Asian Cardiovasc Thorac Ann 1999;7:225-227
© 1999 Asia Publishing EXchange Pte Ltd
Parenchymal Stapling in Pulmonary Lobectomies: Is it Really Necessary?
Ufuk Ca
irici, MD,
Semra Bilacerolu, MD,1,
Mustafa Cikirikçiolu, MD,
Hakan Posaciolu, MD,
Yüksel Atay, MD,
Tahir Yadi, MD,
Önol Bilkay, MD
Departments of Cardiovascular & Thoracic Surgery
Ege University Medical Faculty
Bornova,  zmir, Turkey
1 Department of Chest Diseases
Chest Diseases and Thoracic Surgery Training Hospital
Yenisehir, zmir, Turkey
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For reprint information contact: Ufuk Çairici, MD Tel: 90 232 388 2866 Fax: 90 232 339 0002 email: cagirici{at}med.ege.edu.tr Department of Thoracic Surgery, Ege University Medical Faculty, Bornova, zmir 35100, Turkey.
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Abstract
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Automatic stapling devices are widely used for pulmonary exeresis, particularly in wedge or segmental resections. Infrequently, these instruments are also employed in lobectomies for the division of incomplete fissures. A prospective randomized study was undertaken to determine the efficacy of staplers in performing a lobectomy. Among 102 lobectomy patients, 59 (44 men, 15 women) who had incomplete fissures were included in the study. A stapler was used in 38 patients for completion of the fissures, whereas sharp dissection and the classic suture closure technique were employed in the remaining 21 patients. Duration of air leakage postoperatively did not differ significantly (p > 0.05) but the operation time was found to be shorter in the stapled-lobectomy group (67.63 ± 13.7 min versus 85.71 ± 18.3 min; p < 0.001).
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Introduction
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The classic lobectomy technique involves ligation of the lobar branches of the pulmonary artery, vein, and bronchus by hilar dissection. Completion of an incomplete fissure is an integral part of the resection of a lobe, which may result from congenital fusion of the lung parenchyma, inflammation, or extension of the pathologic process to the adjacent lobe.1 Incomplete fissures can be divided by sharp dissection and suture closure or by using a stapling device. The stapling instruments designed for pulmonary parenchymal resections are considered to facilitate the operative procedure.2–4 However, the effectiveness of these instruments in reducing parenchymal air leaks is somewhat controversial. This study was designed to determine the efficacy of a stapling device in pulmonary lobectomies. Parameters including the duration of postoperative air leaks and the operation time in stapled lobectomy were compared with those obtained by conventional lobectomy techniques.
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Patients and Methods
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Between January 1997 and June 1998, 102 patients underwent pulmonary lobectomy in the thoracic surgery department of Ege University Medical Faculty Hospital. A prospective study was carried out in patients who required parenchymal lung division during the operation because of an incomplete major or minor fissure. These comprised 44 men and 15 women with a mean age of 58.1 ± 9.2 years who were randomly assigned to one of two groups depending on the technique used for division of the fissures. The study group comprised 38 patients who underwent lobectomy with an 80-mm linear cutter stapler (GIA; US Surgical Corp., Norwalk, CT, USA). In the control group of 21 patients, division of the lung parenchyma was accomplished by traditional techniques: two clamps were placed along the fissure line, the fissure was divided by sharp dissection or electrocautery; and the cut surface of the remaining lobe was sutured in a continuous fashion.
All operations were carried out by the same surgical team. The chest was opened in all patients by a standard posterolateral thoracotomy incision along the lower border of the 5th rib. Lobectomy was performed during a period of single-lung anesthesia. The period from encircling the pulmonary vessels with a right angle clamp to removal of the resected lobe was considered the operation time. The rationale was to eliminate the time spent in dissection of pleural adhesions, which varies from case to case. In this manner, control of variations due to anatomic differences was achieved. After completion of the resection, 32F and 28F chest tubes connected to an underwater seal system were placed in the basal and apical regions, respectively, of the chest cavity. The chest tubes were removed when the lung was fully expanded and there was no air or fluid leakage. Normal maneuvers to enhance lung expansion, such as increasing the chest tube suction, appropriate physiotherapy, and therapeutic bronchoscopy were performed when necessary. Time to final chest tube removal was considered to be the time of cessation of air leak.
Student's t test was used for comparison of continuous data, with p < 0.05 considered to be significant. Results were expressed as mean ± standard deviation.
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Results
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Of the 102 patients undergoing pulmonary lobotomy, 59 (57.8%) required parenchymal lung division because of an incomplete major or minor fissure. Profiles of the study and control groups are summarized in Table 1
. There were no significant differences in patient characteristics between the two groups. There was no mortality within 30 days of the operation in either group. One patient in the control group underwent a second thoracotomy on the 2nd postoperative day for persistent bleeding. Minor complications comprising arrhythmias in 6 patients, fever in 5, and wound infection in one patient were noted equally in both groups and could not be attributed to the use of the staplers.
The operation time was significantly shorter in the stapled-lobectomy patients (67.63% ± 13.7 min) compared to the control group (85.71 ± 18.3 min; p < 0.001). However, stapling did not significantly shorten the time to cessation of air leaks (3.92 ± 1.5 days) compared to the traditional dividing and suture closure technique (4.24 ± 1.4 days; p > 0.05).
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Discussion
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The results of this study demonstrate no significant reduction in the duration of post-lobectomy air leaks by the use of a stapler. The similar results obtained by the two techniques suggest that the holes created by the suture needles at the cut edge of the lobe may invite air leakage in the classic suture closure technique, and likewise, air leaks can occur by tearing of the lung caused by excessive surface tension between the two parallel staple lines when the lung is reinflated. Stapler-induced air leaks have been emphasized by many surgeons in the literature and a variety of surgical materials have been used on the staple lines to decrease the occurrence of this complication. Polyglycolic acid fabric, polydioxan ribbon, bovine pericardial strips, bovine collagen, and recently, expanded polytetrafluoroethylene have been employed in an attempt to reinforce the staple lines, especially for resections performed in emphysematous lungs.5–9 Indeed, the need for such reinforcement material indicates the relative inadequacy of the stapling instruments in decreas-ing the incidence of air leaks in pulmonary parenchymal exeresis. Conversely, Temes and colleagues10 described a technique for lobectomy in which all the lung parenchyma is divided using a stapler and reported that surgical morbidity due to air leaks decreased with this technique. In our study, no significant difference was detected in the efficacy of the staplers in reducing the incidence of air leakage. However, there is a considerable cost difference. Each stapler may add $500 to $700 USD to the cost of the operation. Since 2 or 3 staplers or cartridges are needed for division of an incomplete fissure in a lobectomy procedure, stapled-lobectomy can be considered expensive compared to the standard manual closure technique.
On the other hand, staplers significantly shortened the duration of the operative procedure in our study. The operation time was reduced by 15 to 20 minutes. This may be particularly important in high-risk or elderly patients for whom prolonged anesthesia carries a risk.
We concluded that the use of staplers for dividing incomplete fissures in pulmonary lobectomies had no superiority in preventing air leakage although it simplified and expedited the procedure. Whether it is worth using these highly expensive instruments must be questioned in depth.
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References
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Abstract
Introduction
