How to prevent adverse events of vascular stapling in thoracic surgery: recommendations based on a clinical and experimental study

Abstract

Background: Advances in the development of staplers for pulmonary vessels have contributed to safe and convenient procedures in thoracic surgery. However, adverse events (AEs) can occur during vascular stapling and cause fatal hemorrhage. We aimed to assess the risk level of using the vessel stapling procedure to reduce such AEs.

Methods: First, an animal experiment using pig cardiopulmonary blocks was conducted. Pulmonary arteries were closed with staplers under stressful conditions such as lifting or twisting; vessel stump endurance was analyzed through different methods. Second, AEs associated with clinical stapler use for pulmonary vessels were retrospectively reviewed by studying clinical videos of 263 patients.

Results: In the animal experiment, the pressure resistance was significantly lower in the twisted group than in the no strain group (no strain vs. lifting: P=0.2008, no strain vs. twisting: P=0.002, no strain vs. twisting and lifting: P<0.0001). Regarding clinical stapler use, 754 staplers were used against the vessels. AEs occurred in 9 cases, and 7 cases were suspected to be caused by vessel tension.

Conclusions: The pulmonary vessel stapling causes stress due to twisting and lifting that decreased stump durability. Avoiding such stress when using stapler for vessels leads to a safer thoracic surgery.

Keywords: Mechanical stapler; pulmonary artery; thoracoscopy.

Figure 1

Stress to the vessels on firing. (A) Lifting; (B) twisting; (C) lifting and twisting.

Figure 2

Pressure resistance of the vessel stumps in each group. The pressure was significantly lower in the twisted group (C,D) than in the no strain group (A) (*P<0.01).

Figure 3

Shape of the staple lines. They were evaluated macroscopically and categorized into two groups. (A) Optimally formed; (B) deformed; (C) number of the deformed staple lines in each group.