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J Thorac Cardiovasc Surg 2002;124:632-635
© 2002 The American Association for Thoracic Surgery
Brief Communications |
From the Department of Thoracic and Vascular Surgery, Heidehaus Hospital (Hannover Medical School), Hannover, Germany.
Received for publication Jan 4, 2002. Accepted for publication Feb 14, 2002. Address for reprints: Paolo Macchiarini, MD, PhD, Department of Thoracic and Vascular Surgery, Heidehaus Hospital (Hannover Medical School), Am Leineufer 70, 30419 Hannover, Germany (E-mail: pmacchiarini{at}compuserve.com).
Recent anesthetic and surgical advances have remarkably reduced the frequency of airway complications after tracheobronchial resections, yet the end-to-side reimplantation of a main, lobar, or intermedius bronchus onto the trachea or the side of the contralateral main bronchus still represents a major technical challenge with high anastomotic morbidity and procedure-related mortality.
1 We present the results of a simplified anastomotic technique for end-to-side reimplantation of the lobar or intermedius bronchus onto the trachea or contralateral main bronchus after extensive bronchial sleeve resections or carinal lobectomy.
Clinical summary
Since April 1999, 10 patients underwent an elective tracheobronchial resection with 6 different types of end-to-side secondary anastomoses for benign (Table 1) or malignant (Table 2) processes. All patients received total intravenous anesthesia with a process electroencephalogram and were intubated through a double-lumen endobronchial tube, and the intraoperative intermittent cross-field ventilation concept was used. 2 Right-sided tumors were approached through an ipsilateral muscle-sparing posterolateral thoracotomy in the fifth intercostal space, and left-sided tumors were managed with a midline transsternal approach. All patients with cancer had a complete nodal dissection. The basic surgical principles of carinal resection and end-to-end primary anastomosis outlined by Grillo 3 and us 2,4 were followed.
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Second, the end-to-side anastomosis is then started by using the parachute principle (Figure 1). A double-ended polydioxanone (PDS; Ethicon Inc, Sommerville, NJ) 3-0 or 4-0 suture is inserted from within the lumen to complete the deepest and entire aspect of the anastomosis and is left untied (Figure 2, A). Once the placement is completed, the double-ended suture is pulled tight as the reimplanting and recipient lumens are approximated; care must be paid to avoid a purse-string effect. We recommend turning the airway mucosa inward and regularly approximating the parachuting sutures (Figure 2, B) through nerves hooks. While the double-ended PDS suture is kept on traction, it is gently fixed with 2 separate PDS sutures of the same size beyond both edges. Several concentric interrupted 3-0 to 5-0 polyglactin (Vicryl, Ethicon Inc) sutures are then placed on the remaining quadrants 3 to 4 mm apart and 3 to 4 mm from the cut edge of the airway, leaving the membranous wall of the reimplanting bronchus until last to allow balancing of any anastomotic disparity and excessive traction on it. We found that placing small Vicryl sutures (eg, 5-0) on the membranous wall reduces the manipulation risks of injury (Figure 3). Once placement is completed, the walls and sutures are gently approximated, and the knots are tied outside the airway. The anastomosis is then tested for air leaks to 40 mm Hg and repaired if needed. A circumferential anastomotic wrap with viable tissue is optional, but release maneuvers are mandatory.
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Discussion
The advantages of the parachute technique presented here are that it permits a less traumatic handling of the bronchial walls and direct anastomotic visualization and is quicker and easier to perform than the interrupted technique suture, thereby reducing the significant technical challenges traditionally reported with the end-to-side secondary anastomosis. 1 However, beyond those details outlined above, several other technical details are as important as the execution of the parachute technique in determining the outcome, namely the creation of a sufficiently large square orifice on the hosting surface to widely host the reimplanting bronchus, avoidance of the oblique trimming of the reimplanting bronchial takeoff to prevent its kinking and narrowing, and placement of the stump of the right upper lobar bronchus to be reimplanted into the trachea within 0.5 cm before its segmental trifurcation, especially in patients with non-small cell lung cancer, in which the systemic nodal dissection inevitably leads to division of the bronchial blood supply.
With carinal lobectomy, it has been suggested that advancement of the bronchus intermedius to the level of the trachea can lead to airway necrosis and narrowing caused by anastomotic angulation, devascularization, and tension, and thus reimplantation of intermedius bronchus into the left main bronchus appears to be safer. 1 We believe, however, that through an extended pericardial, mediastinal, and tracheal mobilization, a safe tracheal reimplantation is almost feasible when a tension-free anastomosis can be avoided and some surrounding tissue providing some degree of systemic blood supply to the anastomosis is preserved. On the other hand, performing the end-to-side secondary anastomosis on the left main bronchus, although feasible, is almost more technically demanding because the anastomosis must be made between the esophagus dorsally and the pericardium ventrally, especially during the apnea intervals, where the region lies very deep in the mediastinum. However, even in these cases the impaired visualization and handling can be better managed with a modification of the parachute technique by placing a series of running stitches at what will become the heel of the anastomosis, with the reimplanting and hosting bronchi separated, and then pulling tight as the bronchi are approximated.
Conclusion
The described parachute technique significantly simplifies the technical challenges and reduces the potential for postoperative anastomotic complications of the end-to-side secondary reimplantation of a lobar or intermedius bronchus into the trachea or contralateral main bronchus.
References
This article has been cited by other articles:
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  P. Macchiarini, M. Altmayer, T. Go, T. Walles, K. Schulze, I. Wildfang, A. Haverich, M. Hardin, and Hannover Interdisciplinary Intrathoracic Tumor Tas Technical Innovations of Carinal Resection for Nonsmall-Cell Lung Cancer Ann. Thorac. Surg., December 1, 2006; 82(6): 1989 - 1997. [Abstract] [Full Text] [PDF]
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