CORRESPONDENCE

Ann Thorac Surg 1992;54:1018-24

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tinal infection. This should be a useful technique for evaluating the adequacy of the mammary artery as a coronary conduit in patients when there is doubt regarding this vessel.

Frederick L. Grover, M D Division of Cardiothoracic Surgery University of Colorado Health Sciences Center 4200 E Ninth Ave Denver, C O 80262

Manual Versus Stapled Bronchial Closure: Still Controversial To the Editor:

Fig 1 . Typical ultrasonic appearance of a normal internal thoracic artery. (A = 3.7 mm; LT ITA = Left internal thoracic artery.) work for understanding the prospective functional patency of this ideal conduit for myocardial revascularization.

Charles C. Canver, M D

Thirty years after the initial use of surgical staplers for bronchial closure, the development of bronchopleural fistulas after major pulmonary resection still represents one of the greatest challenges for the thoracic surgeons’ current clinical practice. Despite experimental studies by Scott and associates [l], no clear clinical advantages and no less incidence of this ominous complication are expected after mechanically stapled closure of the large bronchi. The newest report on the issue by Vester and colleagues [2] does nothing but confirm that fact. Without a clinical, prospective, randomized study comparing stapled versus sutured bronchial closure, the extended use of mechanical devices is no more than a matter of feeling, and such a feeling should not provoke a false sensation of security. Stapling is not free of likelihood of failure. Keszler and Paris Romeu [3] reported a diminished in-hospital stay after pulmonary resection using staplers. This has important economic implications and could be a last, definitive argument for generalized bronchial stapled closure.

Section of Cardiothoracic Surgery Dartmouth Medical School Dartmou th-Hitchcock Medical Center One Medical Center Dr Lebanon, N H 03756

Rafael Aguilo, M D Miguel Llobera, M D , PhD

References Dignan RJ, Yeh T Jr, Dyke CM, Lutz HA 111, Wechsler AS. The influence of age and sex on human internal mammary artery size and reactivity. Ann Thorac Surg 1992;53:792-7. Canver CC, Ricotta JJ, Bhayana JN, Fiedler RC, Mentzer RM Jr. Use of duplex imaging to assess suitability of the internal mammary artery for coronary artery surgery. J Vasc Surg 1991;13:29&301. Canver CC, Fiedler RC, Hoover EL, Ricotta JJ, Mentzer RM Jr. Noninvasive assessment of internal thoracic artery for reoperative coronary artery surgery. J Cardiovasc Surg (in press).

Spain

Reply

To the Editor:

Dr Canver’s technique of evaluating mammary artery diameter, peak systolic and end-diastolic velocities, and the presence of atherosclerosis with color duplex ultrasound is very interesting and promising. I had asked Dr Dignan and his associates in the discussion of his article whether they had found any correlation of size and reactivity of the mammary artery with the presence of diabetes because of the increased incidence of atherosclerosis in diabetic patients. Dr Canver’s data would suggest that the internal mammary conduit should have similar flow characteristics in diabetic patients as in the rest of the population and, therefore, the decision regarding the use of the mammary in diabetic patients should not be based on fear of inadequate flow but rather should be weighed against the possibility of medias-

Hospital ”Son Dureta” Cl Andrea Doria, 55

07014 Palma de Mallorca

References 1. Scott RN, Faraci RP, Hough A, Chretien PB. Bronchial stump closure techniques following pneumonectomy: a serial comparative study. Ann Surg 1976;184:205-11. 2. Vester SR, Faber LP, Kittle CF, Warren WH, Jensik RJ. Bronchopleural fistula after stapled closure of bronchus. Ann Thorac Surg 1991;52:125%8. 3. Keszler P, Paris Romeu F. Stapling of the bronchus, lung and pulmonary vessels. In: Martini N, Vogt-Moykopf I, eds. Thoracic surgery: frontiers and uncommon neoplasms. St. Louis: C.V. Mosby, 1989519.

Reply

To the Editor:

We are certainly pleased that Drs Aguilo and Llobera believe that we accomplished a little more than nothing, as it took considerable effort on our part to review the records and follow-up information on 2,243 patients undergoing pulmonary resection. It was not our intent to extol the virtues of bronchial stapling, nor did we reach the conclusion that it was the most effective way to close the bronchus. It was our intent to carefully review and report our incidence of fistula after stapled closure of the bronchus. We also did not advocate generalized stapling of the bronchus and did discuss the contraindications to using this technique.

Manual versus stapled bronchial closure: still controversial.

CORRESPONDENCE Ann Thorac Surg 1992;54:1018-24 1021 tinal infection. This should be a useful technique for evaluating the adequacy of the mammary a...
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