<p>The Impact of Endoscopic Stapler Selection on Bleeding at the Vascular Stump in Pulmonary Artery Transection</p>

Abstract

Objective: To assess bleeding following transection of the pulmonary artery with powered and manual endoscopic staplers. Methods: Cases of video-assisted and open-chest thoracic surgical procedures for non-small cell lung cancer at Ishikawa Prefectural Central Hospital were reviewed between 2012 and 2018. Three stapler groups were assessed: Group 1-Ethicon ECHELON FLEX TM Powered Vascular Stapler (PVS), Group 2-Medtronic Endo-GIA TM iDrive TM powered stapler, Group 3-Ethicon and Medtronic manual staplers. Results: Of 239 patients, 82 cases (34.3%) were Group 1, 94 cases (39.3%) were Group 2 and 63 cases (26.4%) were Group 3. Mean age was 68.3 years (range 36-88 years), and most patients received video-assisted right upper lobectomy (82.8%). Bleeding occurred in 24 cases: 17 (70.8%) in Group 2 and 7 (29.2%) cases in Group 3. No bleeding occurred in Group 1. The loaded ECHELON FLEX TM PVS and Endo-GIA TM iDrive TM with gray cartridge combinations had the greatest and smallest closed anvil jaw gaps (>0.63 µm and <0.15 µm, respectively); Endo-GIA TM iDrive TM gray cartridge combinations resulted in ruptures of inner and middle membranes of the pulmonary artery. No ruptures were observed using the ECHELON FLEX TM PVS. Conclusion: An excessively narrow gap between cartridge and anvil may damage the blood vessel wall and lead to bleeding following transection. This study provides preliminary evidence that the use of the ECHELON FLEX TM PVS and tan cartridges for pulmonary artery stapling may help to prevent tissue damage and intraoperative bleeding.

Commentary: How did that happen?

“…In any case, high compression on delicate vessels can cause damage away from the closed ends of the divided structure leading one group of investigators to cite stapler gap distance as an important consideration during pulmonary stapling. 2 In any case, this report underscores the need to surveil for errant, partially embedded, and malformed staples while operating. To the extent that small vessel division might increase this problem because there is less vascular wall for staple incorporation, we might consider greater use of Surgeons need to appreciate the general and device-specific mechanisms by which endomechanical staplers cause vascular injuries.…”

Economic impact of powered stapler in video-assisted thoracic surgery lobectomy for lung Cancer in a Chinese tertiary hospital: a cost-minimization analysis

“…The superior clinical effects of powered staplers over manual staplers in VATS lobectomy for lung cancer have been widely presented [4][5][6][7]. To further compare the two types of staplers, this study uses CMA to assess the economic impact of utilizing a powered stapler in VATS lobectomy for lung cancer in a Chinese tertiary hospital.…”

“…Therefore, a powered stapler was developed to address this limitation by using a motor to power both the staple firing and the cutting action of the blade. A powered stapler can reduce movement at the distal tip by 88% when compared to a manual stapler [4]. In addition, the use of a powered stapler can prevent the operating surgeon's intraoperative hand tremors thereby minimizing tissue damage.…”

“…However, there is dissonance among existing literature on the clinical and economic benefits associated with the use of a powered stapler in VATS lobectomy. For example, four real-world studies from the United States, South Korea, and Japan reported that the use of a powered stapler was associated with significantly lower risk of complications (i.e., bleeding and pleurodesis) and lower hospital costs than the use of a manual powered stapler in VATS lobectomy [4][5][6][7]. In contrast, three studies from the United States and Europe observed no significant differences in the incidences of complications (e.g., air leak, bleeding, post-surgery adverse events, and length of drainage therapy) between the two types of staplers [8][9][10].…”

<p>Comparative Effectiveness Assessment of Two Powered Surgical Stapling Platforms in Laparoscopic Sleeve Gastrectomy: A Retrospective Matched Study</p>

“…A recent study from Japan, presented a case series that showed potential benefits of lower bleeding at the vascular stump in pulmonary artery transection associated with the use of Ethicon's ECHELON FLEX™ Powered Vascular Stapler as compared with Medtronic's iDrive TM powered stapler. 9 However, no other comparative assessment between powered staplers is available to the best of our knowledge at the time of this writing. Therefore, we conducted this retrospective study to assess the comparative real-world risk of hemostasis-related complications and other outcomes associated with the use of the powered staplers GST and SIG among patients undergoing laparoscopic sleeve gastrectomy for obesity.…”