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Potential complications of vascular stapling in thoracoscopic pulmonary resection
CASE R E P O R T S
Potential Complications of Vascular Stapling in Thoracoscopic Pulmonary Resection Stewart R. Craig, FRCS, and William S. Walker, FRCS Department of Thoracic Surgery, City Hospital, Edinburgh, United Kingdom In a series of 57 patients undergoing thoracoscopic pulmonary lobectomy, 2 required expeditious conversion to open thoracotomy when a stapling device (Endo-GIA 30 V3; Autosuture, Ascot, UK) used on the main right lower pulmonary artery in 1 case and on the left superior pulmonary vein in the other cut but failed to staple the vessel involved. In both instances the vessel was successfully controlled while a thoracotomy was performed and the involved vessel was oversewn. Both patients made an uncomplicated postoperative recovery. As the number of thoracoscopic pulmonary resections increases, it is likely that similar episodes will occur in the future. These cases strongly emphasize the fact that patients undergoing this procedure should do so in a center specializing in thoracic surgery where there is the necessary surgical expertise and equipment to deal with such potentially lifethreatening vascular complications.
(Ann Thorac Surg 1995;59:736-8) ideo-assisted thoracoscopic pulmonary resection has progressed substantially over the last few years, allowing surgeons to perform a pneumonectomy or standard dissectional lobectomy with lobar lymph node clearance equal to that obtained with a standard open thoracotomy [1-5]. Thoracoscopic operation offers the patient significant benefits such as reduced postoperative pain and discomfort, resulting in a shorter highdependency unit stay [2]. In performing thoracoscopic pulmonary resection, the main vascular structures are divided with endovascular stapling devices, which simultaneously cut and staple the vessel. This combined action raises the possibility that the endostapling device may cut the vessel and fail to staple it, resulting in massive hemorrhage, given the nature of the vessels involved. We report 2 cases of this potentially life-threatening complication.
V
Case Reports The surgical technique employed for thoracoscopic pulmonary lobectomy at the City Hospital Edinburgh, has been described previously [2, 3]. The patient is prepared, anesthetized, and positioned as for a standard posterolateral thoracotomy with the necessary instruments for this beside the operating table. Before any endovascular stapler is used, both the scrub nurse and surgeon ensure that the stapling cartridge is correctly inserted into the Accepted for publication July 18, 1994. Address reprint requests to Mr Walker, Department of ThoracicSurgery, City Hospital Greenbank Dr, Edinburgh EH105SB,UK. © 1995 by The Society of Thoracic Surgeons
stapling device with no residual staples left from previous firings that could cause the stapling device to misfire.
Patient 1 A 71-year-old woman was referred to the thoracic surgical unit with a 3-cm peripheral opacity in her right lower lobe that was noted on a chest radiograph performed during preoperative work-up for an elective sinus operation. She had no respiratory symptoms, and physical examination and routine hematologic and biochemical profiles were unremarkable. A thoracic computed tomographic scan was performed, confirming the presence of a peripheral opacity in the fight lower lobe with no associated mediastinal lymphadenopathy. The liver and adrenal glands were normal. Rigid bronchoscopy was performed and no endobronchial abnormality was noted. Mediastinoscopy revealed anthrocotic nodes in the subcarinal, right tracheobronchial, and right paratracheal regions; biopsy of these nodes confirmed that they were free of metastatic disease. The patient was scheduled for a thoracoscopic right lower lobectomy; however, when the main stem lower pulmonary artery was stapled (Endo-GIA 30 V3; Autosuture, Ascot, UK) a sudden rush of blood was noted when the jaws of the stapler were partially opened. The staple jaws were closed again, arresting the flow of blood. A standard posterolateral thoracotomy was performed and the proximal end of the pulmonary artery was controlled and oversewn with Prolene (Ethicon Ltd, Edinburgh, UK). The remaining part of the operation proceeded without incident, and the patient made an uncomplicated postoperative recovery. Total blood loss was estimated at 130 mL. Histologic examination of the resected lobe revealed a T2 NO bronchoalveolar carcinoma.
Patient 2 A 69-year-old man was referred to the thoracic surgical unit with a 3-cm peripheral opacity in his left upper lobe that was noted on a chest radiograph taken for an episode of pleuritic chest pain. At the time of referral he was asymptomatic and physical examination was unremarkable. Routine hematologic and biochemical profiles were normal. A thoracic computed tomographic scan revealed a 3 cm peripheral lesion in the left upper lobe with no mediastinal lymphadenopathy. The liver and adrenal glands were normal. Rigid bronchoscopy was performed and no endobronchial abnormality was noted. Mediastinoscopy revealed anthrocotic nodes in the subcarinal and left paratracheal regions, biopsy of these nodes confirmed that they were free of metastatic disease. The patient was scheduled for a thoracoscopic left upper lobectomy and the operation proceeded well until the left superior pulmonary vein was stapled (Endo-GIA 30 V3). When the jaws of the stapler were opened there was a rush of blood from the pulmonary vein and it was apparent that the staple line was incomplete and, in addition, the staple head could not be separated from the staple line. The central end of the vein was grasped with a vascular clamp introduced with ease through the submammary incision, and the hemorrhage was arrested 0003-4975/95/$9.50 0003-4975(94)00731-L
Ann Thorac Surg 1995;59:736-8
while a thoracotomy was performed. The patient made an uncomplicated postoperative recovery. Total blood loss was estimated at 730 mL and no blood transfusion was required. Histologic examination of the resected lobe revealed a T1 NO non-small cell undifferentiated carcinoma.
Comment Bleeding from the main pulmonary artery or one of its branches or from the pulmonary veins is a potential hazard during any thoracoscopic pulmonary resection. In our experience, the most common source of troublesome hemorrhage has occurred while attempting to staple branches of the main pulmonary artery, particularly during the early "'learning curve" [3]. In this situation, applying the stapler to the vessel often involves traction along the branch, which can lead to its avulsion. Traction damage to the vessel was not an issue in our 2 cases; however, it is certain that further development of endoscopic instruments, in particular roticulating instruments, will make their use easier and safer [6]. In both of the reported cases, problems arose due to failure of the stapling action that accompanies vessel division. We have performed 62 video-assisted thoracoscopic pulmonary resections to date (57 lobectomies and 5 pneumonectomies), which required approximately 243 firings of the Endo-GIA 30 V3 stapler. The 2 patients in our series therefore resulted in a 0.82% failure rate for endovascular stapling. When a large branch of the pulmonary artery or a lobar vein is to be stapled, we suggest that a sufficient length of vessel is dissected to allow a vascular clamp to be placed on the proximal end before firing of the staple gun. If it is not possible to use a vascular clamp then the jaws of the staple gun should be partially opened and active bleeding sought. If active bleeding occurs, the staple jaws should be closed again, which will arrest the hemorrhage until a thoracotomy can be performed. Other groups have used an endovascular stapler with the knife blade removed so that correct firing of the staples can be ensured before division of the vessel [7]. This may, however, compromise the product license and would not have helped in our second case, when the staple head could not be separated from the staple line on the pulmonary vein. The submammary incision also allows insertion of mounted swabs, which also can be used to tamponade bleeding temporarily and allow easy insertion of vascular clamps. The two Endo-GIA 30 V3 stapling devices were returned to Autosuture, UK, for evaluation. In both cases, Autosuture reported that the stapling cartridge had been correctly inserted into the staple gun; however, the anvil was incorrectly aligned on manufacture so that on firing the staples were forced into an open, rather than closed (B shaped) position, rendering them ineffective. It is extremely important that the endostapler cannot be fixed if the cartridge is not properly inserted or if the anvil is not correctly aligned. The Endo-GIA 30 V3 stapler has
CASE REPORT CRAIG AND WALKER THORACOSCOPIC PULMONARY RESECTION
737
since been modified. It is, however, unlikely that any mechanical device ever can be guaranteed completely safe. Any potential problem can occur given enough use, and any single failing can result in the death of a patient. It is therefore vital to operate in a manner that incorporates strategies to counter this possibility. Despite these failures, the risk of which should be diminished by the endostaple design change, we have not lost our enthusiasm for video-assisted thoracoscopic pulmonary resection. The operating surgeon must be capable of dealing expeditiously with any unexpected hemorrhage and must also be aware of the complex and variable anatomic relationships of the main structures. For this reason, both in the United States and Great Britain, professional societies recommend that thoracoscopic pulmonary resection should only be undertaken by surgeons trained in thoracic surgery [8]. These cases illustrate the validity of this view and are presented as a reminder that thoracoscopic pulmonary resection, although minimal access, is not a minimally invasive operation.
References 1. Walker WS, Carnochan FM, Mattar S. Video-assisted thoracoscopic pneumonectomy. Br J Surg 1994;81:81-2. 2. Walker WS, Camochan FM, Pugh GC. Thoracoscopic pulmonary lobectomy. J Thorac Cardiovasc Surg 1993;106:1111-7. 3. Walker WS, Carnochan FM, Tin M. Thoracoscopy-assisted pulmonary lobectomy. Thorax 1993;48:921-4. 4. Roviaro G, Varoli F, Rebuffat C, et al. Major pulmonary resections: pneumonectomies and lobectomies. Ann Thorac Surg 1993;56:779-83. 5. Kirby TJ, Mack MJ, Landreneau RJ, Rice TIN. Initial experience with video-assisted thoracoscopic lobectomy. Ann Thorac Surg 1993;56:1248-53. 6. Acuff TE, Mack M], Landreneau RJ, Hazelrigg SR. Role of mechanical stapling devices in thoracoscopic pulmonary resection. Ann Thorac Surg 1993;56:749-51. 7. Kirby TJ, Rice TW. Thoracoscopic lobectomy. Ann Thorac Surg 1993;56:784-6. 8. Statement of the AATS/STS Joint Committee on Thoracoscopy and Video Assisted Thoracic Surgery. Ann Thorac Surg 1992;54:1.
INVITED COMMENTARY I carefully read the article by Craig and Walker, whom I know very well for their thoracoscopic activity. The work reports the most frightening complication that can occur during a videothoracoscopic operation. Bleeding from the great vessels due to endoscopic stapler malfunction represents the most serious complication in the course of a thoracoscopic lobectomy, and is dreaded by all who perform this kind of operation. Indeed, this technique is adversed by many thoracic surgeons in fear of disasters deriving from this complication. This work by Craig and Walker reports 2 cases of bleeding due to endostapler malfunction and focuses
738
CASEREPORT FRASERET AL OPERATIONFOR BRANCHPA STENOSIS
attention on the possibility of this occurrence. Throughout m y personal experience of 85 videothoracoscopic p u l m o n a r y resections (80 lobectomies and 5 pneumonectomies), fortunately, no bleeding ever occurred because of stapler malfunction. Bleeding complications occurred in 3 cases of thoracoscopic lobectomy, 1 case requiring 1 unit of blood, but all 3 took place while the vessels were being isolated. The bleeding (from an artery in 2 cases and from a vein in 1) was controlled thoracoscopically, but the operation had to be converted to thoracotomy. In just I case conversion was necessary apparently because of stapler malfunction: after regular section and suture of a large lingular arterial branch, the stapler could not be freed, as part of the staples were stuck between the arterial wall and the stapler's jaws. But it was impossible to establish whether it was truly a stapler malfunction or an error had been made while assembling the new charge. Undoubtedly these events m a y take place occasionally, but it is crucial that a few important requirements and rules be respected to master these complications. First, it is indispensable that these operations be performed only by surgeons with an extensive experience in open conventional thoracic operation. Second, vascular elements must be isolated m u c h more widely than in conventional open operations, also to facilitate the positioning of the staplers. It is usually not too difficult to isolate the vascular elements, particularly as these operations generally are carried out for peripheral T1 NO and T2 NO tumors with uncompromised vascular structures. Finally, extensive vascular preparation and early performing of a small utility thoracotomy ensure an emergency access. Vascular clamps and tampons may quickly be positioned through the utility thoracotomy to control the bleeding and proceed to conversion. I think that endostaplers are perfect machines, but they must be used properly. They can giv e some trouble on the bronchus or on the fissure if those are too thick for the staples" length, but in this case the trouble is due to the surgeon and not to the machine. Concerning possible bleedings after suture-section of the arteries or veins, it is very important to exclude any h u m a n responsibility, such as excessive traction on the vessel or incorrect Closure of the machine (ie, if one or more staples of the previous shot remain on the anvil fork, the staples of the new loading unit m a y not completely close and bleeding m a y occur). However, the rare occurrence of stapler malfunction (0.82% in this work and 0.30% in m y personal experience) should in no way deter e m p l o y m e n t of these techniques.
Ann Thorac Surg 1995;59:738-40
Surgical Repair of Severe Bilateral Branch Pulmonary Artery Stenosis Charles D. Fraser, Jr, MD, Larry A. Latson, MD, and Roger B. B. Mee, FRACS Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio Management options for severe, bilateral branch pulmonary artery stenosis include percutaneous balloon dilation and direct surgical correction. Results with both balloon angioplasty and operation have been somewhat unpredictable. We report a case of staged surgical correction involving bilateral branch pulmonary artery reconstruction.
(Ann Thorac Surg 1995;59:738-40) ongenital branch pulmonary artery stenosis (PAS) is a challenging clinical problem with symptoms ranging from mild dyspnea to profound cyanosis and right heart failure [1, 2]. Management options include direct surgical repair and balloon angioplasty (BA) with or without stenting. We report here a case of staged surgical m a n a g e m e n t of isolated branch PAS.
C
An 8-year-old girl was referred for treatment of severe bilateral branch PAS. Her past medical history was unremarkable. The child was minimally symptomatic but less active than her peers. She had no physical findings consistent with Williams' syndrome. Cardiac catheterization revealed severe bilateral PAS and systemic right ventricular and main pulmonary ar-
Gian Carlo Roviaro, MD
Fig 1. Pulmonary arteriogram demonstrating severe stenosis of the left pulmonary artery and branches. Note stenosis of the left upper lobe branch.
Department of Surgery S. Giuseppe Hosp,ital FbF University of Milan Milan, Italy
Accepted for publication June 29, 1994. Address reprint requests to Dr Fraser, Congenital Heart Surgery Service, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195.
© 1995 by The Society of Thoracic Surgeons
0003-4975/95/$9.50 0003-4975(94)00581-Q
Potential Complications of Vascular Stapling in Thoracoscopic Pulmonary Resection Stewart R. Craig, FRCS, and William S. Walker, FRCS Department of Thoracic Surgery, City Hospital, Edinburgh, United Kingdom In a series of 57 patients undergoing thoracoscopic pulmonary lobectomy, 2 required expeditious conversion to open thoracotomy when a stapling device (Endo-GIA 30 V3; Autosuture, Ascot, UK) used on the main right lower pulmonary artery in 1 case and on the left superior pulmonary vein in the other cut but failed to staple the vessel involved. In both instances the vessel was successfully controlled while a thoracotomy was performed and the involved vessel was oversewn. Both patients made an uncomplicated postoperative recovery. As the number of thoracoscopic pulmonary resections increases, it is likely that similar episodes will occur in the future. These cases strongly emphasize the fact that patients undergoing this procedure should do so in a center specializing in thoracic surgery where there is the necessary surgical expertise and equipment to deal with such potentially lifethreatening vascular complications.
(Ann Thorac Surg 1995;59:736-8) ideo-assisted thoracoscopic pulmonary resection has progressed substantially over the last few years, allowing surgeons to perform a pneumonectomy or standard dissectional lobectomy with lobar lymph node clearance equal to that obtained with a standard open thoracotomy [1-5]. Thoracoscopic operation offers the patient significant benefits such as reduced postoperative pain and discomfort, resulting in a shorter highdependency unit stay [2]. In performing thoracoscopic pulmonary resection, the main vascular structures are divided with endovascular stapling devices, which simultaneously cut and staple the vessel. This combined action raises the possibility that the endostapling device may cut the vessel and fail to staple it, resulting in massive hemorrhage, given the nature of the vessels involved. We report 2 cases of this potentially life-threatening complication.
V
Case Reports The surgical technique employed for thoracoscopic pulmonary lobectomy at the City Hospital Edinburgh, has been described previously [2, 3]. The patient is prepared, anesthetized, and positioned as for a standard posterolateral thoracotomy with the necessary instruments for this beside the operating table. Before any endovascular stapler is used, both the scrub nurse and surgeon ensure that the stapling cartridge is correctly inserted into the Accepted for publication July 18, 1994. Address reprint requests to Mr Walker, Department of ThoracicSurgery, City Hospital Greenbank Dr, Edinburgh EH105SB,UK. © 1995 by The Society of Thoracic Surgeons
stapling device with no residual staples left from previous firings that could cause the stapling device to misfire.
Patient 1 A 71-year-old woman was referred to the thoracic surgical unit with a 3-cm peripheral opacity in her right lower lobe that was noted on a chest radiograph performed during preoperative work-up for an elective sinus operation. She had no respiratory symptoms, and physical examination and routine hematologic and biochemical profiles were unremarkable. A thoracic computed tomographic scan was performed, confirming the presence of a peripheral opacity in the fight lower lobe with no associated mediastinal lymphadenopathy. The liver and adrenal glands were normal. Rigid bronchoscopy was performed and no endobronchial abnormality was noted. Mediastinoscopy revealed anthrocotic nodes in the subcarinal, right tracheobronchial, and right paratracheal regions; biopsy of these nodes confirmed that they were free of metastatic disease. The patient was scheduled for a thoracoscopic right lower lobectomy; however, when the main stem lower pulmonary artery was stapled (Endo-GIA 30 V3; Autosuture, Ascot, UK) a sudden rush of blood was noted when the jaws of the stapler were partially opened. The staple jaws were closed again, arresting the flow of blood. A standard posterolateral thoracotomy was performed and the proximal end of the pulmonary artery was controlled and oversewn with Prolene (Ethicon Ltd, Edinburgh, UK). The remaining part of the operation proceeded without incident, and the patient made an uncomplicated postoperative recovery. Total blood loss was estimated at 130 mL. Histologic examination of the resected lobe revealed a T2 NO bronchoalveolar carcinoma.
Patient 2 A 69-year-old man was referred to the thoracic surgical unit with a 3-cm peripheral opacity in his left upper lobe that was noted on a chest radiograph taken for an episode of pleuritic chest pain. At the time of referral he was asymptomatic and physical examination was unremarkable. Routine hematologic and biochemical profiles were normal. A thoracic computed tomographic scan revealed a 3 cm peripheral lesion in the left upper lobe with no mediastinal lymphadenopathy. The liver and adrenal glands were normal. Rigid bronchoscopy was performed and no endobronchial abnormality was noted. Mediastinoscopy revealed anthrocotic nodes in the subcarinal and left paratracheal regions, biopsy of these nodes confirmed that they were free of metastatic disease. The patient was scheduled for a thoracoscopic left upper lobectomy and the operation proceeded well until the left superior pulmonary vein was stapled (Endo-GIA 30 V3). When the jaws of the stapler were opened there was a rush of blood from the pulmonary vein and it was apparent that the staple line was incomplete and, in addition, the staple head could not be separated from the staple line. The central end of the vein was grasped with a vascular clamp introduced with ease through the submammary incision, and the hemorrhage was arrested 0003-4975/95/$9.50 0003-4975(94)00731-L
Ann Thorac Surg 1995;59:736-8
while a thoracotomy was performed. The patient made an uncomplicated postoperative recovery. Total blood loss was estimated at 730 mL and no blood transfusion was required. Histologic examination of the resected lobe revealed a T1 NO non-small cell undifferentiated carcinoma.
Comment Bleeding from the main pulmonary artery or one of its branches or from the pulmonary veins is a potential hazard during any thoracoscopic pulmonary resection. In our experience, the most common source of troublesome hemorrhage has occurred while attempting to staple branches of the main pulmonary artery, particularly during the early "'learning curve" [3]. In this situation, applying the stapler to the vessel often involves traction along the branch, which can lead to its avulsion. Traction damage to the vessel was not an issue in our 2 cases; however, it is certain that further development of endoscopic instruments, in particular roticulating instruments, will make their use easier and safer [6]. In both of the reported cases, problems arose due to failure of the stapling action that accompanies vessel division. We have performed 62 video-assisted thoracoscopic pulmonary resections to date (57 lobectomies and 5 pneumonectomies), which required approximately 243 firings of the Endo-GIA 30 V3 stapler. The 2 patients in our series therefore resulted in a 0.82% failure rate for endovascular stapling. When a large branch of the pulmonary artery or a lobar vein is to be stapled, we suggest that a sufficient length of vessel is dissected to allow a vascular clamp to be placed on the proximal end before firing of the staple gun. If it is not possible to use a vascular clamp then the jaws of the staple gun should be partially opened and active bleeding sought. If active bleeding occurs, the staple jaws should be closed again, which will arrest the hemorrhage until a thoracotomy can be performed. Other groups have used an endovascular stapler with the knife blade removed so that correct firing of the staples can be ensured before division of the vessel [7]. This may, however, compromise the product license and would not have helped in our second case, when the staple head could not be separated from the staple line on the pulmonary vein. The submammary incision also allows insertion of mounted swabs, which also can be used to tamponade bleeding temporarily and allow easy insertion of vascular clamps. The two Endo-GIA 30 V3 stapling devices were returned to Autosuture, UK, for evaluation. In both cases, Autosuture reported that the stapling cartridge had been correctly inserted into the staple gun; however, the anvil was incorrectly aligned on manufacture so that on firing the staples were forced into an open, rather than closed (B shaped) position, rendering them ineffective. It is extremely important that the endostapler cannot be fixed if the cartridge is not properly inserted or if the anvil is not correctly aligned. The Endo-GIA 30 V3 stapler has
CASE REPORT CRAIG AND WALKER THORACOSCOPIC PULMONARY RESECTION
737
since been modified. It is, however, unlikely that any mechanical device ever can be guaranteed completely safe. Any potential problem can occur given enough use, and any single failing can result in the death of a patient. It is therefore vital to operate in a manner that incorporates strategies to counter this possibility. Despite these failures, the risk of which should be diminished by the endostaple design change, we have not lost our enthusiasm for video-assisted thoracoscopic pulmonary resection. The operating surgeon must be capable of dealing expeditiously with any unexpected hemorrhage and must also be aware of the complex and variable anatomic relationships of the main structures. For this reason, both in the United States and Great Britain, professional societies recommend that thoracoscopic pulmonary resection should only be undertaken by surgeons trained in thoracic surgery [8]. These cases illustrate the validity of this view and are presented as a reminder that thoracoscopic pulmonary resection, although minimal access, is not a minimally invasive operation.
References 1. Walker WS, Carnochan FM, Mattar S. Video-assisted thoracoscopic pneumonectomy. Br J Surg 1994;81:81-2. 2. Walker WS, Camochan FM, Pugh GC. Thoracoscopic pulmonary lobectomy. J Thorac Cardiovasc Surg 1993;106:1111-7. 3. Walker WS, Carnochan FM, Tin M. Thoracoscopy-assisted pulmonary lobectomy. Thorax 1993;48:921-4. 4. Roviaro G, Varoli F, Rebuffat C, et al. Major pulmonary resections: pneumonectomies and lobectomies. Ann Thorac Surg 1993;56:779-83. 5. Kirby TJ, Mack MJ, Landreneau RJ, Rice TIN. Initial experience with video-assisted thoracoscopic lobectomy. Ann Thorac Surg 1993;56:1248-53. 6. Acuff TE, Mack M], Landreneau RJ, Hazelrigg SR. Role of mechanical stapling devices in thoracoscopic pulmonary resection. Ann Thorac Surg 1993;56:749-51. 7. Kirby TJ, Rice TW. Thoracoscopic lobectomy. Ann Thorac Surg 1993;56:784-6. 8. Statement of the AATS/STS Joint Committee on Thoracoscopy and Video Assisted Thoracic Surgery. Ann Thorac Surg 1992;54:1.
INVITED COMMENTARY I carefully read the article by Craig and Walker, whom I know very well for their thoracoscopic activity. The work reports the most frightening complication that can occur during a videothoracoscopic operation. Bleeding from the great vessels due to endoscopic stapler malfunction represents the most serious complication in the course of a thoracoscopic lobectomy, and is dreaded by all who perform this kind of operation. Indeed, this technique is adversed by many thoracic surgeons in fear of disasters deriving from this complication. This work by Craig and Walker reports 2 cases of bleeding due to endostapler malfunction and focuses
738
CASEREPORT FRASERET AL OPERATIONFOR BRANCHPA STENOSIS
attention on the possibility of this occurrence. Throughout m y personal experience of 85 videothoracoscopic p u l m o n a r y resections (80 lobectomies and 5 pneumonectomies), fortunately, no bleeding ever occurred because of stapler malfunction. Bleeding complications occurred in 3 cases of thoracoscopic lobectomy, 1 case requiring 1 unit of blood, but all 3 took place while the vessels were being isolated. The bleeding (from an artery in 2 cases and from a vein in 1) was controlled thoracoscopically, but the operation had to be converted to thoracotomy. In just I case conversion was necessary apparently because of stapler malfunction: after regular section and suture of a large lingular arterial branch, the stapler could not be freed, as part of the staples were stuck between the arterial wall and the stapler's jaws. But it was impossible to establish whether it was truly a stapler malfunction or an error had been made while assembling the new charge. Undoubtedly these events m a y take place occasionally, but it is crucial that a few important requirements and rules be respected to master these complications. First, it is indispensable that these operations be performed only by surgeons with an extensive experience in open conventional thoracic operation. Second, vascular elements must be isolated m u c h more widely than in conventional open operations, also to facilitate the positioning of the staplers. It is usually not too difficult to isolate the vascular elements, particularly as these operations generally are carried out for peripheral T1 NO and T2 NO tumors with uncompromised vascular structures. Finally, extensive vascular preparation and early performing of a small utility thoracotomy ensure an emergency access. Vascular clamps and tampons may quickly be positioned through the utility thoracotomy to control the bleeding and proceed to conversion. I think that endostaplers are perfect machines, but they must be used properly. They can giv e some trouble on the bronchus or on the fissure if those are too thick for the staples" length, but in this case the trouble is due to the surgeon and not to the machine. Concerning possible bleedings after suture-section of the arteries or veins, it is very important to exclude any h u m a n responsibility, such as excessive traction on the vessel or incorrect Closure of the machine (ie, if one or more staples of the previous shot remain on the anvil fork, the staples of the new loading unit m a y not completely close and bleeding m a y occur). However, the rare occurrence of stapler malfunction (0.82% in this work and 0.30% in m y personal experience) should in no way deter e m p l o y m e n t of these techniques.
Ann Thorac Surg 1995;59:738-40
Surgical Repair of Severe Bilateral Branch Pulmonary Artery Stenosis Charles D. Fraser, Jr, MD, Larry A. Latson, MD, and Roger B. B. Mee, FRACS Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio Management options for severe, bilateral branch pulmonary artery stenosis include percutaneous balloon dilation and direct surgical correction. Results with both balloon angioplasty and operation have been somewhat unpredictable. We report a case of staged surgical correction involving bilateral branch pulmonary artery reconstruction.
(Ann Thorac Surg 1995;59:738-40) ongenital branch pulmonary artery stenosis (PAS) is a challenging clinical problem with symptoms ranging from mild dyspnea to profound cyanosis and right heart failure [1, 2]. Management options include direct surgical repair and balloon angioplasty (BA) with or without stenting. We report here a case of staged surgical m a n a g e m e n t of isolated branch PAS.
C
An 8-year-old girl was referred for treatment of severe bilateral branch PAS. Her past medical history was unremarkable. The child was minimally symptomatic but less active than her peers. She had no physical findings consistent with Williams' syndrome. Cardiac catheterization revealed severe bilateral PAS and systemic right ventricular and main pulmonary ar-
Gian Carlo Roviaro, MD
Fig 1. Pulmonary arteriogram demonstrating severe stenosis of the left pulmonary artery and branches. Note stenosis of the left upper lobe branch.
Department of Surgery S. Giuseppe Hosp,ital FbF University of Milan Milan, Italy
Accepted for publication June 29, 1994. Address reprint requests to Dr Fraser, Congenital Heart Surgery Service, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195.
© 1995 by The Society of Thoracic Surgeons
0003-4975/95/$9.50 0003-4975(94)00581-Q