The question of the volume of resection for the bronchus and trachea, methods of closing the defect, prevention and treatment of the insolvency of bronchial and tracheal sutures has always been one of the key issues in pulmonary surgery.
When performing advanced combined resections about far
advanced stages of lung cancer, he each time sharply stands before the surgeon not only in cases of direct spread of the tumor to the mouth of the main bronchus or the wall of the trachea, but also when performing pneumonectomy with the formation of a stump of the main bronchus. The need to perform “skeletonization” of the trachea, the absence of tissues for pleurisy of the tracheal or bronchial sutures, create real prerequisites for the development of their failure, require an individualized, non-standard approach to this stage of surgery.
Therefore, speaking of surgical interventions on the trachea and the main bronchi, it seems appropriate, first of all, to address the issue of the method of forming the bronchus stump after pneumonectomy. Although it does not directly concern the tracheobronchial resections, it invariably arises when performing most of the extended and expanded combined resections of the lung for cancer.
The failure of the bronchus stump after pneumonectomy is the most severe complication, which is in the first place in the structure of postoperative mortality and has no tendency to decrease. It is also relevant to note that the technique of treating the bronchial stump during pneumonectomy, despite the expansion in the volume of the operation, has changed little since the beginning of the 50s, when the hardware suture entered clinical practice. Unfortunately, the use of bronchodilators, greatly simplifying the treatment of the bronchus stump, did not lead to a significant reduction in the incidence of bronchial stump failure (Lishenka VV, 1986). This problem is especially acute when performing extended and expanded combined resections in patients with advanced stages of lung cancer, when there are all known factorshaving an adverse effect on the healing of the stump of the main bronchus. Among the most significant of these, many authors refer to the “biological inertness of tissues”, the presence of endobronchitis, the reduction of cellular and humoral immunity, etc., that is, consider that the “problem of bronchus stump” is not so much a surgical one as a biological one.
We adhere to a slightly different point of view, believing that the main cause of insolvency of the bronchus stump during pneumonectomy are various technical defects when applying a bronchial suture, and these factors may be the “trigger” for the development of this complication.
The purpose of studying this question was to analyze the immediate results of 228 pneumonectomies performed at the clinic in 1981–2011. for various lung diseases. The vast majority of operations (87.3%) were extended and expanded combined pneumonectomy in patients with advanced stages of lung cancer. The failure of the bronchus stump occurred in 39 patients (17.2%), and its frequency with right-and left-sided pneumonectomy was 24.4 and 7.2%, respectively ( C 2 = 11.6; p <0.001). Approximately the same ratio of insolvency of the bronchus stump with right-and left-sided pneumonectomy was noted by other authors.
The reasons for such significant differences in the incidence of failure of the bronchus stump after right-and left-side pneumonectomy in the literature are explained differently.
Opinions of authors on this issue are sometimes contradictory. But attention is drawn to, one significant fact noted by us — the development of insolvency of the bronchus stump arises mainly in the membranous part of the sutured bronchus. Perhaps differences in the frequency of development
insolvency of the bronchus stump due to differences in its structure on the right and left, and the features of the formation of the stump when using bronchodilators?
All this prompted a study of the range of variability in differences in the cross-sectional shapes, width of the membranous part of the main bronchi and the location of the stump walls when using broncho-binding machines. An employee of the clinic V.V.Lishenko, the indicated parameters were studied on 68 tracheobronchial complexes extracted during anatomopathological autopsies. The results of the research are presented in table 18.
As can be seen from the data presented in the table, there are significant differences in the studied parameters of the right and left main bronchi. From these differences and their ratio depends on the shape of the stump of the main bronchus, formed when the branches of the UCB apparatus approach each other. The study of the mechanism of formation of the walls of the bronchus stump depending on the width of the membranous part of the bronchus and their cross-section, conducted on 51 tracheobronchial complex, showed that with a horseshoe-shaped cross section of the bronchus and the width of the membrane portion of it, 14 ± 3.7 mm, as well as in the semi-circular form, regardless of the width of the membranous part, the cartilaginous ring is not cracked along the edges, as was assumed by I. Kolesnikov et al. After flashing the walls of the bronchus with the apparatus of the UCB and breeding the contiguous branches, the bronchial stump under the influence of the elastic traction of the cartilage skeleton of the bronchus takes on a semi-lunar shape. This is confirmed by the data of other authors who studied the state of bronchus stump after pneumonectomy. Thus, the back wall of the bronchus stump is an over-stretched membranous part, not in contact with mediastinal tissues.
Based on the data in table 18, it can be assumed that this form of bronchus stump is formed in the vast majority of cases of right-sided pneumonectomy. Apparently, the high frequency of insolvency of the bronchial stump with right-sided pneumonectomy is largely determined by this circumstance. If the width of the membranous part of the bronchus was less than 14 mm, then at the approach of the branches of the UCB, the cartilage ring cracked and folded, more often it happened on the one hand, mainly from the medial edge. As a result of overdistension of the membranous part of the bronchus stump did not occur. Such a mechanism of formation of bronchus stump is observed with left-sided pneumonectomy.
As it was established in the experiment, there is a direct relationship between the width of the membranous part of the bronchus and the mechanical strength formed when flashing it with a bronchus stump apparatus. When creating a controlled pneumopression in the preparation with the stumps of the main bronchi, stitched with UCB, the air pressure threshold at which the stump depressurization was observed, with a width of the membranous part of more than 14 mm, was 1.5-2 times less than with a narrower width.
All this suggested that the most rational method for treating the bronchus stump, especially when using a mechanical suture, could be to non-exaggerate the adverse conditions of the bronchus stump formation on the right (eliminating overdistension of the membranous part, ensuring tight contact of the back wall of the stump with mediastinal tissues and being lame ).
Among all previously proposed methods of treatment of bronchus stump with pneumonectomy, from the positions under consideration, the Overholt method and its modification providing the most reasonable
immersing the membrane part of the main bronchus inward, and then stitching together the cartilaginous part of the bronchus, folded in half.
The stump of the bronchus formed by this method of treatment is located in the sagittal plane, its least strong posterior wall is in close contact with the mediastinal tissues. However, these methods did not find widespread clinical application due to the need for manipulations on the open bronchus and other technical difficulties. This was also facilitated by the proliferation of bronchodilators of the UBB type, which make it possible to minimize this phase of the operation and focus on the closure of the bronchus stump in the frontal plane.
In the clinic, a modification of the Overholt method was developed and introduced into clinical practice, which allows to preserve all its positive properties and eliminate the time-consuming and disadvantageous elements of this method. After the extraction and processing of vessels of the lung root, the main bronchus is allocated and taken to the bronchial fixator. Then, at the level of the intersection of the bronchus, the first suture is held: the needle is punctured into the anterior (cartilage) wall of the bronchus, holding it through the membranous part and flashing the latter in the opposite direction. Stitch width 2 mm. The membranous part (posterior wall) is fixed to the cartilaginous (front wall) of the bronchus. After that, the outer and inner edges of the cartilaginous semiring are stitched through all the layers so that when tying the threads, the knot is outside, and the cartilaginous semiring folds in half (second seam-holder). Then the bronchial fixator is removed, the holders are stretched in the sagittal plane and the bronchus stump is formed, in which the cartilaginous semicircle is folded in half and the membranous part is immersed inside the stump. At the same time, the seams of the handle tightly tighten the edges of the bronchus and its depressurization practically does not occur. On the formed stump impose apparatus UKB-25 so that its branches converge in the sagittal plane,and the implementation of the staple hardware seam. Excess tissue of the stump together with taped cut off (Fig. 47 d). After removal of the apparatus, the stump of the bronchus is located in the sagittal plane, its back wall (membranous part) tightly pressed against the surrounding tissues.
When using the described method of suturing the bronchial stump, it is necessary to remember about some of its features. The stapled suture is made through the four walls of the bronchus: through the duplication of the cartilage and the duplication of the membranous part of the bronchus. Therefore, in order to avoid unnecessary injury of the bronchus, the compression branches of the apparatus should not be extended beyond the first mark on the branching pad and clips with a foot length of at least 4.5 mm should be used. The second is to avoid dislocation of the cartilage and the formation of an extra-liscous staple suture, it is advisable to apply the UCB device so that the upper edges of the branches are at the level of the lower edge of the overlying cartilaginous semiring.
The mechanical strength of the bronchus stump, formed by the described method, is twice the strength of the stump, sutured in the usual way with the help of a broncho-bonding device. As a rule, the imposition of additional, so-called amartization joints is not required. And one more thing, from our point of view, the great advantage of the method is that we practically ceased to meet with the development of the inconsistency of the bronchus stump with its divergence over the entire width of the bronchus lumen. All failing stumps were small and were related
with excessive trauma to cartilage. The developed method began to be applied in the clinic since 1986. To evaluate it
efficiency were studied direct results 68 pneumonectomy performed in 1986— ies. about the advanced stages of lung cancer. Of these, 35 operations were performed on the right, and 33 on the left. The dependence of the direct outcome of pneumonectomy and the frequency of development of insolvency of the bronchus stump on the method of processing the stump is presented in table 19.
As can be seen from the above data, when using the proposed method of treating the bronchus stump, the overall incidence of bronchial stump failure after pneumonectomy significantly decreased, mainly due to a sharp decrease in the development of this complication after right-side operations. The difference between the incidence of bronchial stump failure after right- and left-sided pneumonectomy was practically leveled out.
Recently, a modified Overholt method with closure of the bronchus stump with knotted hand stitches has been increasingly used. The essence of the proposed method is as follows. After taking the main bronchus on the bronchial fixator and cutting off the drug, the sutures are held according to the procedure described above to one or two cartilaginous semirings above the place where the bronchial fixer is applied. Then, on the upper edge of the instrument branch, a bronchus stump is resected, preferably at the same time that the bronchus intersection line runs along the interchondral gap. Immediately after crossing the bronchus, the assistant pulls on the stitches-holders — the bronchus stump is formed in the sagittal plane and is almost completely sealed. At the same time, the fixed membrane part is not shifted into the lumen of the bronchus stump. Then a single knotted stitching is applied (Fig.48). It is preferable to use for this purpose direct atraumatic needles. The needle is punctured and punctured through the folded cartilaginous semiring, thus providing reliable mechanical support when the sutures are tightened.
At the time, I.S. Kolesnikov, teaching young surgeons how to put stitches on the bronchial stump, often said: “The bronchial suture should be like a friendly handshake — not very strong and not very weak.” And, indeed, with an excessive effort, the eruption of the suture came from the stretched membranous part of the bronchus. When stitching through the thickness of the cartilage, “this handshake” can be much more energetic.
The stitches are tied from the side of the crossed edge of the bronchus, at last, the stitches-holders are tied and cut off. The technique is technically simple, convenient, does not lead to excessive traumatization of the bronchus stump, everything happens under the control of vision, stitching is performed taking into account the individual structure of the half-rings, the formed stump has great mechanical strength. And one more great advantage of this method — your own, can actually be applied along the mouth of the main bronchus, which, with the hardware method, can lead to trauma to the tracheal cartilage. The results of the application of this method in practice are very encouraging and suggest that it best meets all the above listed requirements for the formation of the main bronchus stump.
The name in the clinic of the modified Overholt method of treating the bronchus stump in patients operated on for lung cancer in 1986— has reduced the incidence of bronchial stump failure to 5.6% in right-sided and 1.6% in left-sided pneumonectomy.
Tracheobronchial resections are performed when the tumor spreads to the entire main bronchus, the tracheobronchial angle, right up to the trachea bifurcation spur, and also during their germination by metastases. The spread of the tumor on the main bronchus
The opposite lung is considered a contraindication to surgery. Depending on the nature of the tumor lesion, it is possible to perform various types of tracheobronchial resections: the trachobronchial angle and lateral wall of the trachea, carina and lateral wall of the trachea, circular resection of the trachea bifurcation. In most cases, the operation involves the performance of pneumonectomy. Much less often it is possible to perform an extended lobectomy in combination with a tracheobronchial resection. This situation may occur when the lateral wall of the trachea is limited to metastasis of the tumor or when the tumor of the upper lobe bronchus of the right lung spreads to the main bronchus along its lateral wall, without affecting the intermediate bronchus.
When planning the volume of the tracheobronchial resection, it was always based on the considerations that it is necessary to retreat not less than 1.5 cm from the visible borders of the tumor when crossing the wall of the trachea or bronchus. At the same time, they were guided not only by the data obtained by the surgeon, but also by the results of intraoperative bronchoscopy. Such a joint study allows us to most accurately judge the prevalence of the tumor by the trachea and bronchus and select a rational volume of tracheobronchial resection. However, in each case it is advisable to conduct an urgent histological (cytological) examination of the section of the trachea and bronchi of the removed drug.