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Stable osteosynthesis after median sternotomy
CORRESPONDENCE
Evolution of Bronchus-First Technique To the Editor: The recent article on "Evolution of Pulmonary Resection Techniques and Review of the Bronchus-First M e t h o d " [1] is a most interesting historical narrative. I would like to make just one comment concerning division of the bronchus before the pulmonary vessels. In the 1940s and early 1950s the bronchus was frequently divided first because of the problem of excessive sputum production and the necessity to control this during anesthesia. With the advent of more effective antibiotics and the consequent reduction in sputum this became less important, and furthermore the advantage of early division of the pulmonary veins to prevent tumor embolization became widely accepted, as had been shown by Aylwin in 1951 [2]. The majority of present-day pulmonary resections are performed for carcinoma, and in these cases many surgeons in the United Kingdom now consider it important to divide the pulmonary veins before the bronchus.
Raymond Hurt, FRCS The White House 8 Loom Lane Radlett Hefts WD78AD United Kingdom References 1. Grismer JT, Read RC. Evolution of pulmonary resection techniques and review of the bronchus-first method. Ann Thorac Surg 1995;60:1133-7. 2. Aylwin JA. Avoidable vascular spread in resection for bronchial carcinoma. Thorax 1951;6:250-67.
R ep l y To the Editor: Doctor Hurt of the United Kingdom is an internationally recognized authority on the history of thoracic surgery, and therefore we are appreciative of his comments regarding our contribution "Evolution of Pulmonary Resection Techniques and Review of the Bronchus-First M e t h o d " [1]. He agrees that pioneer surgeons attempted to control excessive bronchial secretions by early occlusion of the bronchus. Thus, Craaford placed an intrabronchial tampon endoscopically before pneumonectomy. However, Chamberlain promulgated bronchus-first resection of the fight upper lobe because it enabled wide resection of lobar lymph nodes and facilitated ligature of the arterial supply. We would agree that in bulky neoplasms invading hilar structures, the potential exists for gross tumor emboli as Dr Hurt cited [2]. Today this catastrophe can be anticipated preoperatively by diagnostic studies a n d prevented by initial careful inspection and resection at the pulmonary venous-atrial interface. Its rarity does not warrant routine early dissection and division of the pulmonary veins. Studies of neoplasms in the 1950s a n d 1960s documented a significant incidence of microvascular invasion with circulating tumor cells [3, 4]. However, the incidence did not uniformly correlate with 5-year survival [5, 6]. As noted in a 1995 oncology review, "Metastasis is a complex, highly selective multistep process involving n u m e r o u s interactions between tumor cells and the host's extracellular matrix and i m m u n e system. Metastatic foci are derived from only a very small select subpopula© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
tion of the primary t u m o r " [7]. In 1970, in the absence of preoperative systemic metastases, Croxatto and Bareat [8] docu m e n t e d the critical prognostic significance of regional pulmonary lymph node metastases. This study and others formed the basis for the presently accepted International Staging System for Lung Cancer [9]. For these reasons, in this country, surgeons continue to prefer initial control of the pulmonary arterial inflow. Just a few weeks ago, Pantel a n d associates [10] published a detailed analysis of bone marrow metastases from non-small cell lung cancer. They stated, "Because of concern that intraoperative handling of the t u m o u r induces haematogenous dissemination of tumour cells, we examined bone-marrow aspirates from patients before and immediately after operation. We found no evidence for surgery-induced dissemination of tumour cells." Thus, this very recent article reinforces our comments.
Jerome T. Grismer, MD Raymond C. Read, MD Veterans Administration Medical Center 4300 W 7th St Little Rock, AR 72205 References 1. Grismer JT, Read RC. Evolution of pulmonary resection techniques a n d review of the bronchus-first method. Ann Thorac Surg 1995;60:1133-7. 2. Aylwin JA. Avoidable vascular spread in resection for bronchial carcinoma. Thorax 1951;6:250-67. 3. Collier FC, Enterline HT, Kyle RM, Tristran TT, Greening R. The prognostic implication of vascular invasion in primary carcinoma of the lung. A clinicopathologic correlation of two h u n d r e d twenty five cases with one h u n d r e d per cent follow up. Arch Surg 1958;66:594-602. 4. Engell HC. Cancer cells in the circulating blood. A clinical study of the occurrence of cancer cells in the peripheral blood and in venous blood draining the tumor area at operation. Acta Chir Scand 1955;201(Suppl):1-70. 5. Griffiths JD, McKinna JA, Rowbotham HD, Tsolakidis P, Salsbury AJ. Carcinoma of the colon a n d rectum: circulating malignant cell and five-year survival. Cancer 1973;31:226-36. 6. Engell HC. Cancer cells in the blood. Ann Surg 1959;149: 457- 61. 7. Casciato DA. Metastases of u n k n o w n origin. In: Haskell CM, Berek JS, eds. Cancer treatment. Philadelphia: Saunders, 1995:1129. 8. Croxatto OC, Barcat JA. Lymph node metastases in bronchogenic carcinoma. Study of its role in dissemination. Johns Hopkins Med J 1970;126:121-9. 9. Ginsberg RJ, Goldberg M, Waters PF. Surgery for non-small cell lung cancer. In: Roth JA, Ruckdeschel JC, Weisenburger TH, eds. Thoracic oncology, Philadelphia: Saunders, 1995: 127-41. 10. Pantel IG Izbicki J, Passlick B, et al. Frequency a n d prognostic significance of isolated tumour cells in bone marrow of patients with non-small-cell lung cancer without overt metastases. Lancet 1996;347:649-53.
Stable Osteosynthesis After Median Sternotomy To the Editor: Bone stability is certainly one of the most important factors in the prevention of sternum separation and deep sternal w o u n d infection. The method presented by Drs Chlosta and Elefteriades [1l looks easier than the classic weaving-wire closure described by Robicsek and co-workers nearly two decades ago [2]. The vertical wires can certainly act like pledgets on the inner A n n Thorac Surg 1996;61:1585-92 ° 0003-4975/96l$15.00 PII S0003-4975(96)00115-4
1586
CORRESPONDENCE
Ann Thorac Surg
1996;61:1585-92
4. Kollar A, Hajdu L, Sugar T. Partial helical sternotomy to promote enhanced sternal stability. J Cardiac Surg 1995;10: 280.
Reply To the Editor:
Fig 1. The corresponding sternal surfaces easily and tightly fit together after partial helical sternotomy [4]. (Illustration by Judith Kosko.)
a n d outer tables of the sternum, but they offer less protection against lateral tearing forces, which occur at every cough. As compared with their technique the weaving m e t h o d may take somewhat more time, because the rigid wires cannot be easily shaped around the ribs; however, it still o~fers better mechanical stability. We agree with Dr Chlosta and Dr Eiefteriades that especially in high-risk patients tight and secure sternum reapproximation--stable sternal osteosynthesis--should be done. To achieve that we frequently use one or two transsternal figure-of-8 wires as described by G o o d m a n and associates [3]. In high-risk patients we tend to employ the technique of partial helical sternotomy [4], which allows proper reapproximation of the interfacing sternal halves (Fig 1). In cases of multiple fragmented sternum we still use the traditional sternal weave; however, in some cases we replace the parasternal wires with heavy no. 5 Ethibond sutures (Ethicon, Somerville, NJ), which are easier to handle but have adequate tensile strength. According to the surgeon's preference these techniques could be used in any combination.
Andras Kollar, MD R. Mark Stiegel, MD Jay G. Selle, MD Department of Thoracic and Cardiovascular Surgery Carolinas Heart Institute PO Box 32861 Charlotte, NC 28232-2861 References 1. Chlosta WF, Elefteriades JA. Simplified method of reinforced sternal closure. Ann Thorac Surg 1995;60:1428-9. 2. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267-8. 3. G o o d m a n G, Palatianos GM, Bolooki H. Technique of closure of m e d i a n sternotorny with trans-sternal figure-of-eight wires. J Cardiovasc Surg 1986;27:512-3. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science |nc
We thank Dr Kollar and colleagues for their comments on our brief report on a "'Simplified Method of Reinforced Sternal Closure" [1]. We have found the simplified m e t h o d described in our report to provide good reinforcement of the breast bone. The theoretic concerns about the pressure against the lateral portion of the sternum were not borne out by any clinical problems in our series. In fact, in the simplified method described in our report, the vertical wires actually come to lie quite close to the lateral edge of the sternum. It appears that the good support of the inner and outer tables achieved in this way does prevent the transverse wires from tearing through. The weaving-wire closure of Robicsek and co-workers [2] is certainly the most proven method of sternal reinforcement. The additional techniques that are mentioned by Dr Kollar and colleagues, including transsternal figure-of-8 wires a n d partial helical sternotomy, can certainly be useful adjuncts.
William F. Chlosta, MD John A. Elefteriades, MD Section of Cardiothoracic Surgery Yale University School of Medicine 333 Cedar St New Haven, CT 06520-8039 References 1. Chlosta WF, Elefteriades JA. Simplified method of reinforced sternal closure. A n n Thorac Surg 1995;60:1428-9. 2. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267-8.
Simplified Reinforced Sternal Closure To the Editor: We read with interest the article "Simplified Method of Reinforced Sternal Closure" by Chlosta and Elefteriades [1]. We believe that placing the longitudinal wire is a very good idea and definitely strengthens the closure. We have been using a similar but slightly modified technique in those patients who are at higher risk of poor sternal healing and for reclosure of sternal dehiscence with excellent results. The longitudinal wire is passed in and out through the sternal plates along the length of the sternum; the u p p e r a n d the lower ends of the wire are then twisted with their partners from the other side (Fig 1). This modification makes the longitudinal wire more stable and works as a part of the sternum to resist the pulling-through effect of the horizontal wires. We think this is a good addition to the already described technique.
Idris M. Ali, MD Victoria General Hospital ACC 3089 Halifax, NS B3H 2Y9, Canada Abulkasim A. Sanalla, FRCS(Ed) 4 Lunan Pl Leeds LS8 4ES England 0003-4975/96/$15.00
Evolution of Bronchus-First Technique To the Editor: The recent article on "Evolution of Pulmonary Resection Techniques and Review of the Bronchus-First M e t h o d " [1] is a most interesting historical narrative. I would like to make just one comment concerning division of the bronchus before the pulmonary vessels. In the 1940s and early 1950s the bronchus was frequently divided first because of the problem of excessive sputum production and the necessity to control this during anesthesia. With the advent of more effective antibiotics and the consequent reduction in sputum this became less important, and furthermore the advantage of early division of the pulmonary veins to prevent tumor embolization became widely accepted, as had been shown by Aylwin in 1951 [2]. The majority of present-day pulmonary resections are performed for carcinoma, and in these cases many surgeons in the United Kingdom now consider it important to divide the pulmonary veins before the bronchus.
Raymond Hurt, FRCS The White House 8 Loom Lane Radlett Hefts WD78AD United Kingdom References 1. Grismer JT, Read RC. Evolution of pulmonary resection techniques and review of the bronchus-first method. Ann Thorac Surg 1995;60:1133-7. 2. Aylwin JA. Avoidable vascular spread in resection for bronchial carcinoma. Thorax 1951;6:250-67.
R ep l y To the Editor: Doctor Hurt of the United Kingdom is an internationally recognized authority on the history of thoracic surgery, and therefore we are appreciative of his comments regarding our contribution "Evolution of Pulmonary Resection Techniques and Review of the Bronchus-First M e t h o d " [1]. He agrees that pioneer surgeons attempted to control excessive bronchial secretions by early occlusion of the bronchus. Thus, Craaford placed an intrabronchial tampon endoscopically before pneumonectomy. However, Chamberlain promulgated bronchus-first resection of the fight upper lobe because it enabled wide resection of lobar lymph nodes and facilitated ligature of the arterial supply. We would agree that in bulky neoplasms invading hilar structures, the potential exists for gross tumor emboli as Dr Hurt cited [2]. Today this catastrophe can be anticipated preoperatively by diagnostic studies a n d prevented by initial careful inspection and resection at the pulmonary venous-atrial interface. Its rarity does not warrant routine early dissection and division of the pulmonary veins. Studies of neoplasms in the 1950s a n d 1960s documented a significant incidence of microvascular invasion with circulating tumor cells [3, 4]. However, the incidence did not uniformly correlate with 5-year survival [5, 6]. As noted in a 1995 oncology review, "Metastasis is a complex, highly selective multistep process involving n u m e r o u s interactions between tumor cells and the host's extracellular matrix and i m m u n e system. Metastatic foci are derived from only a very small select subpopula© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
tion of the primary t u m o r " [7]. In 1970, in the absence of preoperative systemic metastases, Croxatto and Bareat [8] docu m e n t e d the critical prognostic significance of regional pulmonary lymph node metastases. This study and others formed the basis for the presently accepted International Staging System for Lung Cancer [9]. For these reasons, in this country, surgeons continue to prefer initial control of the pulmonary arterial inflow. Just a few weeks ago, Pantel a n d associates [10] published a detailed analysis of bone marrow metastases from non-small cell lung cancer. They stated, "Because of concern that intraoperative handling of the t u m o u r induces haematogenous dissemination of tumour cells, we examined bone-marrow aspirates from patients before and immediately after operation. We found no evidence for surgery-induced dissemination of tumour cells." Thus, this very recent article reinforces our comments.
Jerome T. Grismer, MD Raymond C. Read, MD Veterans Administration Medical Center 4300 W 7th St Little Rock, AR 72205 References 1. Grismer JT, Read RC. Evolution of pulmonary resection techniques a n d review of the bronchus-first method. Ann Thorac Surg 1995;60:1133-7. 2. Aylwin JA. Avoidable vascular spread in resection for bronchial carcinoma. Thorax 1951;6:250-67. 3. Collier FC, Enterline HT, Kyle RM, Tristran TT, Greening R. The prognostic implication of vascular invasion in primary carcinoma of the lung. A clinicopathologic correlation of two h u n d r e d twenty five cases with one h u n d r e d per cent follow up. Arch Surg 1958;66:594-602. 4. Engell HC. Cancer cells in the circulating blood. A clinical study of the occurrence of cancer cells in the peripheral blood and in venous blood draining the tumor area at operation. Acta Chir Scand 1955;201(Suppl):1-70. 5. Griffiths JD, McKinna JA, Rowbotham HD, Tsolakidis P, Salsbury AJ. Carcinoma of the colon a n d rectum: circulating malignant cell and five-year survival. Cancer 1973;31:226-36. 6. Engell HC. Cancer cells in the blood. Ann Surg 1959;149: 457- 61. 7. Casciato DA. Metastases of u n k n o w n origin. In: Haskell CM, Berek JS, eds. Cancer treatment. Philadelphia: Saunders, 1995:1129. 8. Croxatto OC, Barcat JA. Lymph node metastases in bronchogenic carcinoma. Study of its role in dissemination. Johns Hopkins Med J 1970;126:121-9. 9. Ginsberg RJ, Goldberg M, Waters PF. Surgery for non-small cell lung cancer. In: Roth JA, Ruckdeschel JC, Weisenburger TH, eds. Thoracic oncology, Philadelphia: Saunders, 1995: 127-41. 10. Pantel IG Izbicki J, Passlick B, et al. Frequency a n d prognostic significance of isolated tumour cells in bone marrow of patients with non-small-cell lung cancer without overt metastases. Lancet 1996;347:649-53.
Stable Osteosynthesis After Median Sternotomy To the Editor: Bone stability is certainly one of the most important factors in the prevention of sternum separation and deep sternal w o u n d infection. The method presented by Drs Chlosta and Elefteriades [1l looks easier than the classic weaving-wire closure described by Robicsek and co-workers nearly two decades ago [2]. The vertical wires can certainly act like pledgets on the inner A n n Thorac Surg 1996;61:1585-92 ° 0003-4975/96l$15.00 PII S0003-4975(96)00115-4
1586
CORRESPONDENCE
Ann Thorac Surg
1996;61:1585-92
4. Kollar A, Hajdu L, Sugar T. Partial helical sternotomy to promote enhanced sternal stability. J Cardiac Surg 1995;10: 280.
Reply To the Editor:
Fig 1. The corresponding sternal surfaces easily and tightly fit together after partial helical sternotomy [4]. (Illustration by Judith Kosko.)
a n d outer tables of the sternum, but they offer less protection against lateral tearing forces, which occur at every cough. As compared with their technique the weaving m e t h o d may take somewhat more time, because the rigid wires cannot be easily shaped around the ribs; however, it still o~fers better mechanical stability. We agree with Dr Chlosta and Dr Eiefteriades that especially in high-risk patients tight and secure sternum reapproximation--stable sternal osteosynthesis--should be done. To achieve that we frequently use one or two transsternal figure-of-8 wires as described by G o o d m a n and associates [3]. In high-risk patients we tend to employ the technique of partial helical sternotomy [4], which allows proper reapproximation of the interfacing sternal halves (Fig 1). In cases of multiple fragmented sternum we still use the traditional sternal weave; however, in some cases we replace the parasternal wires with heavy no. 5 Ethibond sutures (Ethicon, Somerville, NJ), which are easier to handle but have adequate tensile strength. According to the surgeon's preference these techniques could be used in any combination.
Andras Kollar, MD R. Mark Stiegel, MD Jay G. Selle, MD Department of Thoracic and Cardiovascular Surgery Carolinas Heart Institute PO Box 32861 Charlotte, NC 28232-2861 References 1. Chlosta WF, Elefteriades JA. Simplified method of reinforced sternal closure. Ann Thorac Surg 1995;60:1428-9. 2. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267-8. 3. G o o d m a n G, Palatianos GM, Bolooki H. Technique of closure of m e d i a n sternotorny with trans-sternal figure-of-eight wires. J Cardiovasc Surg 1986;27:512-3. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science |nc
We thank Dr Kollar and colleagues for their comments on our brief report on a "'Simplified Method of Reinforced Sternal Closure" [1]. We have found the simplified m e t h o d described in our report to provide good reinforcement of the breast bone. The theoretic concerns about the pressure against the lateral portion of the sternum were not borne out by any clinical problems in our series. In fact, in the simplified method described in our report, the vertical wires actually come to lie quite close to the lateral edge of the sternum. It appears that the good support of the inner and outer tables achieved in this way does prevent the transverse wires from tearing through. The weaving-wire closure of Robicsek and co-workers [2] is certainly the most proven method of sternal reinforcement. The additional techniques that are mentioned by Dr Kollar and colleagues, including transsternal figure-of-8 wires a n d partial helical sternotomy, can certainly be useful adjuncts.
William F. Chlosta, MD John A. Elefteriades, MD Section of Cardiothoracic Surgery Yale University School of Medicine 333 Cedar St New Haven, CT 06520-8039 References 1. Chlosta WF, Elefteriades JA. Simplified method of reinforced sternal closure. A n n Thorac Surg 1995;60:1428-9. 2. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267-8.
Simplified Reinforced Sternal Closure To the Editor: We read with interest the article "Simplified Method of Reinforced Sternal Closure" by Chlosta and Elefteriades [1]. We believe that placing the longitudinal wire is a very good idea and definitely strengthens the closure. We have been using a similar but slightly modified technique in those patients who are at higher risk of poor sternal healing and for reclosure of sternal dehiscence with excellent results. The longitudinal wire is passed in and out through the sternal plates along the length of the sternum; the u p p e r a n d the lower ends of the wire are then twisted with their partners from the other side (Fig 1). This modification makes the longitudinal wire more stable and works as a part of the sternum to resist the pulling-through effect of the horizontal wires. We think this is a good addition to the already described technique.
Idris M. Ali, MD Victoria General Hospital ACC 3089 Halifax, NS B3H 2Y9, Canada Abulkasim A. Sanalla, FRCS(Ed) 4 Lunan Pl Leeds LS8 4ES England 0003-4975/96/$15.00