Utilizo la sutura mecanica desde hace años por su rapidez y que no he tenido fistulas bronquiales

Although mechanical stapler are getting more and more accurate in bronchial closure we start to see more bronchopleural fistulas due to the anomalous staple closure and, in some cases, to the aggressive lymph nodal dissection. The great advancement of minimally invasive surgery is the third leading cause of this increasing problem of the bronchial stump (see the aforemantioned abnormal activity of the staplers...). In our center we usually add 2-0 Vicryl stitches and, more likely in patients treated with neoadjuvant therapy, we cover the bronchial stump with the pericardial fat pad.

si la grapadora mecánica funciono correctamente no he visto fistulas. Hace años yo cubría la sutura con un colgajo pleural o pericárdico , ahora no porque confío en la sutura mecánica.Realizo linfadenectomia mediastínica siempre y no he visto relación con fistulas.No creo necesario tampoco en la utilización de pegamentos sobre la sutura . Es muy importante el utilizar el tamaño correcto de la grapadora respecto al del bronquio a cerrar , que queden los extremos bien cerrados y también que la parte membranosa del bronquio no se desgarre en ningún punto. Comprobar llenando con suero la cavidad hasta que cubra la sutura y que tras ventilar no hay fugas de aire.Si existiese ayudarse con puntos de Vicryl u otro tipo de sutura de iguales características.

Antonio I agree with your point of view but believe me with minimally invasive surgery (referred to us mostly from other centre) we unfortunately see patients with this problem. It is important to rely on technology but also be prepared for any black-out.

Me alegro que pienses como yo Niccoló . Por eso hemos de explicar a los que empiezan con la cirugía minimamente invasiva , que antes de empezar a practicarla adquieran experiencia con la manual , por eso encuentro también correcta la pleuralización del muñon bronquial y el que si es preciso refuerces las grapas metálicas con algùn punto de sutura normal. Se me olvido comentar el no dejar muñones bronquiales largos.Piensas igual ?

What really matters for the bronchial stump to heal is the blood supply and mucosal condition of the surgical margin. Overt lymph node dissection should be avoided, especially in patients undergoing neo-adjuvant therapy. It is not uncommon that surgeons try every attempt to eradicate not only the lymph node but also soft tissue covering the bronchus during lymph node dissection. In patients with tuberculosis and severe adhesion around the bronchus, the blood supply would be better preserved if the bronchus is not completely isolated before transection. Literature has reported that a bronchial stump positive for TB culture is risky for the bronchopleural fistula. In our own experience, there has been no bronchopleural fistula in patients undergoing VATS anatomic resection and stapled closure of bronchial stump without reinforcement for pulmonary TB even though some of them were preoperatively sputum positive.

no tenemos pacientes para operar por tuberculosis en la actualidad.Cuando operaba tuberculosis no existia la sutura mecanica.Si que veíamos FB.

Yo extirpo adenopatias sistematicamente en el cancer.pulmonar.No dejo muñones largos ,que quedan con poca vascularización. La sutura mecanica la utilizo siempre .Procuro que quede enterrada en tejido vascularizado. No veo por suerte FB.

I have used the regular TX 30 stapler (Ethicon) for around 3000 "open" pulmonary resections over the last 30 years and had only TWO broncho-pleural fistulas. One after radical (R) pneumonectom(y for Ca., and the other LUL lobectomy for Aspergillosis. I don't cover the stump with any flap unlesss irradiated pre-op..

Kamal G. Khalil MD. UTMSH. Houston, Texas, USA

Kamal you are correct the TX 30 stapler is a great tool for open surgery mostly or, if you do an MIS access on the fourth/fifth intercostal space and is a sufficient opening with the Alexis retractor you might use it as well. Unfortunately is not always the same in MIS for the actor in the surgical field and the stapler...

...or I f you do an MIS access, on the fourth/fifth intercostal space and is opening is enhanced with the Alexis retractor, you might use this stapler as well. Unfortunately is not always the same in MIS for the actor in the surgical field and the stapler...

After lymphadenectomy, the bronchial stump is routinely sutured using resorbable monofilament, closed to the carina and covered with an inercostal or pericardial flap. We take care to not dissect the posterior aspect of the membranous portion of the bronchial stump to preserved the bronchial vascularization.

In our experience, the rate of BPF and its mortality have decreased.

Thorax. 1990 Mar;45(3):183-6.

Nutritional state of patients with lung cancer undergoing thoracotomy.

Bashir Y1, Graham TR, Torrance A, Gibson GJ, Corris PA.

There were from memory two bp fistulas in this small series. They had very poor nutritional status. Consequently, I think that other factors than method of closure are important.

De acuerdo con Ian Gilfillan. Por VATS o resecciones convencionales yo prefiero la sutura mecánica por comodidad y rapidez. No tengo otras razones para no preferir la sutura manual .Los factores que influyen en la aparición de Fistulas Bronquiales , en ambos casos , lo resumiría a mi modo de entender en:

1.- Operar patologías infecciosas.

2.- Estado nutricional del paciente,

3.Pacientes inmunodeprimidos.

4.-Dejar muñones bronquiales largos.

5.-Dejar la parte membranosa a demasiada tensión.

6.-Dejar el muñón bronquial poco vascularizado.

7.-Soy partidario de la linfadenectomía. Si obliga a dejar un muñón poco vascularizado , que pasa a veces a nivel de la membranosa en resecciones cerca de carina , yo pleuralizo o utilizo pericardio.

Es una complicación poco frecuente .