeve resection are anastomosis related-problems, namely dehiscence, fistula, and stricture. Needless to say that the technical factor is largely implicated for the development of these complications.
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Technique
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Starting from 2003 to 2007, we used a multiple running suture technique in 11 patients (9 males and 2 females; age range, 23 to 74 years old; Table 1). This technique differs from our routine sleeve resection only in performing the anastomosis. The anastomosis is performed using three sutures of 4-0 polydioxanone (PDS; Ethicon Inc, Sommerville, NJ). The first suture starts at the middle of the cartilaginous part and continues around the cartilaginous wall in an anti-clockwise direction until the cartilaginous end. The second suture again starts at the same starting point and continues in a clockwise direction until the other cartilaginous end. The third suture involves the membranous wall. Disparity between the cross-sectional area of the distal and proximal orifices is adjusted along the whole circumference. The first two sutures are kept loose (ie, the parachute principle and the cartilage-to-cartilage apposition) is achieved under direct vision; then the ends of the first two parachuting sutures are pulled tight as the two bronchial ends are approximated; a nerve hook is used to achieve proper tightness of sutures without a pursestring effect. The third suture is then applied to close the membranous part. Finally, the adjacent limbs of the sutures are tied together (Figs 1A and 1B). In 2 4patients we used four sutures (each extended for one quarter of the circumference of the anastomosis), and in this case the first three sutures were kept loose before pulling them tight. Bronchoscopy is performed routinely after pulling up and before tying the sutures to make sure there are no loose loops and the sutures are tight enough.
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Fig 1. (A) Diagrammatic illustration of the anastomotic technique: numbers 1, 2, and 3 denotes the sequence of sutures; the small arrows point to the starting point of each suture; the large arrows point to the direction of suturing. (B) Demonstrates the anastomosis after application of only two sutures on the cartilaginous part of the bronchial wall using the parachute principle. The small arrows point to the starting point of each suture; the white arrows point to the entrance and exit of the third suture on the membranous part. Note that the adjacent limbs of the different sutures should be on either side of the anastomosis.
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Follow-up ranged from 3 to 48 months. One patient died 1 month after operation because of sepsis and multiple organ failure with no anastomosis-related problems up to the time of death. All other patients are still alive and none of them had any anastomotic complications develop.
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Comment
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Our routine technique (as with the majority of thoracic surgeons) is the use of interrupted sutures in performing the bronchial anastomosis. Other authors prefer the single running suture technique: Kutlu and Goldstraw [1] reported their experience in a series of 66 sleeve lobectomies with a 5% rate of anastomotic stenosis, which is comparable with the average stenosis rat[e after interrupted suture [2]. Also, Aigner and colleagues [3] used a single running suture technique for bronchial anastomosis in lung transplantation and reported excellent results in 141 patients and recommended its use as a standard suturing technique. Experimentally, Bayram and colleagues [4] compared interrupted and continuous suturing for bronchial anastomosis in dogs using 4-0 Vicryl (Ethicon Inc, Sommerville, NJ); histopathologic examination revealed that the healing of the anastomosis was not affected by the suturing technique applied. Despite these reports, the continuous suture did not gain wide acceptance. In our experience, we found that in cases of left upper sleeve lobectomy without vascular angioplasty the presence of the pulmonary artery in the middle of the field interferes with application of the interrupted sutures, and the artery should be manipulated in different directions during the anastomosis. Also, in the case of right lower sleeve bilobectomy and left lower sleeve lobectomy, the new position of the upper lobe and the significant size mismatch between the main bronchus and the upper lobe bronchus add difficulty to application of the interrupted suture technique. The application of the multiple running sutures in these situations is easier, faster, and requires less number of knots.
Moreover, the main concern of the single running suture technique is that in case of partial dehiscence the whole anastomosis will be compromised, and this may explain why many surgeons are reluctant to adapt this technique. We believe that the use of multiple running sutures minimizes this risk. Also, with the three suture technique the tightness of sutures and distribution of tension can be uniformly adjusted along the whole circumference better than the single suture technique and without the pursestring effect.
In conclusion, we found this technique advantageous in difficult situations where it is easier, faster, and effective; this makes it a potential routine anastomotic technique in bronchial sleeve procedures.
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References
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- Kutlu CA, Goldstraw P. Tracheobronchial sleeve resection with the use of a continuous anastomosis: results of one hundred consecutive cases J Thorac Cardiovasc Surg 1999;117:1112-1117.[Abstract/Free Full Text]
- Tedder M, Anstadt MP, Tedder SD, et al. Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy Ann Thorac Surg 1992;54:387-391.[Abstract/Free Full Text]
- Aigner C, Jaksch P, Seebacher G, et al. Single running suture: the new standard technique for bronchial anastomoses in lung transplantation Eur J Cardiothorac Surg 2003;23:488-493.[Abstract/Free Full Text]
- Bayram AS, Erol MM, Salci H, et al. Basic interrupted versus continuous suturing techniques in bronchial anastomosis following sleeve lobectomy in dogs Eur J Cardiothorac Surg 2007;32:852-854.[Abstract/Free Full Text]
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Abstract
Introduction
