ORIGINAL ARTICLE – THORACIC
Interactive CardioVascular and Thoracic Surgery 20 (2015) 798–804 doi:10.1093/icvts/ivv058 Advance Access publication 24 March 2015
Cite this article as: Palade E, Holdt H, Passlick B. Bronchus anastomosis after sleeve resection for lung cancer: does the suture technique have an impact on postoperative complication rate? Interact CardioVasc Thorac Surg 2015;20:798–804.
Bronchus anastomosis after sleeve resection for lung cancer: does the suture technique have an impact on postoperative complication rate? Emanuel Paladea,b,*, Holger Holdtc and Bernward Passlicka a b c
Department of Thoracic Surgery, Medical University Freiburg, Freiburg, Germany Clinic for Surgery, University of Schleswig-Holstein, Lübeck, Germany Department of Thoracic Surgery, Lung Center Wangen, Wangen im Allgäu, Germany
* Corresponding author. Clinic for Surgery, University of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23582 Lübeck, Germany. Tel: +49-451-5003155; fax: +49-451-5002069; e-mail: [email protected] (E. Palade). Received 14 November 2014; received in revised form 4 February 2015; accepted 19 February 2015
Abstract OBJECTIVES: Bronchoplastic resections emerged as an alternative to pneumonectomy for patients with impaired pulmonary function and have gained popularity due to a marked decrease in morbidity and at least similar oncological outcome. Actual guidelines recommend sleeve resections whenever technically feasible, even in cases with adequate pulmonary reserve for pneumonectomy, in order to maximally preserve functional lung parenchyma. Various suture techniques were described; the existing evidence, however, is insufficient to recommend one of them as standard. The aim of this study was to compare two suture techniques for bronchus repair after sleeve resection. METHODS: Two groups of patients from two separate institutions were retrospectively analysed. In Group A (n = 20), the anastomosis was performed with a running suture at the membranous part and an interrupted suture for the rest of the circumference. In Group B (n = 40), a telescoping continuous suture was used. Intra- and postoperative findings directly related to the anastomosis were compared. The parameters were assessed as absolute numbers and percentages; the statistical significance was determined using Pearson’s χ 2 test for categorical variables and Student’s t-test for continuous data (P < 0.05 considered as significant). RESULTS: Other than tumour location and resection type ( predominance of the right upper lobe for Group B), the groups were comparable regarding patient characteristics. The intraoperative anastomotic assessment revealed: patency 100% in both groups, initial air tightness (100 vs 82.5%; P = 0.047) and buttressing 85 vs 5%. No suture revision was necessary in both groups. The analysis of anastomosisrelated morbidity revealed no significant difference: atelectasis (1 in Group A and 2 in Group B; P = 1), reversible anastomotic changes (0 vs 2; P = 0.309), early stenosis (0 vs 0), bronchopleural fistula (1 vs 0; P = 0.154), bronchovascular fistula (0 vs 0), late stenosis (1 vs 0; P = 0.119) and reoperations (15 vs 5%; P = 0.186). The operative mortality rate was similar (2 vs 3; P = 0.741) without intraoperative deaths. CONCLUSIONS: Sleeve resections are technically challenging, especially concerning the tension in the suture and size mismatch. In our series, there was no significant difference between the two groups regarding parameters directly related to the anastomosis. The interrupted suture without telescoping is the most cited technique, can be performed in several variations and can universally be used with good ability to compensate size mismatch. The telescoping continuous anastomosis is less time- and material-consuming and is especially valuable for large-calibre bronchi and relevant size mismatch. Keywords: Sleeve resection • Bronchoplasty • Bronchoanastomosis • Telescoping anastomosis • Continuous suture
INTRODUCTION Bronchoplastic resections encompass a wide spectrum of resections and reconstructions of the bronchial system and are commonly performed in an attempt to preserve lung parenchyma (lung-sparing operations). For the treatment of lung cancer, the parenchyma of the affected lung area, usually a lobe, is resected together with a segment of the main bronchus (or bronchus intermedius on the right side) [1]. The two resulting resection margins are then approximated (bronchoanastomosis) to reconstruct the bronchial system and allow the ventilation of the remaining lung.
This type of bronchoplastic resection is often termed ‘sleeve resection’ and can be performed as a pneumonectomy, lobectomy, bilobectomy or even segmentectomy. Since its first description by Allison in 1954, the technique of bronchoplasties continues to evolve. Even video-assisted thoracoscopic and robotic-assisted sleeve lobectomies have been reported recently [1–5]. The proportion of bronchoplastic resections for lung cancer in most series ranges between 5 and 8% with a predominance of the right upper lobe sleeve resection in all reports [2, 6]. Typical indications are tumour infiltration reaching a lobar orifice and
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
E. Palade et al. / Interactive CardioVascular and Thoracic Surgery
compare the techniques are lacking. After reviewing the literature on this topic, the interrupted suture (with various modifications) seems to be the most commonly used technique for reconstruction after sleeve resection. Continuous and telescoping anastomoses are usually used in the context of lung transplantation.
MATERIALS AND METHODS This study is a retrospective analysis of two groups of patients from two separate departments of thoracic surgery. Group A (n = 20) was operated at the Department of Thoracic Surgery, Medical University Freiburg, between March 2004 and December 2007. Group B (n = 40) was treated at the Lung Center Wangen between August 2001 and September 2007. The two suture techniques were routinely used in each institution; the procedures were performed by experienced surgeons. A learning effect can therefore be excluded. The first author was at that time affiliated to both departments. The comparison of the two suture techniques was performed based on the postoperative morbidity and mortality by analysing the specific complications of the anastomosis (atelectasis, bronchovascular fistula, oedema or localized necrosis of the mucosa at the level of the anastomosis, anastomotic insufficiency, early and late stenosis). Oncological aspects such as recurrence or tumour-related survival were not addressed. To rule out eventual late complications, a minimum follow-up of 1 year was maintained in all cases. Data acquisition was based on the archived patient files. The analysed collective is summarized in Table 2; the different parameters were assessed as absolute numbers and percentages. Statistical significance was determined using Pearson’s χ 2 test for categorical variables and Student’s t-test for continuous data. The difference was considered significant for a value of P < 0.05.
Patient selection and perioperative management The preoperative assessment of the patients included in both groups encompassed clinical evaluation, a computer tomography of the chest and the abdomen, a bronchoscopy with biopsy, a pulmonary function test and evaluation of the cardiovascular status. If deemed necessary, further diagnostic testing, such as exercise
Table 1: Overview of representative series (n > 100 patients) presenting a detailed description of the suture technique [8–13] Authors and study
n
Suture technique
Suture material
Schirren et al. [12]
466
Interrupted
Ludwig et al. [8]
116
2/3 running, 1/3 interrupted
Yildizeli et al. [13]
218
Resorbable monofilament Not systematically (polydioxanone) 4-0 or 5-0 Maxon 4-0 Pericardial, pleural or mediastinal fatty tissue Vicryl 3-0 or 4-0 Pericardial or pleural flap PDS 4-0 None
Vicryl or Maxon Prolene 3-0
1/3 anterior running, 2/3 interrupted Icard et al. [10] 110 Posterior wall interrupted, anterior running Hollaus et al. [9] 108 Interrupted telescoping by mismatch Kutlu and Goldstraw [11] 100 (16 tracheal Running without resections) telescoping
Buttressing
Operative mortality (%) 8
Morbidity (%) –
4.3
23
4.1
22.9
2.75
44
None
5.5
26.8
None
2
12
ORIGINAL ARTICLE
peribronchial lymph node metastasis which centrally infiltrates a lobar bronchus. Bronchoplastic resections are no longer considered as compromise operations for patients unsuitable for pneumonectomy. In fact, actual guidelines such as those from the American College of Chest Physicians recommend that ‘for patients with clinical stage I or II central NSCLC in whom a complete resection can be achieved, a sleeve or bronchoplastic resection is suggested over a pneumonectomy’ [7]. However, there is no established standard regarding the suture technique of the anastomosis. Evidence that favours one or another modality is poor. Considering the type of the suture, the position of the two bronchial margins against each other and the thickness of the bronchial wall taken into the suture, the following technical variations can be used: continuous versus interrupted suture, end-to-end versus telescope anastomosis and full thickness versus extramucosal suture. Combinations of these modalities are possible and frequently described in the literature. Table 1 summarizes an overview of representative papers (n > 100 patients) containing a description of the suture technique. Anastomotic insufficiency, which can progress to a bronchovascular fistula with catastrophic consequences, is a rare (incidence
Interactive CardioVascular and Thoracic Surgery 20 (2015) 798–804 doi:10.1093/icvts/ivv058 Advance Access publication 24 March 2015
Cite this article as: Palade E, Holdt H, Passlick B. Bronchus anastomosis after sleeve resection for lung cancer: does the suture technique have an impact on postoperative complication rate? Interact CardioVasc Thorac Surg 2015;20:798–804.
Bronchus anastomosis after sleeve resection for lung cancer: does the suture technique have an impact on postoperative complication rate? Emanuel Paladea,b,*, Holger Holdtc and Bernward Passlicka a b c
Department of Thoracic Surgery, Medical University Freiburg, Freiburg, Germany Clinic for Surgery, University of Schleswig-Holstein, Lübeck, Germany Department of Thoracic Surgery, Lung Center Wangen, Wangen im Allgäu, Germany
* Corresponding author. Clinic for Surgery, University of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23582 Lübeck, Germany. Tel: +49-451-5003155; fax: +49-451-5002069; e-mail: [email protected] (E. Palade). Received 14 November 2014; received in revised form 4 February 2015; accepted 19 February 2015
Abstract OBJECTIVES: Bronchoplastic resections emerged as an alternative to pneumonectomy for patients with impaired pulmonary function and have gained popularity due to a marked decrease in morbidity and at least similar oncological outcome. Actual guidelines recommend sleeve resections whenever technically feasible, even in cases with adequate pulmonary reserve for pneumonectomy, in order to maximally preserve functional lung parenchyma. Various suture techniques were described; the existing evidence, however, is insufficient to recommend one of them as standard. The aim of this study was to compare two suture techniques for bronchus repair after sleeve resection. METHODS: Two groups of patients from two separate institutions were retrospectively analysed. In Group A (n = 20), the anastomosis was performed with a running suture at the membranous part and an interrupted suture for the rest of the circumference. In Group B (n = 40), a telescoping continuous suture was used. Intra- and postoperative findings directly related to the anastomosis were compared. The parameters were assessed as absolute numbers and percentages; the statistical significance was determined using Pearson’s χ 2 test for categorical variables and Student’s t-test for continuous data (P < 0.05 considered as significant). RESULTS: Other than tumour location and resection type ( predominance of the right upper lobe for Group B), the groups were comparable regarding patient characteristics. The intraoperative anastomotic assessment revealed: patency 100% in both groups, initial air tightness (100 vs 82.5%; P = 0.047) and buttressing 85 vs 5%. No suture revision was necessary in both groups. The analysis of anastomosisrelated morbidity revealed no significant difference: atelectasis (1 in Group A and 2 in Group B; P = 1), reversible anastomotic changes (0 vs 2; P = 0.309), early stenosis (0 vs 0), bronchopleural fistula (1 vs 0; P = 0.154), bronchovascular fistula (0 vs 0), late stenosis (1 vs 0; P = 0.119) and reoperations (15 vs 5%; P = 0.186). The operative mortality rate was similar (2 vs 3; P = 0.741) without intraoperative deaths. CONCLUSIONS: Sleeve resections are technically challenging, especially concerning the tension in the suture and size mismatch. In our series, there was no significant difference between the two groups regarding parameters directly related to the anastomosis. The interrupted suture without telescoping is the most cited technique, can be performed in several variations and can universally be used with good ability to compensate size mismatch. The telescoping continuous anastomosis is less time- and material-consuming and is especially valuable for large-calibre bronchi and relevant size mismatch. Keywords: Sleeve resection • Bronchoplasty • Bronchoanastomosis • Telescoping anastomosis • Continuous suture
INTRODUCTION Bronchoplastic resections encompass a wide spectrum of resections and reconstructions of the bronchial system and are commonly performed in an attempt to preserve lung parenchyma (lung-sparing operations). For the treatment of lung cancer, the parenchyma of the affected lung area, usually a lobe, is resected together with a segment of the main bronchus (or bronchus intermedius on the right side) [1]. The two resulting resection margins are then approximated (bronchoanastomosis) to reconstruct the bronchial system and allow the ventilation of the remaining lung.
This type of bronchoplastic resection is often termed ‘sleeve resection’ and can be performed as a pneumonectomy, lobectomy, bilobectomy or even segmentectomy. Since its first description by Allison in 1954, the technique of bronchoplasties continues to evolve. Even video-assisted thoracoscopic and robotic-assisted sleeve lobectomies have been reported recently [1–5]. The proportion of bronchoplastic resections for lung cancer in most series ranges between 5 and 8% with a predominance of the right upper lobe sleeve resection in all reports [2, 6]. Typical indications are tumour infiltration reaching a lobar orifice and
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
E. Palade et al. / Interactive CardioVascular and Thoracic Surgery
compare the techniques are lacking. After reviewing the literature on this topic, the interrupted suture (with various modifications) seems to be the most commonly used technique for reconstruction after sleeve resection. Continuous and telescoping anastomoses are usually used in the context of lung transplantation.
MATERIALS AND METHODS This study is a retrospective analysis of two groups of patients from two separate departments of thoracic surgery. Group A (n = 20) was operated at the Department of Thoracic Surgery, Medical University Freiburg, between March 2004 and December 2007. Group B (n = 40) was treated at the Lung Center Wangen between August 2001 and September 2007. The two suture techniques were routinely used in each institution; the procedures were performed by experienced surgeons. A learning effect can therefore be excluded. The first author was at that time affiliated to both departments. The comparison of the two suture techniques was performed based on the postoperative morbidity and mortality by analysing the specific complications of the anastomosis (atelectasis, bronchovascular fistula, oedema or localized necrosis of the mucosa at the level of the anastomosis, anastomotic insufficiency, early and late stenosis). Oncological aspects such as recurrence or tumour-related survival were not addressed. To rule out eventual late complications, a minimum follow-up of 1 year was maintained in all cases. Data acquisition was based on the archived patient files. The analysed collective is summarized in Table 2; the different parameters were assessed as absolute numbers and percentages. Statistical significance was determined using Pearson’s χ 2 test for categorical variables and Student’s t-test for continuous data. The difference was considered significant for a value of P < 0.05.
Patient selection and perioperative management The preoperative assessment of the patients included in both groups encompassed clinical evaluation, a computer tomography of the chest and the abdomen, a bronchoscopy with biopsy, a pulmonary function test and evaluation of the cardiovascular status. If deemed necessary, further diagnostic testing, such as exercise
Table 1: Overview of representative series (n > 100 patients) presenting a detailed description of the suture technique [8–13] Authors and study
n
Suture technique
Suture material
Schirren et al. [12]
466
Interrupted
Ludwig et al. [8]
116
2/3 running, 1/3 interrupted
Yildizeli et al. [13]
218
Resorbable monofilament Not systematically (polydioxanone) 4-0 or 5-0 Maxon 4-0 Pericardial, pleural or mediastinal fatty tissue Vicryl 3-0 or 4-0 Pericardial or pleural flap PDS 4-0 None
Vicryl or Maxon Prolene 3-0
1/3 anterior running, 2/3 interrupted Icard et al. [10] 110 Posterior wall interrupted, anterior running Hollaus et al. [9] 108 Interrupted telescoping by mismatch Kutlu and Goldstraw [11] 100 (16 tracheal Running without resections) telescoping
Buttressing
Operative mortality (%) 8
Morbidity (%) –
4.3
23
4.1
22.9
2.75
44
None
5.5
26.8
None
2
12
ORIGINAL ARTICLE
peribronchial lymph node metastasis which centrally infiltrates a lobar bronchus. Bronchoplastic resections are no longer considered as compromise operations for patients unsuitable for pneumonectomy. In fact, actual guidelines such as those from the American College of Chest Physicians recommend that ‘for patients with clinical stage I or II central NSCLC in whom a complete resection can be achieved, a sleeve or bronchoplastic resection is suggested over a pneumonectomy’ [7]. However, there is no established standard regarding the suture technique of the anastomosis. Evidence that favours one or another modality is poor. Considering the type of the suture, the position of the two bronchial margins against each other and the thickness of the bronchial wall taken into the suture, the following technical variations can be used: continuous versus interrupted suture, end-to-end versus telescope anastomosis and full thickness versus extramucosal suture. Combinations of these modalities are possible and frequently described in the literature. Table 1 summarizes an overview of representative papers (n > 100 patients) containing a description of the suture technique. Anastomotic insufficiency, which can progress to a bronchovascular fistula with catastrophic consequences, is a rare (incidence
