- Email: [email protected]
Clamshell Closure With Absorbable Sternal Pins in Lung Transplant Recipients
Clamshell Closure With Absorbable Sternal Pins in Lung Transplant Recipients Anne Olland, MD, PhD, J er emie Reeb, MD, MSc, Sophie Guinard, MSc, Joseph Seitlinger, MD, Nicola Santelmo, MD, Romain Kessler, MD, PhD, Pierre-Emmanuel Falcoz, MD, PhD, and Gilbert Massard, MD, PhD ˇ
Lung Transplantation Group, Nouvel Hopital Civil, University Hospital Strasbourg, Strasbourg; and EA7293 SVTT, Translational Medicine Federation, Medicine School Strasbourg, University of Strasbourg, Strasbourg, France
Clamshell (bilateral anterolateral thoracotomy combined to transverse sternotomy) is an invasive surgical approach that is helpful in particular situations, especially bilateral lung transplantation. The closure technique remains challenging because clamshell incision can end with override, separation, or sternal pseudarthrosis complications. We describe
the use of new absorbable sternal pins to stabilize the sternal closure and to help avoid additional sternal complications.
C
During closure, we place four crossed sutures of polydioxanone cord (Ethicon, Somerville, NJ) or polyglactin 910 (decimal 5; Ethicon, Somerville, NJ) on each thoracotomy to prepare the closure of both right and left intercostal spaces. A crossed suture of polydioxanone cord (Ethicon) is placed at the parasternal side of the intercostal space. Depending on the width of the sternal
lamshell incision (bilateral anterolateral thoracotomy combined with transverse sternotomy) is a traumatic and invasive surgical approach, though helpful in particular situations of bilateral lung transplantation [1]. Most of the time, separate bilateral anterolateral thoracotomies provide a sufficient exposure. In case of narrow chest, dense pleural adhesion, or need for central circulatory bypass, clamshell offers easier approach and increased safety [1–3]. Closure of a clamshell incision in such patients can be challenging, because of the upcoming immunosuppressive regimen with high-dose steroids, prior osteoporosis in patients with chronic obstructive pulmonary disease, long-lasting steroid therapy before transplantation, and malnutrition. Indeed, the postoperative recovery of transplant recipients who underwent a clamshell is jeopardized by a relatively high incidence of sternal complications, whereas patients operated through bilateral thoracotomy without sternal division have more favorable outcomes [2]. The most common variant of sternal dehiscence is overriding of both segments, which may evolve toward complete sternal separation. Parasternal crossed sutures may lower the rate of sternal complications, but they do not completely prevent sternal dehiscence [4]. In this context, we completed sternal closure of clamshell incision with intramedullary tutors, using absorbable sternal pins made of poly-L-lactide (Gunze, Tokyo, Japan; Fig 1) [5].
(Ann Thorac Surg 2017;104:e207–9) Ó 2017 by The Society of Thoracic Surgeons
Technique Clamshell incision in the context of lung transplantation is usually performed through the fourth or fifth intercostal spaces with transversal sternal division. Address correspondence to Dr Olland, Lung Transplantation Group, Thoracic Surgery Department, Nouvel Hopital Civil, University Hospital Strasbourg, Strasbourg, France; email: [email protected]. ˇ
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
Fig 1. (A) Poly-L-lactide sternal pin. (B) Hole sizer. (C) Holder. (D) T-shaped hole performer.
The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2017.04. 036] on http://www.annalsthoracicsurgery.org.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2017.04.036
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HOW TO DO IT OLLAND ET AL STERNAL PINS FOR CLAMSHELL CLOSURE
Ann Thorac Surg 2017;104:e207–9
normal bone structure with an electric oscillating saw. At least two sternal pins are placed to stabilize the transverse sternotomy (Fig 3B). Insert the pins into the overriding extremity, realign the sternum, and use the pin holder to pull out the pin from one sternal section to push into the other half while they are aligned. Next, polydioxanone cords are placed around the intercostal spaces on each side of the sternum and on the sternum itself. Lastly, sutures can be tightened and tied (Fig 3C).
Fig 2. Operative view of primary closure of a clamshell incision in a lung transplant recipient. Sutures and sternal pins are ready for closure.
section, one or two crossed polydioxanone cords are placed on the sternum. Once all sutures are placed and ready to be tightened, sternal extremities are prepared for placing the pins (Video). A T-shaped instrument with sharp edges is used to prepare corresponding holes facing each other in the spongy part of each sternal section (Fig 2). Ideally, two pins are required. Once the holes are dug, a sizer enables widening of the hole to fit with the size of the pin to be implanted. Once all four holes have been sized appropriately, both pins are placed in the upper or in the lower sternal section (Fig 2; Video). Sutures are progressively tightened and sternal extremities are carefully approximated, while a pin holder guides appropriate placement of the pins into the opposite hemisternum. Once the pins are inserted into both sternal segments, all sutures can be tightened and tied (Video). In patients with sternal complications after primary clamshell closure, such as override, separation or pseudarthrosis, sternal pins can also be used during reoperation to realign and stabilize the sternum. The skin incision should be wide enough to ensure adequate exposure of the sternum and the parasternal end of the corresponding intercostal space. Soft tissues are dissected off the cartilage and bone, and the site of sternotomy is exposed (Fig 3A). Any fibrotic scar tissue or granulation should be cleared. The sternum is trimmed down to
Comment The absorbable pins have become available since January 1, 2016, in our clinical practice. From January 2016 to October 31, 2016, we have performed 43 lung transplants; 14 of them required a clamshell incision. In two patients, the sternal pins were not available for closure because of logistical reasons. Sternal healing was achieved in all 12 clamshell patients who underwent closure and sternal tutorizing with absorbable pins; however, sternal complications arose in both patients closed without the use of pins. One patient was a 36-year-old woman undergoing redo bilateral lung transplantation for bronchiolitis obliterans following primary heart–lung transplantation; central circulatory bypass was needed during the surgery. The other patient was a 64-year-old man undergoing bilateral lung transplantation for fibrosis; the clamshell incision was used because of a narrow chest with dense pleural adhesions, but no bypass was needed. Both patients had an uneventful immediate postoperative outcome. The woman required longer mechanical ventilation support following surgery and was extubated at day 10. Both patients presented 6 weeks after surgery with chest pain and paradoxic chest wall movements; palpation revealed painful sternal overriding in both patients. Secondary closure using intramedullary stabilization with sternal pins led to uneventful recovery. The sternum appeared stable and without pain at 3 months. The overall risk for sternal complications after clamshell thoracotomy is estimated between 34% and 48% [2, 6]. The latter includes override, pseudarthrosis, and separation [4]. Hence, the use of intramedullary pins to
Fig 3. (A) Operative view of an override of the sternum. (B) The overriding part of the sternum is separated from the underriding part and to realign the sternum and place the pins. (C) Finally, sutures are placed, and the transection is ready to be closed on both pins.
Ann Thorac Surg 2017;104:e207–9
improve sternal stabilization is meaningful. Previous attempts with metallic pins have been limited by migration complications. In the context of immunosuppression joined to potential osteoporosis, long-lasting steroid therapy and malnutrition, absorbable material offers the advantage of lowering the risk for infection or foreign body reaction, and their edges are not as sharp as metallic pins, thus avoiding the risk of migration. Mechanical properties of poly-L-lactide pins are reliable; the bending strength will maintain close to 100% until the fourth month following implantation, which is long enough to ensure normal bone healing. Furthermore, absorbable material does not require a second operation for removal. We recommend routine use of at least two pins to neutralize anteroposterior, lateral, and torque movements [7]. Although we did not observe any failure of absorbable intramedullary stabilization, we became aware that fixed rigid metal implants in the sternal area were at risk for disruption in almost half the patients [7]. Previous publications have demonstrated an advantage from incurved transection of the sternum as it increases the bone healing surface and stabilizes lateral movements, but it will not stabilize anteroposterior movements [8]. In conclusion, sternal closure after clamshell thoracotomy is a high-risk situation for disabled bone healing.
HOW TO DO IT OLLAND ET AL STERNAL PINS FOR CLAMSHELL CLOSURE
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The risk may be considerably lowered by intramedullary stabilization with absorbable pins.
References 1. Wright C. Transverse sternothoracotomy. Chest Surg Clin N Am 1996;6:149–56. 2. Meyers BF, Sundaresan RS, Guthrie T, Cooper JD, Patterson GA. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications. J Thorac Cardiovasc Surg 1999;117:358–64. 3. Venuta F, Rendina EA, De Giacomo T, et al. Bilateral sequential lung transplantation without sternal division. Eur J Cardiothorac Surg 2003;23:894–7. 4. Koster TD, Ramjankhan FZ, van de Graaf EA, et al. Crossed wiring closure technique for bilateral transverse thoracosternotomy is associated with less sternal dehiscence after bilateral sequential lung transplantation. J Thorac Cardiovasc Surg 2013;146:901–5. 5. Saito T, Iguchi A, Sakurai M, Tabayashi K. Biomechanical study of a poly-L-lactide (PLLA) sternal pin in sternal closure after cardiothoracic surgery. Ann Thorac Surg 2004;77:684–7. 6. Macchiarini P, Ladurie FL, Cerrina J, Fadel E, Chapelier A, Dartevelle P. Clamshell or sternotomy for double lung or heartlung transplantation? Eur J Cardiothorac Surg 1999;15:333–9. 7. Berthet JP, Caro AG, Silovei L, et al. Titanium implant failure after chest wall osteosynthesis. Ann Thorac Surg 2015;99: 1945–52. 8. Costa J, Sonett JR, D’Ovidio F. Modified transverse thoracosternotomy and cost-effective reinforced sternal closure. Ann Thorac Surg 2015;100:2376–8.
Lung Transplantation Group, Nouvel Hopital Civil, University Hospital Strasbourg, Strasbourg; and EA7293 SVTT, Translational Medicine Federation, Medicine School Strasbourg, University of Strasbourg, Strasbourg, France
Clamshell (bilateral anterolateral thoracotomy combined to transverse sternotomy) is an invasive surgical approach that is helpful in particular situations, especially bilateral lung transplantation. The closure technique remains challenging because clamshell incision can end with override, separation, or sternal pseudarthrosis complications. We describe
the use of new absorbable sternal pins to stabilize the sternal closure and to help avoid additional sternal complications.
C
During closure, we place four crossed sutures of polydioxanone cord (Ethicon, Somerville, NJ) or polyglactin 910 (decimal 5; Ethicon, Somerville, NJ) on each thoracotomy to prepare the closure of both right and left intercostal spaces. A crossed suture of polydioxanone cord (Ethicon) is placed at the parasternal side of the intercostal space. Depending on the width of the sternal
lamshell incision (bilateral anterolateral thoracotomy combined with transverse sternotomy) is a traumatic and invasive surgical approach, though helpful in particular situations of bilateral lung transplantation [1]. Most of the time, separate bilateral anterolateral thoracotomies provide a sufficient exposure. In case of narrow chest, dense pleural adhesion, or need for central circulatory bypass, clamshell offers easier approach and increased safety [1–3]. Closure of a clamshell incision in such patients can be challenging, because of the upcoming immunosuppressive regimen with high-dose steroids, prior osteoporosis in patients with chronic obstructive pulmonary disease, long-lasting steroid therapy before transplantation, and malnutrition. Indeed, the postoperative recovery of transplant recipients who underwent a clamshell is jeopardized by a relatively high incidence of sternal complications, whereas patients operated through bilateral thoracotomy without sternal division have more favorable outcomes [2]. The most common variant of sternal dehiscence is overriding of both segments, which may evolve toward complete sternal separation. Parasternal crossed sutures may lower the rate of sternal complications, but they do not completely prevent sternal dehiscence [4]. In this context, we completed sternal closure of clamshell incision with intramedullary tutors, using absorbable sternal pins made of poly-L-lactide (Gunze, Tokyo, Japan; Fig 1) [5].
(Ann Thorac Surg 2017;104:e207–9) Ó 2017 by The Society of Thoracic Surgeons
Technique Clamshell incision in the context of lung transplantation is usually performed through the fourth or fifth intercostal spaces with transversal sternal division. Address correspondence to Dr Olland, Lung Transplantation Group, Thoracic Surgery Department, Nouvel Hopital Civil, University Hospital Strasbourg, Strasbourg, France; email: [email protected]. ˇ
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
Fig 1. (A) Poly-L-lactide sternal pin. (B) Hole sizer. (C) Holder. (D) T-shaped hole performer.
The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2017.04. 036] on http://www.annalsthoracicsurgery.org.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2017.04.036
e208
HOW TO DO IT OLLAND ET AL STERNAL PINS FOR CLAMSHELL CLOSURE
Ann Thorac Surg 2017;104:e207–9
normal bone structure with an electric oscillating saw. At least two sternal pins are placed to stabilize the transverse sternotomy (Fig 3B). Insert the pins into the overriding extremity, realign the sternum, and use the pin holder to pull out the pin from one sternal section to push into the other half while they are aligned. Next, polydioxanone cords are placed around the intercostal spaces on each side of the sternum and on the sternum itself. Lastly, sutures can be tightened and tied (Fig 3C).
Fig 2. Operative view of primary closure of a clamshell incision in a lung transplant recipient. Sutures and sternal pins are ready for closure.
section, one or two crossed polydioxanone cords are placed on the sternum. Once all sutures are placed and ready to be tightened, sternal extremities are prepared for placing the pins (Video). A T-shaped instrument with sharp edges is used to prepare corresponding holes facing each other in the spongy part of each sternal section (Fig 2). Ideally, two pins are required. Once the holes are dug, a sizer enables widening of the hole to fit with the size of the pin to be implanted. Once all four holes have been sized appropriately, both pins are placed in the upper or in the lower sternal section (Fig 2; Video). Sutures are progressively tightened and sternal extremities are carefully approximated, while a pin holder guides appropriate placement of the pins into the opposite hemisternum. Once the pins are inserted into both sternal segments, all sutures can be tightened and tied (Video). In patients with sternal complications after primary clamshell closure, such as override, separation or pseudarthrosis, sternal pins can also be used during reoperation to realign and stabilize the sternum. The skin incision should be wide enough to ensure adequate exposure of the sternum and the parasternal end of the corresponding intercostal space. Soft tissues are dissected off the cartilage and bone, and the site of sternotomy is exposed (Fig 3A). Any fibrotic scar tissue or granulation should be cleared. The sternum is trimmed down to
Comment The absorbable pins have become available since January 1, 2016, in our clinical practice. From January 2016 to October 31, 2016, we have performed 43 lung transplants; 14 of them required a clamshell incision. In two patients, the sternal pins were not available for closure because of logistical reasons. Sternal healing was achieved in all 12 clamshell patients who underwent closure and sternal tutorizing with absorbable pins; however, sternal complications arose in both patients closed without the use of pins. One patient was a 36-year-old woman undergoing redo bilateral lung transplantation for bronchiolitis obliterans following primary heart–lung transplantation; central circulatory bypass was needed during the surgery. The other patient was a 64-year-old man undergoing bilateral lung transplantation for fibrosis; the clamshell incision was used because of a narrow chest with dense pleural adhesions, but no bypass was needed. Both patients had an uneventful immediate postoperative outcome. The woman required longer mechanical ventilation support following surgery and was extubated at day 10. Both patients presented 6 weeks after surgery with chest pain and paradoxic chest wall movements; palpation revealed painful sternal overriding in both patients. Secondary closure using intramedullary stabilization with sternal pins led to uneventful recovery. The sternum appeared stable and without pain at 3 months. The overall risk for sternal complications after clamshell thoracotomy is estimated between 34% and 48% [2, 6]. The latter includes override, pseudarthrosis, and separation [4]. Hence, the use of intramedullary pins to
Fig 3. (A) Operative view of an override of the sternum. (B) The overriding part of the sternum is separated from the underriding part and to realign the sternum and place the pins. (C) Finally, sutures are placed, and the transection is ready to be closed on both pins.
Ann Thorac Surg 2017;104:e207–9
improve sternal stabilization is meaningful. Previous attempts with metallic pins have been limited by migration complications. In the context of immunosuppression joined to potential osteoporosis, long-lasting steroid therapy and malnutrition, absorbable material offers the advantage of lowering the risk for infection or foreign body reaction, and their edges are not as sharp as metallic pins, thus avoiding the risk of migration. Mechanical properties of poly-L-lactide pins are reliable; the bending strength will maintain close to 100% until the fourth month following implantation, which is long enough to ensure normal bone healing. Furthermore, absorbable material does not require a second operation for removal. We recommend routine use of at least two pins to neutralize anteroposterior, lateral, and torque movements [7]. Although we did not observe any failure of absorbable intramedullary stabilization, we became aware that fixed rigid metal implants in the sternal area were at risk for disruption in almost half the patients [7]. Previous publications have demonstrated an advantage from incurved transection of the sternum as it increases the bone healing surface and stabilizes lateral movements, but it will not stabilize anteroposterior movements [8]. In conclusion, sternal closure after clamshell thoracotomy is a high-risk situation for disabled bone healing.
HOW TO DO IT OLLAND ET AL STERNAL PINS FOR CLAMSHELL CLOSURE
e209
The risk may be considerably lowered by intramedullary stabilization with absorbable pins.
References 1. Wright C. Transverse sternothoracotomy. Chest Surg Clin N Am 1996;6:149–56. 2. Meyers BF, Sundaresan RS, Guthrie T, Cooper JD, Patterson GA. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications. J Thorac Cardiovasc Surg 1999;117:358–64. 3. Venuta F, Rendina EA, De Giacomo T, et al. Bilateral sequential lung transplantation without sternal division. Eur J Cardiothorac Surg 2003;23:894–7. 4. Koster TD, Ramjankhan FZ, van de Graaf EA, et al. Crossed wiring closure technique for bilateral transverse thoracosternotomy is associated with less sternal dehiscence after bilateral sequential lung transplantation. J Thorac Cardiovasc Surg 2013;146:901–5. 5. Saito T, Iguchi A, Sakurai M, Tabayashi K. Biomechanical study of a poly-L-lactide (PLLA) sternal pin in sternal closure after cardiothoracic surgery. Ann Thorac Surg 2004;77:684–7. 6. Macchiarini P, Ladurie FL, Cerrina J, Fadel E, Chapelier A, Dartevelle P. Clamshell or sternotomy for double lung or heartlung transplantation? Eur J Cardiothorac Surg 1999;15:333–9. 7. Berthet JP, Caro AG, Silovei L, et al. Titanium implant failure after chest wall osteosynthesis. Ann Thorac Surg 2015;99: 1945–52. 8. Costa J, Sonett JR, D’Ovidio F. Modified transverse thoracosternotomy and cost-effective reinforced sternal closure. Ann Thorac Surg 2015;100:2376–8.