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Influence of suture on bronchial anastomosis in growing puppies
J
THoRAc CARDIOVASC SURG
1988;95:998-1002
Influence of suture on bronchial anastomosis in . . growing puppies A comparison study of synthetic nonabsorbable suture (nylon or Prolene) with absorbable suture (Dexon-S or Vicryl) for bronchoplasty was performed in growing puppies. The experiments (n = 15) were followed up for 185 to 381 days (average 323.8 days). Bronchoscopic and bronchographic studies were done at intervals. No stenosis was observed in the group receiving absorbable suture (n = 8), and the anastomoses grew proportionately with the proximal and distal bronchi. In the group receiving nonabsorbable suture (n = 7), variable stenoses developed; two moderate and two severe stenoses were observed during the early healing stage by bronchoscopic examination. In the sequential bronchograms, an increase of stenosis was noted in two dogs. The results suggest that absorbable suture is superior to nonabsorbable suture in pediatric bronchoplasty.
Chia-Ming Hsieh, MD, Masao Tomita, MD, Hiroyoshi Ayabe, MD, Katsunobu Kawahara, MD, Hiroshi Hasegawa, MD, and Ryuichiro Yoshida, MD, Nagasaki. Japan
During the past decade, thoracic surgeons have become familar with the bronchoplastic procedure as an operative modality for selected malignant and benign bronchial diseases to preserve pulmonary function in adults. However, bronchoplasty for infants or children is still an incompletely developed field of tracheobronchial surgery. A few reports demonstrate the clinical experience in primary end-to-end bronchial anastomosis after traumatic rupture and segmental resection for congenital stenosis or localized bronchial tumor.':" Nonabsorbable suture such as silk, nylon, Tevdec, or steel is frequently used; consequently, there is a high incidence of stenosis or granuloma, or both, at the suture line when the children grow up. In patient without complications at the anastomosis, follow-up to adulthood has not been reported. Although anastomoses with chromic catgut or cotton suture after bronchial resection and reconstruction grow with the growth of puppies," reports concerning evaluation of the use of new synthetic absorbable or nonabsorbable suture for bronchoplasty in growing animals are limited. This long-term study investigated From the First Department of Surgery. Nagasaki University Schoolof Medicine. Nagasaki. Japan. Received for publication June 26. 1987. Accepted for publication Sept. 21. 1987. Address for reprints: Chia-Ming Hsieh. MD. The First Department of Surgery. Nagasaki University Schoolof Medicine. 7-1 SakamotoMachi. Nagasaki. Japan.
998
whether a synthetic absorbable suture is superior to a nonabsorbable one for bronchial anastomosis in growing puppies. Materials and methods After institution of intravenous anesthesia (pentobarbital sodium [Nembutal] 25 rug/kg body weight) and positivepressure ventilation (Harvard ventilator, Harvard Apparatus Co., Inc., S. Natick, Mass.), transection and reanastomosis of the left main bronchus or left upper sleeve lobectomy was performed through the left fifth intercostal space on puppies weighing between 1.6 and 4.8 kg. Sutures were placed about 1.5 mm from the bronchial edges and tied exterior to the bronchus. Each anastomosis was completed with 10 to 15 stitches. Immediately after the operation a bronchoscope was used to aspirate airway secretions and to confirm the integrity of the bronchial anastomosis. Ampicillin (50 mg/kg) was given intramuscularly for 3 days after operation. The animals were divided into two groups according to the suture material used in the anastomoses. In the group having absorbable suture (n = 8), either 4-0 Dexon-S (Davis & Geck, Wayne, N J.) or Vicryl suture (Ethicon, Inc., Somerville, N.J.) was used; a running technique was used in four puppies and an interrupted technique in four. In the group having nonabsorbable suture (n = 7), either 4-0 monofilament nylon or Prolene suture was used; a running suture was done in three animals and an interrupted suture in four. Bronchoscopic and bronchographic examinations were done at intervals to evaluate healing and growth of the bronchial anastomosis. The animals were observed for 185 to 381 days (average 323.8 days). At the time the dogs were killed, inner coronal (a) and sagittal (b) diameters of the anastomosis and these diameters 5 mm proximal to the anastomosis were measured with calipers.
Volume 95 Number 6
Suture in bronchial anastomosis
June 1988
999
Table I. Results in the group having nonabsorbable suture BW(kg)
No. I 2 3 4 5 6 7
Procedure S S T S S S T
(I) (I) (I) (I)
(R) (R) (R)
Suture
Op
Death
Survival (days)
Nylon Nylon Nylon Prolene Prolene Nylon Nylon
2.1 3.0 4.8 5.0 1.6 2.7 3.7
8.5 7.5 10.0 7.0 10.5 8.3 10.0
305 354 262 185 322 308 381
%CSA 32.5 64.4 23.3 23.2 37.2 67.1
S. Left upper sleeve lobectomy; T. transection and reanastomosis of left main bronchus; I. interrupted suture; R, running suture; BW, body weight: Op, at operation; Death, at death; 'XCSA, see text in Materials and methods section.
Table II. Results in the group having absorbable suture BW(kg)
No.
Procedure S S S S S S S
2 3 4 5 6 7 8
(I) (I) (I) (I)
(R) (R) (R)
T (R)
Suture
Op
Death
Survival (days)
%CSA
Dexon-S Vicryl Dexon-S Dexon-S Dexon-S Vicryl Dexon-S Dexon-S
2.4 3.9 3.4 3.0 3.0 2.2 3.4 3.5
7.8 8.3 10.5 7.5 12.0 9.0 7.0 10.8
338 310 372 329 326 351 342 372
84.6 83.9 79.2 81.5 85.7 83.9 91.0 76.0
See Table I for abbreviations.
The cross-sectional area (CSA) of the bronchial lumen was calculated according to the following equations; the degree of stenosis of the anastomosis was expressed as %CSA: CSA = 11 X (a/2) X (b/2) %CSA = (CSA of anastomosis/CSA 5 mm proximal to anastomosis) X 100%
(I) (2)
Results During the early stage of this study, four puppies died of pneumonia after anastomotic stenosis as a result of technical failure, Three of the 15 long-term survivors required bronchoscopic suction to maintain the patency of the bronchial anastomoses during the early postoperative days. The individual results are defined as follows, according to %CSA when the animals were killed: more than 75%, good; 50% to 75%, slight stenosis; 30% to 50%, moderate stenosis; less than 30%, severe stenosis. Two dogs in the nonabsorbable suture group showed slight stenosis of the bronchial anastomoses at death (Table I). Moderate or severe stenosis developed in four of this group; stenoses were found within 2 months after operation at bronchoscopic study. During sequential bronchograms (Fig. 1), an increase of stenosis was found
in the two animals with moderate stenosis at death. The dog followed up for 185 days showed slight stenosis by bronchoscopic study at death. Rotation of the interrupted suture knots into the bronchial lumen was observed in one dog. Bridging of suture across the anastomosis was noted in a bronchus with running suture. Histologic examination showed that monofilament nylon or Prolene sutures had not been absorbed and were surrounded by fibrotic tissue. None of the group having absorbable suture had suture granuloma or stenosis at when put to death (Table 11). Bronchoscopic examination within 2 months after operation demonstrated excellent bronchial anastomoses covered with normal mucosa (Fig. 2). Sequential bronchographic and bronchoscopic studies showed an increase in size of the anastomoses proportional to the proximal and distal bronchi (Fig. 3). By histologic assessment, although incomplete absorption was found in four animals, all the dogs in the absorbable suture group had no suture reactions in the anastomoses. Discussion Because the bronchial lumen was small in the growing subjects, the anastomoses were easily obstructed by
The Journal of Thoracic and Cardiovascular
1000 Hsieh et al.
Surgery
,
Fig. 1. Running nylon suture was used. At 171 postoperative days (A I, slight stenosis of bronchial anastomosis was revealed. Stenosis became obvious at 288 days (B).
Fig. 2. Bronchoscopy. A, Interrupted Dexon-S suture was used. 1\0 stenosis at 56 days. B, Interrupted nylon suture was used. Suture remained and anastomosis was irregular and stenotic at 158 days after operation.
bronchial secretions and local edema after bronchoplasty. Close observation during the early postoperative stage and proper bronchoscopic suction are mandatory in studies such as this. Short-term administration of corticosteroids may decrease the local edema of the small bronchial anastomosis. iJ Transient drainage of the distal bronchus with a small catheter through the cricothyroid membrane can be useful. 14
In a study of growth of bronchial anastomosis by Kiriluk and Merendino," three of eight dogs, in which chromic catgut suture was used, had fair or poor results. It has been reported that synthetic absorbable suture is superior to nonabsorbable suture in preventing anastomotic stenosis or suture granuloma, or both, after tracheobronchoplasty in adult humans and animals.":" Similarly, in this study, no granuloma or stenosis
Volume 95 Number 6 June 1988
Suture in bronchial anastomosis
10 0 1
Fig. 3. Running Dexon-S suture was used. Smooth bronchial continuity was shown on bronchograrns at 197 days (A) and 310 days (B) after operation.
occurred in conjunction with Dexon-S and Vicryl sutures. Conventionally, interrupted suture is preferred to anastomose hollow organs of children for preventing stenosis. In the nonabsorbable suture group of this study, neither the interrupted technique nor the running suture had satisfactory results. In the absorbable suture group, both the running and the interrupted techniques had excellent outcomes. These results suggest that when Dexon-S or Vicryl suture is used in pediatric bronchoplasty, both running and interrupted sutures are promising. Although this series is small, the results suggest that synthetic absorbable suture is preferable for bronchoplastic procedures in growing children. We thank Su-Pi Hsiao, who typed the manuscript. REFERENCES 1. Ellis FH, Anderson HA, Hayles AB. Complete traumatic rupture of the bronchus with successful surgical repair: report of a case in a 3-year-old child. Proc Staff Meet Mayo Clin 1955;30:268-76. 2. Litt RE, Mencia LF, Altman DH. Congenital stenosis of the right main bronchus. Am J Roentgenol 1963;89: 10 179.
3. Sherman F, Neville J, Kent E. Bronchial adenomas occurring in childhood. J Pediatr 1956;49:583-91. 4. Chang N, Hertzler JH, Gregg RH, Lofti MW, Brough AJ. Congenital stenosis of the right mainstem bronchus: a case report. Pediatrics 1968;41:739-42. 5. Verska JJ, Connolly JE. Bronchial adenomas in children. J THORAC CARDIOVASC SURG 1968;55:411-7. 6. Logeais Y, Florent GD, Barre DE, et al. Traumatic rupture of the right main bronchus in an eight-year-old child successfully repaired eight years after injury. Ann Surg 1970;172:1039-46. 7. Myers WO, Leape LL, Holder TM. Bronchial rupture in a child, with subsequent stenosis, resection and anastomosis. Ann Thorac Surg 1971;12:442-5. 8. Lynn RB, Iyengar K. Traumatic rupture of the bronchus. Chest 1972;61:81-3. 9. Guest JL, Anderson IN. Major airway injury in closed chest trauma. Chest 1977;72:63-6. 10. Rahbar A, Chang FC, Farha SJ. Rupture of bronchus: case report of successful resection and anastomosis in a 13-month-old infant. J Trauma 1978; 18:140-1. 11. Amauchi W, Birolini D, Branco PD, Oliveira MR. Injuries to the tracheobronchial tree in closed trauma. Thorax 1983;38:923-8. 12. Kiriluk LB, Merendino KA. Experimental bronchial transection, resection, and transplantation in the growing dog. Surg Forum 1953;4:261-6.
1002 Hsieh et al.
13. Hsieh C. Influence of short-term corticosteroid therapy on bronchial anastomosis. Acta Med Nagasaki 1986;31:3342. 14. Hsieh C, Ayabe H, Kawahara K, Mori M, Kimino K, Tomita M. Traumatic disruptions of right upper bronchus and truncus intermedius in a five-year-old boy. J Trauma 1987;27:333-4. IS. Grillo HC, Zannini P, Michelassi F. Complications of tracheal reconstruction. J THORAC CARDIOVASC SURG 1986;91 :322-8.
The Journal of Thoracic and Cardiovascular Surgery
16. Naruke T, Yoneyama T, Ogata T, Suemasu K. Bronchoplastic procedures for lung cancer. J THORAC CARDIOVASC SURG 1977;73:927-35. 17. Gibbons JA, Peniston RL, Diamond SS, Aaron BL. A comparison of synthetic absorbable suture with synthetic non-absorbable suture for construction of tracheal anastomoses. Chest 1981 ;73:340-2.
Bound volumes available to subscribers Bound volumes of THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY are available to subscribers (only) for the 1988 issues from the Publisher, at a cost of $51.00 ($68.00 international) for Vol. 95 (January-June) and Vol. 96 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA: phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
THoRAc CARDIOVASC SURG
1988;95:998-1002
Influence of suture on bronchial anastomosis in . . growing puppies A comparison study of synthetic nonabsorbable suture (nylon or Prolene) with absorbable suture (Dexon-S or Vicryl) for bronchoplasty was performed in growing puppies. The experiments (n = 15) were followed up for 185 to 381 days (average 323.8 days). Bronchoscopic and bronchographic studies were done at intervals. No stenosis was observed in the group receiving absorbable suture (n = 8), and the anastomoses grew proportionately with the proximal and distal bronchi. In the group receiving nonabsorbable suture (n = 7), variable stenoses developed; two moderate and two severe stenoses were observed during the early healing stage by bronchoscopic examination. In the sequential bronchograms, an increase of stenosis was noted in two dogs. The results suggest that absorbable suture is superior to nonabsorbable suture in pediatric bronchoplasty.
Chia-Ming Hsieh, MD, Masao Tomita, MD, Hiroyoshi Ayabe, MD, Katsunobu Kawahara, MD, Hiroshi Hasegawa, MD, and Ryuichiro Yoshida, MD, Nagasaki. Japan
During the past decade, thoracic surgeons have become familar with the bronchoplastic procedure as an operative modality for selected malignant and benign bronchial diseases to preserve pulmonary function in adults. However, bronchoplasty for infants or children is still an incompletely developed field of tracheobronchial surgery. A few reports demonstrate the clinical experience in primary end-to-end bronchial anastomosis after traumatic rupture and segmental resection for congenital stenosis or localized bronchial tumor.':" Nonabsorbable suture such as silk, nylon, Tevdec, or steel is frequently used; consequently, there is a high incidence of stenosis or granuloma, or both, at the suture line when the children grow up. In patient without complications at the anastomosis, follow-up to adulthood has not been reported. Although anastomoses with chromic catgut or cotton suture after bronchial resection and reconstruction grow with the growth of puppies," reports concerning evaluation of the use of new synthetic absorbable or nonabsorbable suture for bronchoplasty in growing animals are limited. This long-term study investigated From the First Department of Surgery. Nagasaki University Schoolof Medicine. Nagasaki. Japan. Received for publication June 26. 1987. Accepted for publication Sept. 21. 1987. Address for reprints: Chia-Ming Hsieh. MD. The First Department of Surgery. Nagasaki University Schoolof Medicine. 7-1 SakamotoMachi. Nagasaki. Japan.
998
whether a synthetic absorbable suture is superior to a nonabsorbable one for bronchial anastomosis in growing puppies. Materials and methods After institution of intravenous anesthesia (pentobarbital sodium [Nembutal] 25 rug/kg body weight) and positivepressure ventilation (Harvard ventilator, Harvard Apparatus Co., Inc., S. Natick, Mass.), transection and reanastomosis of the left main bronchus or left upper sleeve lobectomy was performed through the left fifth intercostal space on puppies weighing between 1.6 and 4.8 kg. Sutures were placed about 1.5 mm from the bronchial edges and tied exterior to the bronchus. Each anastomosis was completed with 10 to 15 stitches. Immediately after the operation a bronchoscope was used to aspirate airway secretions and to confirm the integrity of the bronchial anastomosis. Ampicillin (50 mg/kg) was given intramuscularly for 3 days after operation. The animals were divided into two groups according to the suture material used in the anastomoses. In the group having absorbable suture (n = 8), either 4-0 Dexon-S (Davis & Geck, Wayne, N J.) or Vicryl suture (Ethicon, Inc., Somerville, N.J.) was used; a running technique was used in four puppies and an interrupted technique in four. In the group having nonabsorbable suture (n = 7), either 4-0 monofilament nylon or Prolene suture was used; a running suture was done in three animals and an interrupted suture in four. Bronchoscopic and bronchographic examinations were done at intervals to evaluate healing and growth of the bronchial anastomosis. The animals were observed for 185 to 381 days (average 323.8 days). At the time the dogs were killed, inner coronal (a) and sagittal (b) diameters of the anastomosis and these diameters 5 mm proximal to the anastomosis were measured with calipers.
Volume 95 Number 6
Suture in bronchial anastomosis
June 1988
999
Table I. Results in the group having nonabsorbable suture BW(kg)
No. I 2 3 4 5 6 7
Procedure S S T S S S T
(I) (I) (I) (I)
(R) (R) (R)
Suture
Op
Death
Survival (days)
Nylon Nylon Nylon Prolene Prolene Nylon Nylon
2.1 3.0 4.8 5.0 1.6 2.7 3.7
8.5 7.5 10.0 7.0 10.5 8.3 10.0
305 354 262 185 322 308 381
%CSA 32.5 64.4 23.3 23.2 37.2 67.1
S. Left upper sleeve lobectomy; T. transection and reanastomosis of left main bronchus; I. interrupted suture; R, running suture; BW, body weight: Op, at operation; Death, at death; 'XCSA, see text in Materials and methods section.
Table II. Results in the group having absorbable suture BW(kg)
No.
Procedure S S S S S S S
2 3 4 5 6 7 8
(I) (I) (I) (I)
(R) (R) (R)
T (R)
Suture
Op
Death
Survival (days)
%CSA
Dexon-S Vicryl Dexon-S Dexon-S Dexon-S Vicryl Dexon-S Dexon-S
2.4 3.9 3.4 3.0 3.0 2.2 3.4 3.5
7.8 8.3 10.5 7.5 12.0 9.0 7.0 10.8
338 310 372 329 326 351 342 372
84.6 83.9 79.2 81.5 85.7 83.9 91.0 76.0
See Table I for abbreviations.
The cross-sectional area (CSA) of the bronchial lumen was calculated according to the following equations; the degree of stenosis of the anastomosis was expressed as %CSA: CSA = 11 X (a/2) X (b/2) %CSA = (CSA of anastomosis/CSA 5 mm proximal to anastomosis) X 100%
(I) (2)
Results During the early stage of this study, four puppies died of pneumonia after anastomotic stenosis as a result of technical failure, Three of the 15 long-term survivors required bronchoscopic suction to maintain the patency of the bronchial anastomoses during the early postoperative days. The individual results are defined as follows, according to %CSA when the animals were killed: more than 75%, good; 50% to 75%, slight stenosis; 30% to 50%, moderate stenosis; less than 30%, severe stenosis. Two dogs in the nonabsorbable suture group showed slight stenosis of the bronchial anastomoses at death (Table I). Moderate or severe stenosis developed in four of this group; stenoses were found within 2 months after operation at bronchoscopic study. During sequential bronchograms (Fig. 1), an increase of stenosis was found
in the two animals with moderate stenosis at death. The dog followed up for 185 days showed slight stenosis by bronchoscopic study at death. Rotation of the interrupted suture knots into the bronchial lumen was observed in one dog. Bridging of suture across the anastomosis was noted in a bronchus with running suture. Histologic examination showed that monofilament nylon or Prolene sutures had not been absorbed and were surrounded by fibrotic tissue. None of the group having absorbable suture had suture granuloma or stenosis at when put to death (Table 11). Bronchoscopic examination within 2 months after operation demonstrated excellent bronchial anastomoses covered with normal mucosa (Fig. 2). Sequential bronchographic and bronchoscopic studies showed an increase in size of the anastomoses proportional to the proximal and distal bronchi (Fig. 3). By histologic assessment, although incomplete absorption was found in four animals, all the dogs in the absorbable suture group had no suture reactions in the anastomoses. Discussion Because the bronchial lumen was small in the growing subjects, the anastomoses were easily obstructed by
The Journal of Thoracic and Cardiovascular
1000 Hsieh et al.
Surgery
,
Fig. 1. Running nylon suture was used. At 171 postoperative days (A I, slight stenosis of bronchial anastomosis was revealed. Stenosis became obvious at 288 days (B).
Fig. 2. Bronchoscopy. A, Interrupted Dexon-S suture was used. 1\0 stenosis at 56 days. B, Interrupted nylon suture was used. Suture remained and anastomosis was irregular and stenotic at 158 days after operation.
bronchial secretions and local edema after bronchoplasty. Close observation during the early postoperative stage and proper bronchoscopic suction are mandatory in studies such as this. Short-term administration of corticosteroids may decrease the local edema of the small bronchial anastomosis. iJ Transient drainage of the distal bronchus with a small catheter through the cricothyroid membrane can be useful. 14
In a study of growth of bronchial anastomosis by Kiriluk and Merendino," three of eight dogs, in which chromic catgut suture was used, had fair or poor results. It has been reported that synthetic absorbable suture is superior to nonabsorbable suture in preventing anastomotic stenosis or suture granuloma, or both, after tracheobronchoplasty in adult humans and animals.":" Similarly, in this study, no granuloma or stenosis
Volume 95 Number 6 June 1988
Suture in bronchial anastomosis
10 0 1
Fig. 3. Running Dexon-S suture was used. Smooth bronchial continuity was shown on bronchograrns at 197 days (A) and 310 days (B) after operation.
occurred in conjunction with Dexon-S and Vicryl sutures. Conventionally, interrupted suture is preferred to anastomose hollow organs of children for preventing stenosis. In the nonabsorbable suture group of this study, neither the interrupted technique nor the running suture had satisfactory results. In the absorbable suture group, both the running and the interrupted techniques had excellent outcomes. These results suggest that when Dexon-S or Vicryl suture is used in pediatric bronchoplasty, both running and interrupted sutures are promising. Although this series is small, the results suggest that synthetic absorbable suture is preferable for bronchoplastic procedures in growing children. We thank Su-Pi Hsiao, who typed the manuscript. REFERENCES 1. Ellis FH, Anderson HA, Hayles AB. Complete traumatic rupture of the bronchus with successful surgical repair: report of a case in a 3-year-old child. Proc Staff Meet Mayo Clin 1955;30:268-76. 2. Litt RE, Mencia LF, Altman DH. Congenital stenosis of the right main bronchus. Am J Roentgenol 1963;89: 10 179.
3. Sherman F, Neville J, Kent E. Bronchial adenomas occurring in childhood. J Pediatr 1956;49:583-91. 4. Chang N, Hertzler JH, Gregg RH, Lofti MW, Brough AJ. Congenital stenosis of the right mainstem bronchus: a case report. Pediatrics 1968;41:739-42. 5. Verska JJ, Connolly JE. Bronchial adenomas in children. J THORAC CARDIOVASC SURG 1968;55:411-7. 6. Logeais Y, Florent GD, Barre DE, et al. Traumatic rupture of the right main bronchus in an eight-year-old child successfully repaired eight years after injury. Ann Surg 1970;172:1039-46. 7. Myers WO, Leape LL, Holder TM. Bronchial rupture in a child, with subsequent stenosis, resection and anastomosis. Ann Thorac Surg 1971;12:442-5. 8. Lynn RB, Iyengar K. Traumatic rupture of the bronchus. Chest 1972;61:81-3. 9. Guest JL, Anderson IN. Major airway injury in closed chest trauma. Chest 1977;72:63-6. 10. Rahbar A, Chang FC, Farha SJ. Rupture of bronchus: case report of successful resection and anastomosis in a 13-month-old infant. J Trauma 1978; 18:140-1. 11. Amauchi W, Birolini D, Branco PD, Oliveira MR. Injuries to the tracheobronchial tree in closed trauma. Thorax 1983;38:923-8. 12. Kiriluk LB, Merendino KA. Experimental bronchial transection, resection, and transplantation in the growing dog. Surg Forum 1953;4:261-6.
1002 Hsieh et al.
13. Hsieh C. Influence of short-term corticosteroid therapy on bronchial anastomosis. Acta Med Nagasaki 1986;31:3342. 14. Hsieh C, Ayabe H, Kawahara K, Mori M, Kimino K, Tomita M. Traumatic disruptions of right upper bronchus and truncus intermedius in a five-year-old boy. J Trauma 1987;27:333-4. IS. Grillo HC, Zannini P, Michelassi F. Complications of tracheal reconstruction. J THORAC CARDIOVASC SURG 1986;91 :322-8.
The Journal of Thoracic and Cardiovascular Surgery
16. Naruke T, Yoneyama T, Ogata T, Suemasu K. Bronchoplastic procedures for lung cancer. J THORAC CARDIOVASC SURG 1977;73:927-35. 17. Gibbons JA, Peniston RL, Diamond SS, Aaron BL. A comparison of synthetic absorbable suture with synthetic non-absorbable suture for construction of tracheal anastomoses. Chest 1981 ;73:340-2.
Bound volumes available to subscribers Bound volumes of THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY are available to subscribers (only) for the 1988 issues from the Publisher, at a cost of $51.00 ($68.00 international) for Vol. 95 (January-June) and Vol. 96 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA: phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.