Double stapling method for closure of intraoperative alveolar air leakage adjacent to the staple line: a randomized experimental study on ex vivo porcine lungs

Abstract

Background: Alveolar air leakage from a pleural defect around the staple line is one of the complications after wedge resection of the lung. An intraoperative closure of the pleural defect by suturing can cause additional pleural rupture due to tension of the pleura adjacent to staple lines. Therefore, we have introduced a novel closure method for pleural defect adjacent to the staple line, named the double stapling method. This study compared the efficacy of two closure methods; the double stapling method and conventional suturing method with pledgets using ex vivo porcine lungs. Methods:The double stapling method involves closing the pleural defect by suturing the two parallel staple lines at both sides of the pleural defect. This method was developed to distribute the pleural tension around the needle holes of suturing. As a model of pleural defect adjacent to the staple line after wedge resection, wedge resection of the caudal lobe of left porcine lungs was performed, and a superficial square pleural defect (10 mm × 10 mm) adjacent to the staple line was made by scalpel. The defect was closed using the following two methods: (I) suturing with pledgets (n=10); and (II) double stapling method (n=10). The lobe was inflated in water at an airway pressure of 20, 25, and 30 cmH 2 O; closure success or failure was judged by the absence or presence of air leakage. Results:The closure success was confirmed in 2 (20%) out of 10 cases in the suturing with pledgets group and 9 (90%) out of 10 in the double stapling method group (P=0.007). In 4 out of 10 cases in the suturing with pledgets group, new pleural clefts longer than 3 mm were created around the needle holes of suturing. Conclusions:Ex vivo experiments have suggested the superiority of the double stapling method for the intraoperative closure of alveolar air leakage adjacent to the staple line after wedge resection, compared to conventional suturing with the pledget method.

Air leaks: leave well enough alone

“…Intra operative air leaks reflecting the duration of postoperative air leak (4), it is important to be able to minimize the leakage during the same intra operative time. Precisely, Suzuki et al (5) have described a novel intraoperative closure method. The authors conducted an interesting in vitro experiment, maybe a preamble to a larger in vivo study.…”

“…The two methods seem similar in terms of postoperative complications and respiratory function (8,9), but if stapling allows a reduction in the hospital length of stay, it generates a defect of pulmonary re-expansion in 2.5% of cases at 1 month (10). At last, the method described by Suzuki et al (5) is not applicable to pleural defect related to dissection or made outside the stapling area. It is therefore not a unique method but a useful complement to methods already described.…”