Use of staplers and adverse events in thoracic surgery

A real-world study evaluating the safety and utility of a two-row stapler reload on pulmonary vasculature

Background

Endoscopic staplers are common surgical devices used for the ligation and division of vasculature in thoracic procedures. When a stapler ligates and divides pulmonary vasculature, potentially catastrophic intraoperative bleeding at the staple-line may occur. The aim of this study was to confirm the safety and discuss the utility of a two-row stapler reload, by assessing the incidence of clinically necessary intraoperative hemostatic intervention when applied to pulmonary vasculature in real-world applications.

Methods

This study was designed as a prospective non-comparative registry study conducted in seven centers across the United States, to confirm the safety and performance of Signia™ Small Diameter Reloads (SDR) when used for indicated thoracic surgical procedures. The primary endpoint was the incidence of hemostatic intervention related to the ligation and division of pulmonary arteries and veins. A five-point Likert scale scored hemostasis of each SDR staple-line. Secondary endpoints included the incidence of device-related only adverse events (AEs), device deficiencies, and procedure-related hospital readmission up to and including 30 days post operation.

Results

SDR was fired 302 times across pulmonary vasculature in 120 subjects. Three firings required clinically necessary hemostatic intervention for an intervention rate of 0.99% (3 of 302 firings). Moreover, 97.5% (117 of 120 subjects) had intact SDR staple-lines regardless of surgical access or stapler handle preference. Only 4 (3.3%) thoracoscopic and robotic procedures converted to open, but none were due to SDR staple-lines. There was no statistically significant difference between the Likert score of transected arteries compared to veins (P=0.61). There were no device deficiencies or device-only related AEs reported.

Conclusions

In this study, the two-row stapler reloads demonstrated favorable safety and efficacy profiles when fired across hilar vessels in the thoracic space with a 99% hemostatic rate, independent of surgical access and stapler handle preference.

Design and preliminary validation of a high-fidelity vascular simulator for robot-assisted manipulation

The number of robot-assisted minimally invasive surgeries is increasing annually, together with the need for dedicated and effective training. Surgeons need to learn how to address the novel control modalities of surgical instruments and the loss of haptic feedback, which is a common feature of most surgical robots. High-fidelity physical simulation has proved to be a valid training tool, and it might help in fulfilling these learning needs. In this regard, a high-fidelity sensorized simulator of vascular structures was designed, fabricated and preliminarily validated. The main objective of the simulator is to train novices in robotic surgery to correctly perform vascular resection procedures without applying excessive strain to tissues. The vessel simulator was integrated with soft strain sensors to quantify and objectively assess manipulation skills and to provide real-time feedback to the trainee during a training session. Additionally, a portable and user-friendly training task board was produced to replicate anatomical constraints. The simulator was characterized in terms of its mechanical properties, demonstrating its realism with respect to human tissues. Its face, content and construct validity, together with its usability, were assessed by implementing a training scenario with 13 clinicians, and the results were generally positive.

Examination of resistance of various methods of pulmonary vessel occlusion to hydrostatic pressure

Objective

The aim of this study was to compare pressure resistance of the most common methods of vessel occlusion during thoracic surgical procedures: ligations, clips, and vascular endostaplers.

Methods

Pulmonary vessels were obtained during routine thoracic surgeries. A ball-tipped cannula was inserted through an opening in the side wall and secured with a linen ligature from slipping out. Subsequently, saline was infused into the vessel. We recorded the pressure on which a leakage occurred.

Results

A total of 65 vessels, divided between 3 groups, were enrolled in the study. In the endostaplers group, median bursting pressures were 262.5 mmHg and 300 mmHg for arteries and veins, respectively. In the case of clips, it was over 750 mmHg in both types of the vessels. The same results were observed in the ligation group. Minimal bursting pressures in endostapler occlusion were 187.5 mmHg and 225 mmHg in arteries and veins, respectively. In the case of clips, it was 600 mmHg for arteries and 675 mmHg for veins. A total of 525 mmHg (arteries) and 750 mmHg (veins) were the minimal leaking values observed in vessels occluded with ligations. Comparative analysis showed statistically significant differences in endostapler-clips and endostapler-ligations pairs (p < 0.001). There were no differences between clips and ligations.

Conclusions

The examined methods are capable of occluding pulmonary vessels under physiological conditions. Furthermore, ligations and clips are resistant to pressures highly exceeding physiological values.

Outcomes following combined median sternotomy and ventral midline laparotomy for bicavitary penetrating wooden foreign bodies

Combined abdominal and thoracic pathology caused by extra-gastrointestinal migration of an ingested wooden foreign body (WFB) is an uncommon but serious injury. Presenting clinical signs are typically nonspecific and, in the absence of observed WFB ingestion, diagnosis is challenging. Treatment requires concurrent abdominal and thoracic surgical exploration to remove the WFB and address injuries caused by its migration. This case series describes perioperative characteristics and outcomes in 4 dogs following combined median sternotomy and ventral midline laparotomy (CMSVML) for bicavitary penetrating WFBs. Key clinical message: Treatment of bicavitary penetrating WFBs with CMSVML provided postoperative outcomes similar to those in previous reports; however, high-grade complications and prolonged hospitalization were commonly encountered.

Cold coagulation in thoracoscopic treatment of primary pneumothorax: a comparison with apicectomy

OBJECTIVES

Primary spontaneous pneumothorax is a common disease, whose surgical treatment is still enigmatic in terms of timing and technique. Herein, we reported our experience with the parenchymal-sparing technique via cold coagulation (CC), in comparison to stapler apicectomy (SA).

METHODS

We retrospectively collected data of all patients with apical blebs or <2 cm bullae treated with minimally invasive surgery for recurrent or persistent spontaneous pneumothorax, from 2010 to 2020. Two different surgical techniques were used: SA and the parenchymal-sparing CC of the apex. Perioperative and long-term results were analysed and compared.

RESULTS

Out of 177 patients enrolled, 77 patients (CC group) underwent cold-coagulation of the apex while 100 patients (SA group) were treated with SA. Two groups were comparable in terms of age, surgical indication, intraoperative findings and affected side. CC group had a mean operative time of 43.2 min (standard deviation ± 19.5), shorter than SA group with 49.3 min (standard deviation ± 20.1, P-value: 0.050). Complication rate was significantly different between 2 groups, 5 (7%) and 16 (16%), for the CC and SA groups, respectively (P: 0.048), even if not in terms of prolonged postoperative air leak (P: 0.16). During the follow-up, 13 homolateral recurrences were reported: 2 (3%) in group CC and 11 (11%) in group SA; with a significant difference (P: 0.044). All reinterventions (postoperative prolonged air leak and recurrences) required an SA.

CONCLUSIONS

Parenchymal-sparing technique through CC of apical blebs and bullae is an effective treatment for primary spontaneous pneumothorax and guarantees a good immediate lung sealing, despite stapling still represents the choice treatment in complex cases.

The technique of stump closure has no impact on post-pneumonectomy bronchopleural fistula in the non-small cell lung cancer-a cross-sectional study

Background

Pneumonectomy is a high-risk radical resection procedure, with bronchopleural fistula (BPF) being its most challenging and severe complication. This study aimed to assess the surgical risk factors and the impact of the bronchial stump closure technique on the incidence of the BPF.

Methods

This is a single-center, cross-sectional study of the medical records of 455 post-pneumonectomy patients operated due to non-small cell lung cancer (NSCLC) in 2006-2017. We analyzed the following variables and their influence on the occurrence of the BPF: operation side, surgical techniques (i.e., manual suture or the stapler), stump buttressing, the extension of pneumonectomy, comorbidities, and postoperative complications.

Results

BPF occurred in 7.47% of post-pneumonectomy patients. BPF was more prevalent in right-sided pneumonectomy versus left-sided (10.98% vs. 5.32%; P=0.026). The use of a stapler or manual suture was not associated with the incidence of the BPF (7.96% vs.7.09%, P=0.72). There were no significant differences in the occurrence of BPF among bronchial stump buttressing with the parietal pleura (P=0.80), intercostal muscle flap (IMF) (P=0.46), and pericardial fat pad (P=0.88). When comparing data from 2006-2012 with those from 2013-2017, we found a steady decrease in the number of performed stump reinforcements, but this was not associated with a higher risk of BPF.

Conclusions

The method used for stump closure, additional tissue buttressing of the bronchial stump and year of the surgery had no significant impact on the occurrence of BPF. Only right-sided pneumonectomy was associated with higher BPF occurrence.