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Nonabsorbable interrupted sutures for tracheal anastomosis in childhood
1150
CORRESPONDENCE
A X i 1l a w N
Ann Thorac Surg 1992;531147-52
.
Radial N.
2. Shaw PJ, Bates D, Cartlidge NEF, Heaviside D, Julian DG, Shaw DA. Early neurological complications of coronary artery bypass surgery. Br Med J 1985;291:1384-7. 3. Vincent JG. A compact single post internal mammary dissection retractor. Eur J Cardiothorac Surg 1989;3:276-7. 4. Beg RA, Naraghipour H, Kay EB, Rullo P. Internal mammary retractor. Ann Thorac Surg 1985;3Y:286-7. 5. McKeown PP, Crew J, Hanna ES, Jones R. A modified sternal retractor for exposure of the internal mammary artery. Ann Thorac Surg 1981;32:619-20. 6. Chaux A, Blanche C. A new concept in sternal retraction: applications for internal mammary artery dissection and valve replacement surgery. Ann Thorac Surg 1986;42:4734. 7. Hasan RI, Yonan NA, Moussalli H. Technique of dissecting the internal mammary after using the Moussalli bar. Eur J Cardio-thorac Surg 1990;4571-2. 8. Angelini GD, Azzu AA. A fiber-optic retractor for harvesting the internal mammary artery. Ann Thorac Surg 1990;50:314-5.
Nonabsorbable Interrupted Sutures for Tracheal Anastomosis in Childhood To the Editor: Fig 1 . Diagram of radial nerve and its branches to show site of injuy by retractor stem. bypass grafting has previously been reported [2] although the cause was not specified. In each of our patients, the left internal mammary artery was mobilized from the thoracic wall using a retractor with a single central stem fixed to the operating table with a clamp, and a T-bar from which the two sternal elevating hooks were suspended. We believe that this stem can cause a neuropraxia by local pressure on the radial nerve (Fig l), particularly as the vulnerable section of the nerve is at a level with the middle of the sternum and hence at the optimum position for the retractor stem. Several types of sternal elevating retractor are available, and the single-stem type is said to have the advantage of easy relocation for mobilization of the contralateral mammary artery [3,4]. We suggest that this nerve injury can be avoided by careful protection of the upper arm with pads when using a retractor of this type. Particular care is required with an obese patient to ensure that the arm does not overhang the side of the operating table. Other methods of sternal retraction [5-8]are well described, and we have never experienced this complication in a larger group of patients in whom the mammary artery was mobilized using a retractor with two stems, one positioned at each end of the cross-bar, thus entirely avoiding the area of the radial nerve.
In a recent issue of The Annals, McKeown and associates [ l ] presented an experimental study on tracheal anastomosis in rabbits and concluded that absorbable suture material combined with interrupted sutured technique proved to be significantly superior to other methods in avoiding postoperative narrowing. I successfully used interrupted nonabsorbable suture several years ago in a 5-year-old boy admitted for severe tracheal obstruction after congenital aplasia of three cartilaginous rings. The narrowing, already evident on chest roentgenogram (Fig l), was better defined by tomography. The patient underwent a 3.5-cm-long resection just above the carina, and the two tracheal stumps were approximated with 3-0 interrupted Vitalon (Deknatel, Neustadt, Germany) stitches; the procedure was completed by overriding the suture line with a pleural flap. A fibrin glue (Tissucol; Immuno AG, Vien, Austria) was then used to keep the tissues firm, preventing a possible air leak. Because of the extensive resection, cervical flexion after the anastomosis was maintained with large sutures between the skin of the chest and chin. Extubation was performed soon after the operation, and cervical flexion was ended after 7 days. The postoperative course was uneventful. Three years later the patient was free of symptoms. No sign of inflammatory reaction or dehiscence was seen at bronchoscopy, and tomography showed a widely patent anastomosis (Fig 2). My experience suggests that nonabsorbable suture material can also be successfully employed in childhood, even when an extensive tracheal resection is required.
Edoardo Santoli, M D
Norman P . Brifa, FRCS Colin Price, FRCS Geir I. Grotte, FRCS Daniel I. M . Keenan, FRCS
Department of Thoracic and Cardiovascular Surgey L . Sacco Hospital V . G. B. Grassi, 74 20157 Milan, Italy
Department of Cardiothoracic Surge y Manchester Royal Infirma y Oxford Rd Manchester, United Kingdom M13 9WL
Reference 1. McKeown PP, Tsuboi H, Togo T, Thomas R, Tuck R, Gordon D. Growth of tracheal anastomoses: advantage of absorbable interrupted sutures. Ann Thorac Surg 1991;51:63@1.
References
Reply
1. Morin JE, Long R, Elleker MG, Eisen AA, Wynands E, Ralphs-Thibodeau S. Upper extremity neuropathies following median sternotomy. Ann Thorac Surg 1982;34:181-5.
To the Editor: I congratulate Dr Santoli for a successful outcome in tracheal reconstruction in a 5-year-old boy with congenital aplasia. The
CORRESPONDENCE
A X i 1l a w N
Ann Thorac Surg 1992;531147-52
.
Radial N.
2. Shaw PJ, Bates D, Cartlidge NEF, Heaviside D, Julian DG, Shaw DA. Early neurological complications of coronary artery bypass surgery. Br Med J 1985;291:1384-7. 3. Vincent JG. A compact single post internal mammary dissection retractor. Eur J Cardiothorac Surg 1989;3:276-7. 4. Beg RA, Naraghipour H, Kay EB, Rullo P. Internal mammary retractor. Ann Thorac Surg 1985;3Y:286-7. 5. McKeown PP, Crew J, Hanna ES, Jones R. A modified sternal retractor for exposure of the internal mammary artery. Ann Thorac Surg 1981;32:619-20. 6. Chaux A, Blanche C. A new concept in sternal retraction: applications for internal mammary artery dissection and valve replacement surgery. Ann Thorac Surg 1986;42:4734. 7. Hasan RI, Yonan NA, Moussalli H. Technique of dissecting the internal mammary after using the Moussalli bar. Eur J Cardio-thorac Surg 1990;4571-2. 8. Angelini GD, Azzu AA. A fiber-optic retractor for harvesting the internal mammary artery. Ann Thorac Surg 1990;50:314-5.
Nonabsorbable Interrupted Sutures for Tracheal Anastomosis in Childhood To the Editor: Fig 1 . Diagram of radial nerve and its branches to show site of injuy by retractor stem. bypass grafting has previously been reported [2] although the cause was not specified. In each of our patients, the left internal mammary artery was mobilized from the thoracic wall using a retractor with a single central stem fixed to the operating table with a clamp, and a T-bar from which the two sternal elevating hooks were suspended. We believe that this stem can cause a neuropraxia by local pressure on the radial nerve (Fig l), particularly as the vulnerable section of the nerve is at a level with the middle of the sternum and hence at the optimum position for the retractor stem. Several types of sternal elevating retractor are available, and the single-stem type is said to have the advantage of easy relocation for mobilization of the contralateral mammary artery [3,4]. We suggest that this nerve injury can be avoided by careful protection of the upper arm with pads when using a retractor of this type. Particular care is required with an obese patient to ensure that the arm does not overhang the side of the operating table. Other methods of sternal retraction [5-8]are well described, and we have never experienced this complication in a larger group of patients in whom the mammary artery was mobilized using a retractor with two stems, one positioned at each end of the cross-bar, thus entirely avoiding the area of the radial nerve.
In a recent issue of The Annals, McKeown and associates [ l ] presented an experimental study on tracheal anastomosis in rabbits and concluded that absorbable suture material combined with interrupted sutured technique proved to be significantly superior to other methods in avoiding postoperative narrowing. I successfully used interrupted nonabsorbable suture several years ago in a 5-year-old boy admitted for severe tracheal obstruction after congenital aplasia of three cartilaginous rings. The narrowing, already evident on chest roentgenogram (Fig l), was better defined by tomography. The patient underwent a 3.5-cm-long resection just above the carina, and the two tracheal stumps were approximated with 3-0 interrupted Vitalon (Deknatel, Neustadt, Germany) stitches; the procedure was completed by overriding the suture line with a pleural flap. A fibrin glue (Tissucol; Immuno AG, Vien, Austria) was then used to keep the tissues firm, preventing a possible air leak. Because of the extensive resection, cervical flexion after the anastomosis was maintained with large sutures between the skin of the chest and chin. Extubation was performed soon after the operation, and cervical flexion was ended after 7 days. The postoperative course was uneventful. Three years later the patient was free of symptoms. No sign of inflammatory reaction or dehiscence was seen at bronchoscopy, and tomography showed a widely patent anastomosis (Fig 2). My experience suggests that nonabsorbable suture material can also be successfully employed in childhood, even when an extensive tracheal resection is required.
Edoardo Santoli, M D
Norman P . Brifa, FRCS Colin Price, FRCS Geir I. Grotte, FRCS Daniel I. M . Keenan, FRCS
Department of Thoracic and Cardiovascular Surgey L . Sacco Hospital V . G. B. Grassi, 74 20157 Milan, Italy
Department of Cardiothoracic Surge y Manchester Royal Infirma y Oxford Rd Manchester, United Kingdom M13 9WL
Reference 1. McKeown PP, Tsuboi H, Togo T, Thomas R, Tuck R, Gordon D. Growth of tracheal anastomoses: advantage of absorbable interrupted sutures. Ann Thorac Surg 1991;51:63@1.
References
Reply
1. Morin JE, Long R, Elleker MG, Eisen AA, Wynands E, Ralphs-Thibodeau S. Upper extremity neuropathies following median sternotomy. Ann Thorac Surg 1982;34:181-5.
To the Editor: I congratulate Dr Santoli for a successful outcome in tracheal reconstruction in a 5-year-old boy with congenital aplasia. The