Use of a Lung Stapler in Pulmonary Resection

Transcription

1 Use of a Lung Stapler in Pulmonary Resection Reeve H. Betts, M.D., and Timothy Takaro, M.D. A lthough the results of pulmonary resection by standard techniques are good, there is a continuing need for, and interest in, refinements in these techniques [5, 8, 141. There are two main areas of concern. The first is the control of blood and air leakage from the nonpleural surfaces after sublobar resection. The second is the elimination of the small but persistent number of bronchopleural fistulas. The mechanical stapler here described has been effective in our experience in approaching attainment of both objectives. A report from this hospital [15] on the use of the Russian UKB-25 stapler, formerly employed, indicated that it had some advantages but did not produce the marked improvement over previous techniques of bronchial closure that had been anticipated. The UKB-25 stapler lays down a single row of staples with the long axis of the staples parallel to the long axis of the bronchus. This report is on the use of the Russian stapler UKL-40,* which was designed primarily for resection of pulmonary parenchyma, but which can be used for hilar structures as well (Fig. 1). In contrast to the UKB-25, it implants two rows of staples, staggered in respect to each other, across the structure being stapled, the long axis of each staple lying transversely to the long axis of the tissue. We have abandoned the bronchus stapler in favor of the lung stapler, even for closure of the bronchus. Ravitch et al. [l 1, 121 and Wilder et nl. [16] have reported on the experimental and clinical use of the UKB-25, and Goldman [6, 71 on the UKL-601. and -40. Amosov [ 11 reported in the American literature a series of 670 operations in which the UKL-60 was used, and a subsequent unpublished report [4] from the same clinic covers a total of 1,384 operations with a very low incidence of bronchopleural fistula and empyema. Reports are also available in the English language on the use of the UKB-25 by Androsov [3] and by Laitinen et al. [9], and on the UKL-60 by Rzepecki et al. [13]. From Veterans Administration Hospital, Oteen, N.C. Received for publication Aug. 11, *A modified version is available from U.S. Surgical Corp., 375 Park Ave., New York, N.Y +This is the same as the UKL-40 except that the jaw is 20 mm. longer. VOL. I, NO. z, MAR.,

2 BETTS AND TAKARO FIG. 1. Stapler head with staples partly extruded. Above it are two stapleholding magazines. The lower magazine is that of the lung stapler. The two rows of ouerlapping slots for the staples are shown. The upper magazine is that of the bronchus stapler, which implants a single row of staples parallel to the structure being divided. We have used the UKL-40 for three purposes: (1) to accomplish sublobar or transsegmental resections; (2) to staple vascular structures; and (3) to effect bronchial closures. The conditions treated included pulmonary tuberculosis (about half of the cases), bronchogenic carcinoma (one-fourth of the cases), and lung abscesses, cysts, and fungus infections. 1. In patients with extensive bilateral pulmonary tuberculosis and resultant impaired pulmonary function, it is important to conserve all undiseased, functioning pulmonary parenchyma. While segmental resections by standard techniques achieve this best, reports [2, 101 indicate an appreciable incidence of residual pleural space problems with or without demonstrable bronchial fistulas. Further surgical therapy may be necessary in such cases, with further diminution of pulmonary function. The stapler permits resection of sublobar pulmonary lesions with a minimal amount of contiguous normal tissue. At the same time, it 198 THE ANNALS 01: THORACIC SURGERY

3 NOTE: Lung Stapler effectively seals the pulmonary parenchyma, thus markedly reducing air and blood leakage and the complications associated therewith. Tuberculous foci can be resected without regard to segmental divisions (Fig. 2). The bronchial, arterial, and venous supply of the lung is such that it FIG. 2. Postoperatiue roentgenogram of the chest showing the staples in the right upper lobe following a transsegmental resection of the apicoposterior segment. is possible to resect almost any area of the lung without damage to the surrounding pulmonary tissue as long as it is approached from the periphery of the lobe. This type of transsegmental resection was performed in 35 patients. In an appreciable number of these patients the superior segment of the lower lobe, as well as the upper lobe, was involved with tuberculosis. The stapler permitted resection of the diseased portion of the lower lobe simply and rapidly, without the additional hazard of a formal superior segmental resection in addition to the upper lobectomy. Tailoring thoracoplasties were performed in 2 patients to reduce the size of the pleural space, but not because of bronchopleural fistulas. 2. The stapler can also be used when necessary on hilar vessels; and in an emergency when a major vessel has been injured and hemorrhage VOL. I, NO. 2, MAR.,

4 BETTS AND TAKARO cannot be controlled easily by conventional measures, the bleeding can usually be checked by finger pressure while the stapler is inserted and the vascular structures secured with the stapler. Occasionally, in carrying out resection for advanced carcinoma of the lung, the device has been useful in suturing very short, broad, major vessels and even the atrial wall itself. We have used it for this purpose in 11 instances, with no complications. 3. A third obvious advantage of the stapling technique is the ease and simplicity of bronchial closure which the device affords. During the past year we have used the UKL-40 stapler with increasing frequency for this purpose. Over 120 segmental, lobar, and main bronchi have been sutured mechanically, in patients with carcinoma, tuberculosis, and a variety of other lesions. Bronchopleural fistulas developed once in 47 instances of segmental bronchial closures and twice following 40 main bronchial closures (in both instances in patients with advanced bronchogenic carcinoma); no fistula developed following 45 lobectomies. There are two objections to closure of the bronchus by this technique. It does not permit visualization of the lumen of the proximal bronchus for evidence of residual disease or for aspiration of any material that may have collected proximal to the line of resection. Also, the instrument may crush an unsuspected intraluminal extension of the tumor (as occurred in one of Ravitch s cases [12]), or even squeeze off a portion of the tumor which might then gain access to some other part of the tracheobronchial tree, as occurred in one of our cases. Fortunately, the tumor fragment was removed by the anesthetist s suction tube when the patient was extubated. In patients with carcinoma, one should palpate the bronchus carefully before applying the stapler. If there is any question about the presence of tumor at the line of application of the stapler, it probably would be wise to open the bronchus first for adequate inspection; the stapler could then be applied proximally under direct vision. Among the total of 159 patients having operations in which the UKL-40 was used, there were 9 deaths within the first 30 days following surgery. In no case, however, was the death in any way attributable to the use of the stapling device. Ravitch [12], in his most recent report on the UKB-25 or bronchial stapler, concluded: In actual fact, the UKL instrument [UKL-401 which applies two rows of staggered staples parallel with the cut edge of the bronchus rather than at right angles to it, as with the instrument which we have been employing, is probably superior, not only for the vascular elements of the hilum but for the bronchial stump itself. With this statement we agree. 200 THE ANNALS OF THORACIC SURGERY

5 NOTE: Lung Stapler SUMMARY In a series of 159 pulmonary resections for a wide variety of pathologic conditions, the Russian lung stapler U KL-40 was employed for closure of the bronchial stump, across lung parenchyma, and across vascular hilar structures. This instrument differs from the Russian bronchial stapler UKB-25 in the orientation of the staples with regard to the structure being mechanically sutured. It is a much more versatile instrument than the UKB-25, since it can be used to control blood and air leaks from nonpleural surfaces after sublobar resections as well as to effect a secure bronchial or vascular closure. While the stapler has not eliminated bronchopleural fistulas, in our hands it is superior to the routine suture method of bronchial closure. The ability to remove all tuberculous foci without sacrificing normal parenchyma, the decreased operative time, diminished blood loss, and minimal postoperative problems of residual space have led us to believe that the UKL-40 is a useful instrument in the excisional treatment of pulmonary lesions. ACKNOWLEDGMENT We wish to thank Dr. Ivan W. Brown, Jr., for long-term loans of two models of staplers, which helped to stimulate our interest initially in the use of a lung stapler in pulmonary resection. REFERENCES 1. Amosov, N. M., and Berezovsky, K. K. Pulmonary resection with mechanical suture. J. Thorac. Cardiov. Surg. 41:325, Andrews, N. C., Marshall, F., and Christoforidis, A. J. An evaluation of segmental resection of the right upper lobe. Dis. Chest 42:36, Androsov, P. I. New instruments for thoracic surgery. Dis. Chest 44:550, Berezovsky, K. K., and Rosenberg, G. I. Immediate and late results of pulmonary resection with mechanical suture. (Unpublished.) Personal communication, Burch, B. H., Michals, A. A., and Miller, A. C. A new method for avoiding persistent air leaks following segmental pulmonary resection. Dis. Chest 44:381, Goldman, A. In discussion on Wilder, R. J., Playforth, H., Bryant, M., and Ravitch, M. M. The use of plastic adhesive in pulmonary surgery. J. Thorac. Cardiov. Surg. 46:587, Goldman, A. An evaluation of automatic suture with UKL-60 and UKL- 40 devices by pulmonary resection. Dis. Chest 46:30, Healey, J. E., Jr., Sheena, K. S., Gallagher, H. S., and Clark, R. L. Bronchial closure following pneumonectomy utilizing a plastic adhesive. Ann. Surg. 159: 172, Laitinen, E., Merikallio, E., and Perasalo, 0. Suture of the bronchial stump at pneumonectomy by Androsov s stapling device. Ann. Chir. Gynaec. Fenn. 50:423, VOL. 1, NO. 2, MAR.,

6 BETTS AND TAKARO 10. Moore, J. A., Walkup, H. E., Rayl, J. E., and Chapman, J. P., Jr. End results of pulmonary resection for tuberculosis. Ann. Surg. 147:659, Ravitch, M. M., Brown, I. W., and Daviglus, G. F. Experimental and clinical use of the Soviet bronchus stapling instrument. Surgery 46:97, Ravitch, M. M., Steichen, F. M., Fishbein, R. H., Knowles, P. W., and Weil, P. Clinical experiences with the Soviet mechanical bronchus stapler (UKB-25). J. Thorac. Cardiov. Surg. 47:446, Rzepecki, W., Birecka, A., and Goralczyk, J. Mechanical suture with metallic material in resection of pulmonary tissue (the UKLdO apparatus). Amer. Rev. Resp. Dis. 86:798, Sawyers, J. L., and Vasko, J. Sealing cut lung surfaces with plastic adhesive. J. Thorac. Cardiov. Surg. 46:526, Smith, D. E., Karish, A. F., Chapman, J. P., and Takaro, T. Healing of the bronchial stump after pulmonary resection. J. Thorac. Cardiov. Surg. 46: 548, Wilder, R. J., Playforth, H., Bryant, M., and Ravitch, M. M. The use of plastic adhesive in pulmonary surgery. J. Thorac. Cardiov. Surg. 46:576, THE ANNALS OF THORACIC SURGERY