Cartilage folding method for main bronchial stapling

Single-port video-assisted thoracoscopic surgery (VATS) right pneumonectomy: a case report

When it comes to surgical treatment of non-small cell lung cancer (NSCLC), modern principles dictate that every possible effort should be made to avoid pneumonectomy, its debilitating consequences and a higher rate of complications. In marginal cases where video-assisted thoracoscopic surgery (VATS) sleeve or double sleeve lobectomy cannot be performed a conversion to open sleeve lobectomy is always preferred over a VATS pneumonectomy. We present a case of a 64-year-old male patient with two synchronous tumors of the right lung, both centrally located in the right upper and the right lower lobe. A single-port VATS right pneumonectomy was performed. The patient was discharged on the post-operative day 5 in good general condition.

Surgical stapling device-tissue interactions: what surgeons need to know to improve patient outcomes

The introduction of both new surgical devices and reengineered existing devices leads to modifications in the way traditional tasks are carried out and allows for the development of new surgical techniques. Each new device has benefits and limitations in regards to tissue interactions that, if known, allow for optimal use. However, most surgeons are unaware of these attributes and, therefore, new device introduction creates a “knowledge gap” that is potentially dangerous. The goal of this review is to present a framework for the study of device– tissue interactions and to initiate the process of “filling in” the knowledge gap via the available literature. Surgical staplers, which are continually being developed, are the focus of this piece. The integrity of the staple line, which depends on adequate tissue compression, is the primary factor in creating a stable anastomosis. This review focuses on published studies that evaluated the creation of stable anastomoses in bariatric, thoracic, and colorectal procedures. Understanding how staplers interact with target tissues is key to improving patient outcomes. It is clear from this review that each tissue type presents unique challenges. The thickness of each tissue varies as do the intrinsic biomechanical properties that determine the ideal compressive force and prefiring compression time for each tissue type. The correct staple height will vary depending on these tissue-specific properties and the tissue pathology. These studies reinforce the universal theme that compression, staple height, tissue thickness, tissue compressibility, and tissue type must all be considered by the surgeon prior to choosing a stapler and cartridge. The surgeon’s experience, therefore, is a critical factor. Educational programs need to be established to inform and update surgeons on the characteristics of each stapler. It is hoped that the framework presented in this review will facilitate this process.

Bronchial Stump Coverage With a Pedicled Pericardial Flap: An Effective Method for Prevention of Postpneumonectomy Bronchopleural Fistula

BACKGROUND

Bronchopleural fistula is a serious complication after pneumonectomy. The aim of this retrospective study was to investigate the efficacy of bronchial stump reinforcement with a pedicled flap of whole pericardium.

METHODS

The bronchial stump of 93 consecutive patients who underwent pneumonectomy between July 1988 and March 2003 was covered with a pedicled pericardial flap. Pneumonectomy was performed for primary lung cancer in 89.2% of patients. The study patients received concomitant extensive mediastinal lymphadenectomy, resection of adjacent structures (aorta, vena cava, thoracic wall), and neoadjuvant or planned adjuvant chemotherapy or radiotherapy, or both. Operative and perioperative complications were recorded, and patients were followed up for a mean of 15 +/- 21.2 months (range, 9 to 126).

RESULTS

Perioperative mortality was 4.3% (n = 4; pulmonary embolism, sepsis, cardiac arrest, and sudden death in 1 patient each). Perioperative complications occurred in 2 patients: renal failure and hemiplegia in 1 patient and cardiac tamponade in 1 patient. The latter complication, caused by tight reconstruction of the pericardium, was directly related to the applied method and required reoperation. No evidence of postpneumonectomy bronchopleural fistula was observed perioperatively and during the whole follow-up. One-year and 2-year survival was 65.7% and 44.8%, respectively.

CONCLUSIONS

Bronchial stump reinforcement with a pericardial flap is a highly effective method for preventing postpneumonectomy bronchopleural fistula in selected patients.

Impact of different coverage techniques on incidence of postpneumonectomy stump fistula

OBJECTIVE

Postpneumonectomy bronchial stump fistula (PBSF) is a serious complication with a reported incidence between 0 and 12%. The aim of this retrospective study was to investigate the effectiveness of different coverage techniques of the bronchial stump applied in a consecutive series of pneumonectomies in avoiding this particular problem.

METHODS

Between 1/87 and 10/97, 129 patients (90 male, 39 female, mean age 57.8 years, range: 15-78 years) underwent pneumonectomy by one surgeon (W.K.). In 14 patients, additional resection procedures were performed (aorta n = 6, vena cava n = 5, thoracic wall n = 3). In all patients with malignancies (n = 123), mediastinal lymphadenectomy was routinely added to the procedure. Bronchial stump closure was performed by means of stapling devices in all patients. Coverage of the bronchial stump was performed with a generous pedicled pericardial flap and concomitant reconstruction of the pericardium with Vicryl mesh (n = 50), with a portion of the posterior pericardium (n = 16), with the azygos vein (n = 12), with surrounding mediastinal tissue (n = 25), with pleura (n = 16), or with intercostal muscle flap (n = 3); no coverage at all was performed in seven patients. In all patients with high risk for development of PBSF, i.e. patients who received any form of neoadjuvant therapy or had extended resections, the pericardial flap technique was used.

RESULTS

Perioperative mortality was 5.4% (n = 7) and five patients (3.9%) experienced significant perioperative complications, with one of them directly related to the method of bronchial stump coverage (cardiac tamponade due to the use of a too small Vicryl mesh for reconstruction of the pericardium). Follow-up was 96.1% complete (five patients were lost to follow-up). Fourty-seven patients (36.4%) died late after operation (mean 19+/-13 months, median 17 months), mainly due to recurrence of their underlying malignant disease. PBSF occurred in one patient only (0.8%), 2 weeks after operation (coverage with pleura). No PBSF was seen in the long term follow-up period.

CONCLUSION

Coverage of the bronchial stump contributes to a low incidence of PBSF. In view of the fact, that this serious complication was completely avoided in the pericardial flap group (used in patients with expected higher risk for PBSF), this particular technique seems to offer the best results.