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J Thorac Cardiovasc Surg 1994;107:596-0599
© 1994 Mosby, Inc.
General Thoracic Surgery |
Milan, Italy
Received for publication March 2, 1993. Accepted for publication May 31, 1993. Address for reprints: Ugo Pastorino, MD, Department of Thoracic Surgery, Istituto Nazionale Tumori, Via Venezian 1, 20133 Milan, Italy.
Abstract
The reliability of polyglyconate monofilament (Maxon) suture for sternal closure was tested on 216 consecutive sternotomies, performed on 208 patients in our department from January 1986 to December 1990. The reason of sternotomy was primary lung cancer in 34 cases (16%), lung metastases in 127 (59%), and disorders of the thymus in 55 (25%). Mean age was 38 years (range 3 to 78 years); multiple lung resections were performed in 102 patients (average 7 lesions, range 2 to 30); maximum extent of the operation was pneumonectomy in 2 cases, lobectomy in 53, segmentectomy in 27, and wedge resection in 74. Prior chemotherapy had been administered in 75 cases (35%). A second sternotomy was performed in 8 cases. No cases of sternal dehiscence, sternal infection, or empyema were observed, after a median follow-up of 27 months. Overall perioperative mortality was 0.9% (2/216). Our series demonstrates the safety of polyglyconate monofilament (Maxon) suture for sternal closure. Absorbable sutures appear to be a safe alternative to steel wire closure in patients undergoing extended pulmonary or mediastinal resection. (J THORAC CARDIOVASC SURG 1994;107:596-9)
Over the past decade, median sternotomy has become a popular approach for pulmonary and mediastinal operations. In fact, thoracic surgeons are increasingly being confronted with patients bearing multiple synchronous lung tumors, bilateral pulmonary metastases, or extended mediastinal neoplasms.
1-4 Moreover, in salvage operations for metastatic sarcomas, bilateral screening through sternotomy may be advantageous in patients with unilateral lesions to achieve diagnosis and one-stage resection of occult contralateral metastases. 5
Compared with cardiac surgery, pulmonary resection poses particular problems for sternal wound fixation and healing because of the higher chance of contamination of the surgical field as a result of opening the bronchi. Traditionally, sternal closure is obtained with nonabsorbable sutures, such as steel wire or braided polyester. Both materials are difficult for the surgeon to handle and may cause discomfort for the patient. 6
New synthetic absorbable monofilaments appear effective in terms of handling, strength, and lack of inflammatory reaction. They may therefore be a valid alternative to steel wire for sternal closure. 7 This article reports our experience with absorbable polyglyconate monofilament for sternal fixation in patients who have undergone sternotomy for pulmonary or mediastinal resection.
PATIENTS AND METHODS
Patients
The efficacy of polyglyconate monofilament suture (Maxon; Davis & Geck, Danbury, Conn.) for sternal closure was tested on 216 consecutive sternotomies performed on 208 patients in our department from January 1986 to December 1990. The principal characteristics of the patients are illustrated in Table I. Mean age was 38 years (range 3 to 78 years). The reason for sternotomy was primary lung cancer in 34 patients (16%), lung metastases in 127 (59%), and disorders of the thymus in 55 (25%). The third group included patients who underwent radical thymectomy for malignant thymoma (n = 19), benign thymic hyperplasia (n = 11), or normal thymus (n = 25) associated with a myasthenic syndrome. Multiple lung resections were performed in 102 patients (average 7 lesions, range 2 to 30); maximum extent of the operation was pneumonectomy in 2 cases, lobectomy in 53, segmentectomy in 27, and wedge resection in 74. Prior chemotherapy had been administered in 75 patients (35%).
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The technique of sternal closure was modified to improve the performance of the absorbable monofilament suture. As illustrated in Fig. 1, A, a series of double-loop stitches were passed (twice) through the intercostal spaces, with only one transsternal stitch used to close the manubrium. Both types of suture were tied with square knots. Intercostal suture was either simple (one separate stitch for each intercostal space, Fig. 1, B) or crossed (one stitch for two adjacent spaces with posterior crossing, Fig. 1, C).
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Table I). Before sternotomy, 6 patients had undergone anterolateral thoracotomy for pulmonary resection, and a second sternotomy was performed in 8 patients in this series. An average of 6 sutures were used to fix the sternum, both in the patients treated with combined polyglyconate/metal and in those treated with polyglyconate alone.
RESULTS
The results of our experience in terms of postoperative outcome can be summarized as follows. The average length of the operation was 125 minutes (range 43 to 315 minutes), being somewhat shorter for mediastinal operations than for pulmonary resections (103 versus 133 minutes). Chest drains were removed after an average period of 4 days (range 1 to 28 days).
Minor complications occurred in 14% of patients (30/216). They were mainly related to pulmonary resection, namely, ventilatory dysfunction (n = 9), prolonged air leakage (n = 13), or pleural effusion (n = 2). Transient local redness and inflammation of the wound was observed in 2 cases, without evidence of infection or positive cultures, and had subsided spontaneously by the time of discharge from the hospital (8 and 9 days after sternotomy).
Acute postoperative bleeding and hemothorax occurred in 3 patients and necessitated immediate reoperation. Thrombosis of the superior vena cava occurred in 1 patient after extended thymectomy with prosthetic replacement of the superior vena cava; the patient recovered after surgical thrombectomy. Intolerance to the metal suture, with pain and low-grade inflammation, was observed in 1 patient and resolved after removal of the steel wire.
Postoperative outcome was similar among patients who underwent a second operation after a prior sternotomy (n = 8) or thoracotomy (n = 6): wound healing was just as good as after primary sternotomy, with an average hospital stay of 11 days (range 6 to 20 days). The same held true for the 75 patients treated with preoperative chemotherapy (average 12 days, range 5 to 44 days).
The overall perioperative mortality was 0.9% (2/216). Median follow-up of the whole series of patients was 27 ± 16 months, with a range of 2 to 66 months. Overall survival at 3 years was 62% for patients with primary or metastatic lung cancer and 95% for patients with disorders of the thymus. No cases of sternal dehiscence, sternal infection, or empyema were observed in the immediate postoperative period, nor at the long-term follow-up.
DISCUSSION
The prevalence of sternal dehiscence and major sternal or mediastinal infection after cardiac operations is in the order of 1% to 2%. 8-12 Although relatively rare, these complications are associated with a high mortality rate (10% to 30%).
On a theoretical basis, pulmonary surgery could bear a higher risk of sternal or wound infection, whenever the bronchial epithelium is exposed during a major pulmonary resection. However, the reported surgical series are too small in this area to allow comparison. 1-4
The interest in absorbable sutures as alternatives to steel wire is justified by a number of reasons. They are easier to handle and may reduce the risk of accidental damage to the surgeon's fingers and, consequently, the potential risk of viral infection (hepatitis, human immunodeficiency virus).
Particularly in children or very thin adult patients, absorbable sutures may prevent chronic local infection as well as patient discomfort caused by a permanent foreign body. 6 The new generation of synthetic absorbable monofilaments appears adequate for this purpose, because of their handling and knotting features, mechanical strength, and lack of inflammatory reaction.
Polyglyconate monofilament (Maxon) has been tested with satisfactory results in pediatric surgery 13 and for mass closure of midline laparotomy with continuous running suture 14 or interrupted suture. 15 Tensile strength and knot-holding security of polyglyconate is similar to that of nonabsorbable steel or nylon in flexor tendon repair, 16 and the rate of incisional hernia is similar to that of polyamide (Ethilon; Ethicon, Inc., Somerville, N.J.) according to a randomized trial of abdominal wall closure. 17 Polyglyconate monofilament has been more effective for biliary anastomosis than other absorbable sutures, such as polygalactin 910 or chromic catgut, both in the animal 18 and in the human 19 setting. The available reports comparing polyglyconate with polydioxanone (PDS; Ethicon) show similar performance with respect to bursting strength in muscular, gastric, and colonic sutures 20 or to in vivo and in vitro degradation of tensile strength. 21
A pilot study 22 on sternal fixation with braided polydioxanone (PDS, size 1 or 2) has resulted in an unacceptable dehiscence rate of 20% (2/10). According to the authors, the negative results were attributable to a primary failure of the suture and not to the improper use of it. However, one may argue that transfixion of the sternum is not the optimal technique to be used with absorbable monofilaments, because the sharp angle at the surface of the bone may break the suture. As a matter of fact, the authors report that all PDS sutures had broken at the sternal puncture sites. 22
The present larger series does not support these negative results of absorbable sutures for sternal fixation. Our technique of double-loop stitches, developed to offer the best of the physical and mechanical features of polyglyconate monofilament, has been effective for permanent sternal fixation in children as well as in adult patients. This technique is similar to the one described recently by Di Marco and associates 23 as figure-of-eight peristernal steel wire suture, but we have used double-loop instead of interlocking sutures. The single steel wire suture, used for the fixation of manubrium during the first part of our experience, was replaced by polyglyconate as soon as we realized the safety of absorbable suture. During the whole series, we did not observe any sternal or mediastinal infection. The absence of acute and chronic infection may be of particular value in patients with metastatic sarcomas, having received intensive chemotherapy 2 to 4 weeks before and after sternotomy. The performance of this technique was not impaired in patients undergoing a second sternotomy.
In conclusion, our experience demonstrates the safety of polyglyconate monofilament (Maxon) for sternal closure in patients who have undergone sternotomy for pulmonary or mediastinal resection. Therefore, polyglyconate monofilament may be considered a suitable replacement of steel wire or braided polyester in other domains of thoracic surgery.
Footnotes
From the Departments of Thoracic Surgerya and Anesthesiology,b Istituto Nazionale Tumori, Milan, Italy. 
References
This article has been cited by other articles:
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  X. N. Yang and U. Pastorino Are absorbable sutures inadequate to close the sternum? J. Thorac. Cardiovasc. Surg., December 1, 2006; 132(6): 1503 - 1503. [Full Text] [PDF]
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 R. Bruhin, U. A. Stock, J.-P. Drucker, T. Azhari, J. Wippermann, J. M. Albes, D. Hintze, S. Eckardt, C. Konke, and T. Wahlers Numerical Simulation Techniques to Study the Structural Response of the Human Chest Following Median Sternotomy Ann. Thorac. Surg., August 1, 2005; 80(2): 623 - 630. [Abstract] [Full Text] [PDF]
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L. Spaggiari and U. Pastorino Double transmanubrial approach and sternotomy for resection of a giant thymic carcinoid tumor Ann. Thorac. Surg., August 1, 2001; 72(2): 629 - 631. [Abstract] [Full Text] [PDF]
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