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SUTURELESS BRONCHIAL STUMP CLOSURE
SUTURELESS BRONCHIAL STUMP CLOSURE A n Experimental Study B. A. Glass, M.D., and H. M. Albert, M.D., New Orleans, La.
S
UTURE closure of the bronchial stump after lobectomy or pneumonectomy has long been a standard procedure. In recent years the use of Eastman 910 monomer and/or Eastman 910 adhesive,* a less pure form of the same plastic, has been reported for closure of the bronchial stump following pneumonectomy,1 for sealing the cut edges of lung tissue after wedge resection, 2 ' 3 for gastrointes tinal anastomosis,4 for blood vessel anastomoses and repairs,5"9 and many other purposes.10"14 This study was instituted to evaluate the comparative merits of closure of the bronchial stump with sutures, with Eastman 910 monomer, and with East man 910 adhesive. METHOD AND RESULTS
Mongrel dogs were anesthetized with intravenous Nembutal sodium. Positive pressure endotracheal respiration was supported with a Harvard respirator. A left posterolateral thoracotomy was performed through the fifth intercostal space. In all animals of all groups a fresh supply of either the monomer or the ad hesive was used. All vials of monomer and adhesive were refrigerated until used and, once opened, no vial was used after it had been opened for over 5 days. GROUP I.—A left pneumonectomy was performed in a routine fashion with the exception that the left main bronchus was not divided close to the carina; it was purposely left long enough to allow separate closure of the bronchus to the left upper lobe and the bronchus to the left lower lobe. In 15 dogs the left upper lobe bronchus was closed with interrupted 3-0 silk sutures and the left lower lobe bronchus was closed with Eastman 910 monomer. In 5 dogs, the left upper lobe bronchus was closed with Eastman 910 monomer while the lower lobe bronchus was closed with sutures. Application of the monomer was carried out by the technique described by Healey. 1 The thoracic incision was closed anatomi cally in layers. From the Department of Surgery, Louisiana State University School of Medicine, New Orleans, La. Supported in part by U. S. Public Health Service Grant No. Gs-76, and in part by U. S. Public Health Service Grant No. HE-02573-08. Received for publication May 18, 1964. ♦Eastman 910 monomer and adhesive supplied through the courtesy of Ethicon, Inc., Sommerville, N. J. 194
Vol. 49, No. 2 February, 1965
SUTURELESS BRONCHIAL STUMP CLOSURE
195
Fifteen animals died from 1 to 8 days following surgery. The cause of death in each case was tension pneumothorax. Without exception, the site of origin of the pneumothorax was the bronchus which had been closed with the Eastman 910 monomer, be it upper or lower lobe bronchus. In most instances the nonsutured bronchus was completely disrupted. In all cases, the site of the bronchial air leak was obvious. All of the sutured bronchi were intact and no leakage was evident. Five of the animals were sacrificed at intervals of 24 hours to 6 days follow ing surgery. An endotracheal tube was tied snugly in the trachea and the right main bronchus was clamped. The endotracheal tube was filled with water and positive pressure applied to the endotracheal tube with the use of a mercury blood pressure cuff to deliver a measured amount of positive pressure. The left bronchial stumps were observed for water leakage as the endotracheal pressure was increased by 10 mm. increments. In 4 of the 5 animals the bronchus which had been closed with the monomer disrupted under pressures ranging from 40 to 120 mm. Hg. In 1 animal both bronchial closures disrupted at 130 mm. Hg. GROUP II.—The technique was identical to Group I with the exception that Eastman 910 adhesive was substituted for the monomer. Ten dogs were studied. In 5 dogs the left upper lobe bronchus was closed with 3-0 silk interrupted sutures and the lower lobe bronchus was closed with adhesive. In 5 dogs the left upper lobe was closed with adhesive while the left lower lobe was closed with sutures. Nine of the 10 animals died within 9 days as a result of tension pneumo thorax. In each instance the source of the air leak was either partial or complete disruption of the bronchus which had been closed with adhesive. The tenth animal was sacrificed at 24 hours. Pressure applied endobronchially, as described in Group I, caused disruption of the bronchus closed with adhesive at 50 mm. Hg. The sutured bronchus remained intact. GROUP in.—Five dogs were submitted to a standard left pneumonectomy with a short bronchial stump. The stump was closed, as described by Healey, 1 but Eastman 910 adhesive was used. All animals survived and were sacrificed from 6 days to 35 days. At autopsy 2 dogs showed the left main bronchus stump to be sealed only by a very thin, fibrous membrane. Three dogs showed a well-healed left main bronchus stump. GROUP rv.—Three dogs were submitted to left thoracotomy and wedge resec tion of a large portion of lung tissue. The cut edges of the lung were sealed with Eastman 910 adhesive. All animals survived and were autopsied at 7 months. The sites of wedge resection were so well healed as to actually be difficult to find. At no time was there any evidence of a pneumothorax. DISCUSSION
In all dogs studied, both the monomer and the adhesive proved messy and difficult to handle. In Groups I and I I suturing of the bronchus was accomlished more quickly and with greater ease than was bronchial closure by means
196
GLASS AND ALBERT
J. Thoracic and Cardiovas. Surg.
of the monomer or adhesive. Even with the use of siliconized clamps and forceps, the monomer and the adhesive showed a perverse preference to adhere to instru ments and to rubber gloves much more quickly than to living tissue. In all groups, absolute hemostasis as well as completely dry tissues were necessary for either monomer or adhesive to effect a closure. "We had hoped that either the monomer, the adhesive, or both would prove superior to suture closure of the bronchus. In spite of the fact that suture material, in our hands, proved easier to handle, we believed that if either the monomer or the adhesive proved superior to suture material they would be valuable adjuncts to the armamentarium of the thoracic surgeon. Because we suspected the poor results obtained in Groups I and I I might be the results of faulty technique, the experiments described in Groups I I I and IV were carried out with the resultant duplication of good results obtained by others. 1 - 2 Namely, we were able to obtain good results in closure of a short, left, main bronchus or of an area of wedge resection of the lung with the use of monomer or adhesive without sutures. It might be argued that the long bronchial stumps left in Groups I and I I are unnecessarily severe tests of the ability of the monomer and/or the adhesive to seal a bronchus. That a long bronchial stump is more prone to leak is not denied. The fact that the bronchi closed with sutures did not disrupt, while those closed with either monomer or adhesive invariably disrupted, seems to us, however, to be quite significant. Further, it did not matter whether the upper lobe was sutured and the lower lobe closed with monomer or adhesive, or vice versa. The bronchus closed with monomer or adhesive invariably disrupted while the sutured bronchus remained intact. CONCLUSIONS
In spite of the favorable reports of others, the authors find themselves in the position of an apparently small minority 15 who are unfavorably impressed with Eastman 910 monomer and Eastman 910 adhesive. On the basis of these experiments we must conclude that, although either the monomer or the adhesive may be a reasonably satisfactory method of closing either a pneumonectomy stump or raw lung surface, neither is as satisfactory, or as safe, as an interrupted silk closure of the bronchial stump. It is our feeling that neither the monomer nor the adhesive will replace the needle and thread. SUMMARY
An experimental study was undertaken to evaluate the relative merits of closure of the bronchial stump following lobectomy by means of interrupted silk sutures, Eastman 910 monomer, and Eastman 910 adhesive. Results indicate that suture closure is easier from a technical standpoint and is safer than closure with either the monomer or the adhesive. REFERENCES 1. Healey, J . E., Jr., Sheena, K. S., Gallager, H. S., Clark, E. L., and O'Neill, P . : The Use of a Plastic Adhesive in t h e Technique of Bronchial Closure, S. Forum 13: 153, 1962.
Vol. 49, No. 2 February, 1965
SUTURELESS BRONCHIAL STUMP CLOSURE
197
2. Wilder, R. J., Playforth, H., Bryant, M., and Raviteh, M. M.: The Use of Plastic Adhesive in Pulmonary Surgery, J . THORACIC & CARDIOVAS. SURG. 46: 576, 1963.
3. Thomas, P . A., J r . , Nims, R. M., Hunt, R. D., and Aronstam, E. M.: Experimental Observations W i t h a Plastic Adhesive, Methyl 2-Cyanoacrylate, as a Sealing Agent in Pulmonary and Bronchial Surgery, Cohesivenews 3 : 1, 1963. 4. O'Neill, P., Healey, J . E., J r . , Clark, R. L., and Gallager, H . S.: Nonsuture Intestinal Anastomosis, Am. J . Surg. 104: 761, 1962. 5. Hafner, C. D., Fogarty, T. J., a n d Cranley, J . J . : Nonsuture Anastomosis of small Arteries Using a Tissue Adhesive, Surg., Gynec. & Obst. 116: 417, 1963. 6. Carton, C. A., Kessler, L. A., Seidenberg, B., a n d H u r w i t t , E. S.: Experimental Studies in Surgery of Small Blood Vessels. I I . P a t c h i n g of Arteriotomy Using Plastic Adhesive, J . Neurosurg. 18: 188, 1961. 7. Carton, C. A., Heifetz, M. D., a n d Kessler, L. A.: P a t c h i n g of I n t r a c r a n i a l I n t e r n a l Carotid A r t e r y in M a n Using a Plastic Adhesive ( E a s t m a n 910 Adhesive), J . Neurosurg. 19: 887, 1962. 8. Healey, J . E., J r . , Clark, R. L., Gallager, H . S., O'Neill, P., and Sheena, K. S.: Non suture Repair of Blood Vessels, Ann. Surg. 155: 817, 1962. 9. Nathan, H . S., Nachlas, M. M., Solomon, R. D., Halpern, B . D., and Seligman, A. M . : Nonsuture Closure of Arterial Incisions Using a Rapidly Polymerizing Adhesive, Ann. Surg. 152: 648, 1960. 10. Braunwald, N . 8., a n d Awe, W. C : Control of Hemorrhage From t h e H e a r t a n d Aorta Utilizing a Plastic Adhesive, Surgery 51: 786, 1962. 11. Bloomfield, S., Barnert, A. H., a n d Kanter, P . D . : The Use of E a s t m a n 910 Monomer as a n Adhesive in Ocular Surgery. I . Biologic Effects on Ocular Tissues, Am. J . Ophthalmol. 55: 742, 1963. 12. Albin, M. S., D'agostino, A. N., White, R. J., and Grindlay, J . H . : Nonsuture Sealing of a Dural Substitute Utilizing a Plastin Adhesive, Methyl 2-Cyanoacrylate, J . Neurosurg. 19: 545 ; 1962. 13. Fischl, R. A . : An Adhesive for Primary Closure of Skin Incisions, Plastic & Reconstruct. Surg. 30: 607, 1962. 14. Ashley, F . L., Stone, R. S., Polak, T., Berman, D. D., and Delabar, M.: F u r t h e r Studies Involving Wound Closure W i t h a Rapidly Polymerizing Adhesive, Plastic & Reconstruct. Surg. 3 1 : 333, 1963. 15. Weilbaecher, D. A., Mathieu, F . J., and Cohn, I., J r . : Nonsuture Intestinal Anastomosis, Am. J . Surg. 107: 353, 1964.
S
UTURE closure of the bronchial stump after lobectomy or pneumonectomy has long been a standard procedure. In recent years the use of Eastman 910 monomer and/or Eastman 910 adhesive,* a less pure form of the same plastic, has been reported for closure of the bronchial stump following pneumonectomy,1 for sealing the cut edges of lung tissue after wedge resection, 2 ' 3 for gastrointes tinal anastomosis,4 for blood vessel anastomoses and repairs,5"9 and many other purposes.10"14 This study was instituted to evaluate the comparative merits of closure of the bronchial stump with sutures, with Eastman 910 monomer, and with East man 910 adhesive. METHOD AND RESULTS
Mongrel dogs were anesthetized with intravenous Nembutal sodium. Positive pressure endotracheal respiration was supported with a Harvard respirator. A left posterolateral thoracotomy was performed through the fifth intercostal space. In all animals of all groups a fresh supply of either the monomer or the ad hesive was used. All vials of monomer and adhesive were refrigerated until used and, once opened, no vial was used after it had been opened for over 5 days. GROUP I.—A left pneumonectomy was performed in a routine fashion with the exception that the left main bronchus was not divided close to the carina; it was purposely left long enough to allow separate closure of the bronchus to the left upper lobe and the bronchus to the left lower lobe. In 15 dogs the left upper lobe bronchus was closed with interrupted 3-0 silk sutures and the left lower lobe bronchus was closed with Eastman 910 monomer. In 5 dogs, the left upper lobe bronchus was closed with Eastman 910 monomer while the lower lobe bronchus was closed with sutures. Application of the monomer was carried out by the technique described by Healey. 1 The thoracic incision was closed anatomi cally in layers. From the Department of Surgery, Louisiana State University School of Medicine, New Orleans, La. Supported in part by U. S. Public Health Service Grant No. Gs-76, and in part by U. S. Public Health Service Grant No. HE-02573-08. Received for publication May 18, 1964. ♦Eastman 910 monomer and adhesive supplied through the courtesy of Ethicon, Inc., Sommerville, N. J. 194
Vol. 49, No. 2 February, 1965
SUTURELESS BRONCHIAL STUMP CLOSURE
195
Fifteen animals died from 1 to 8 days following surgery. The cause of death in each case was tension pneumothorax. Without exception, the site of origin of the pneumothorax was the bronchus which had been closed with the Eastman 910 monomer, be it upper or lower lobe bronchus. In most instances the nonsutured bronchus was completely disrupted. In all cases, the site of the bronchial air leak was obvious. All of the sutured bronchi were intact and no leakage was evident. Five of the animals were sacrificed at intervals of 24 hours to 6 days follow ing surgery. An endotracheal tube was tied snugly in the trachea and the right main bronchus was clamped. The endotracheal tube was filled with water and positive pressure applied to the endotracheal tube with the use of a mercury blood pressure cuff to deliver a measured amount of positive pressure. The left bronchial stumps were observed for water leakage as the endotracheal pressure was increased by 10 mm. increments. In 4 of the 5 animals the bronchus which had been closed with the monomer disrupted under pressures ranging from 40 to 120 mm. Hg. In 1 animal both bronchial closures disrupted at 130 mm. Hg. GROUP II.—The technique was identical to Group I with the exception that Eastman 910 adhesive was substituted for the monomer. Ten dogs were studied. In 5 dogs the left upper lobe bronchus was closed with 3-0 silk interrupted sutures and the lower lobe bronchus was closed with adhesive. In 5 dogs the left upper lobe was closed with adhesive while the left lower lobe was closed with sutures. Nine of the 10 animals died within 9 days as a result of tension pneumo thorax. In each instance the source of the air leak was either partial or complete disruption of the bronchus which had been closed with adhesive. The tenth animal was sacrificed at 24 hours. Pressure applied endobronchially, as described in Group I, caused disruption of the bronchus closed with adhesive at 50 mm. Hg. The sutured bronchus remained intact. GROUP in.—Five dogs were submitted to a standard left pneumonectomy with a short bronchial stump. The stump was closed, as described by Healey, 1 but Eastman 910 adhesive was used. All animals survived and were sacrificed from 6 days to 35 days. At autopsy 2 dogs showed the left main bronchus stump to be sealed only by a very thin, fibrous membrane. Three dogs showed a well-healed left main bronchus stump. GROUP rv.—Three dogs were submitted to left thoracotomy and wedge resec tion of a large portion of lung tissue. The cut edges of the lung were sealed with Eastman 910 adhesive. All animals survived and were autopsied at 7 months. The sites of wedge resection were so well healed as to actually be difficult to find. At no time was there any evidence of a pneumothorax. DISCUSSION
In all dogs studied, both the monomer and the adhesive proved messy and difficult to handle. In Groups I and I I suturing of the bronchus was accomlished more quickly and with greater ease than was bronchial closure by means
196
GLASS AND ALBERT
J. Thoracic and Cardiovas. Surg.
of the monomer or adhesive. Even with the use of siliconized clamps and forceps, the monomer and the adhesive showed a perverse preference to adhere to instru ments and to rubber gloves much more quickly than to living tissue. In all groups, absolute hemostasis as well as completely dry tissues were necessary for either monomer or adhesive to effect a closure. "We had hoped that either the monomer, the adhesive, or both would prove superior to suture closure of the bronchus. In spite of the fact that suture material, in our hands, proved easier to handle, we believed that if either the monomer or the adhesive proved superior to suture material they would be valuable adjuncts to the armamentarium of the thoracic surgeon. Because we suspected the poor results obtained in Groups I and I I might be the results of faulty technique, the experiments described in Groups I I I and IV were carried out with the resultant duplication of good results obtained by others. 1 - 2 Namely, we were able to obtain good results in closure of a short, left, main bronchus or of an area of wedge resection of the lung with the use of monomer or adhesive without sutures. It might be argued that the long bronchial stumps left in Groups I and I I are unnecessarily severe tests of the ability of the monomer and/or the adhesive to seal a bronchus. That a long bronchial stump is more prone to leak is not denied. The fact that the bronchi closed with sutures did not disrupt, while those closed with either monomer or adhesive invariably disrupted, seems to us, however, to be quite significant. Further, it did not matter whether the upper lobe was sutured and the lower lobe closed with monomer or adhesive, or vice versa. The bronchus closed with monomer or adhesive invariably disrupted while the sutured bronchus remained intact. CONCLUSIONS
In spite of the favorable reports of others, the authors find themselves in the position of an apparently small minority 15 who are unfavorably impressed with Eastman 910 monomer and Eastman 910 adhesive. On the basis of these experiments we must conclude that, although either the monomer or the adhesive may be a reasonably satisfactory method of closing either a pneumonectomy stump or raw lung surface, neither is as satisfactory, or as safe, as an interrupted silk closure of the bronchial stump. It is our feeling that neither the monomer nor the adhesive will replace the needle and thread. SUMMARY
An experimental study was undertaken to evaluate the relative merits of closure of the bronchial stump following lobectomy by means of interrupted silk sutures, Eastman 910 monomer, and Eastman 910 adhesive. Results indicate that suture closure is easier from a technical standpoint and is safer than closure with either the monomer or the adhesive. REFERENCES 1. Healey, J . E., Jr., Sheena, K. S., Gallager, H. S., Clark, E. L., and O'Neill, P . : The Use of a Plastic Adhesive in t h e Technique of Bronchial Closure, S. Forum 13: 153, 1962.
Vol. 49, No. 2 February, 1965
SUTURELESS BRONCHIAL STUMP CLOSURE
197
2. Wilder, R. J., Playforth, H., Bryant, M., and Raviteh, M. M.: The Use of Plastic Adhesive in Pulmonary Surgery, J . THORACIC & CARDIOVAS. SURG. 46: 576, 1963.
3. Thomas, P . A., J r . , Nims, R. M., Hunt, R. D., and Aronstam, E. M.: Experimental Observations W i t h a Plastic Adhesive, Methyl 2-Cyanoacrylate, as a Sealing Agent in Pulmonary and Bronchial Surgery, Cohesivenews 3 : 1, 1963. 4. O'Neill, P., Healey, J . E., J r . , Clark, R. L., and Gallager, H . S.: Nonsuture Intestinal Anastomosis, Am. J . Surg. 104: 761, 1962. 5. Hafner, C. D., Fogarty, T. J., a n d Cranley, J . J . : Nonsuture Anastomosis of small Arteries Using a Tissue Adhesive, Surg., Gynec. & Obst. 116: 417, 1963. 6. Carton, C. A., Kessler, L. A., Seidenberg, B., a n d H u r w i t t , E. S.: Experimental Studies in Surgery of Small Blood Vessels. I I . P a t c h i n g of Arteriotomy Using Plastic Adhesive, J . Neurosurg. 18: 188, 1961. 7. Carton, C. A., Heifetz, M. D., a n d Kessler, L. A.: P a t c h i n g of I n t r a c r a n i a l I n t e r n a l Carotid A r t e r y in M a n Using a Plastic Adhesive ( E a s t m a n 910 Adhesive), J . Neurosurg. 19: 887, 1962. 8. Healey, J . E., J r . , Clark, R. L., Gallager, H . S., O'Neill, P., and Sheena, K. S.: Non suture Repair of Blood Vessels, Ann. Surg. 155: 817, 1962. 9. Nathan, H . S., Nachlas, M. M., Solomon, R. D., Halpern, B . D., and Seligman, A. M . : Nonsuture Closure of Arterial Incisions Using a Rapidly Polymerizing Adhesive, Ann. Surg. 152: 648, 1960. 10. Braunwald, N . 8., a n d Awe, W. C : Control of Hemorrhage From t h e H e a r t a n d Aorta Utilizing a Plastic Adhesive, Surgery 51: 786, 1962. 11. Bloomfield, S., Barnert, A. H., a n d Kanter, P . D . : The Use of E a s t m a n 910 Monomer as a n Adhesive in Ocular Surgery. I . Biologic Effects on Ocular Tissues, Am. J . Ophthalmol. 55: 742, 1963. 12. Albin, M. S., D'agostino, A. N., White, R. J., and Grindlay, J . H . : Nonsuture Sealing of a Dural Substitute Utilizing a Plastin Adhesive, Methyl 2-Cyanoacrylate, J . Neurosurg. 19: 545 ; 1962. 13. Fischl, R. A . : An Adhesive for Primary Closure of Skin Incisions, Plastic & Reconstruct. Surg. 30: 607, 1962. 14. Ashley, F . L., Stone, R. S., Polak, T., Berman, D. D., and Delabar, M.: F u r t h e r Studies Involving Wound Closure W i t h a Rapidly Polymerizing Adhesive, Plastic & Reconstruct. Surg. 3 1 : 333, 1963. 15. Weilbaecher, D. A., Mathieu, F . J., and Cohn, I., J r . : Nonsuture Intestinal Anastomosis, Am. J . Surg. 107: 353, 1964.