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Ann Thorac Surg 1995;60:1458-1459
© 1995 The Society of Thoracic Surgeons
Division III Department of Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao Miyamae-ku, Kawasaki, Japan, 216
To the Editor:
The simplest and the least invasive method of resecting a dumbbell neurogenic tumor of the posterior mediastinum has to be established. Having read with interest the recent article by Vallières and associates [1], I feel that they could have been able to avoid reintubation and even the thoracoscopic procedure, if they had resected just a short segment of the rib(s) next to the laminectomy site and dissected the thoracic portion of the tumor extrapleurally.
My associates and I have earlier published [2] a single-staged method without thoracotomy. With intubation using a regular single-lumen tube the patient is placed in a prone position. A single skin incision in the back is enough to do both laminectomy and minimal rib resection as mentioned above. Thus in 3 patients we successfully removed such tumors without entering the thoracic cavity at all. We did not need microneurosurgical techniques either. Postoperative pain was minimal.
I would appreciate it if Dr Vallières and associates could compare these close but still different approaches with comments.
References
Division of Thoracic Surgery, Ottawa Civic Hospital, 1053 Carling Ave, Ottawa, Ont, Canada K1Y 4E9
Division of Neurosurgery MacKenzie Health Sciences Centre 2D1.02 8440 112 St Edmonton, AB Canada T6G 287
To the Editor:
The superiority of a single-staged procedure over a two-stage approach to posterior dumbbell tumors is supported by most recent reports on the topic [1–5]. A variety of single-staged procedures have been described, all combining various types of incisions and different patient positions, in which either the laminectomy or the intrathoracic work is done first. Osada and associates [2] had indeed reported on their experience back in 1991 using a technique very similar to the one described by the Mayo group in 1978 [5], where costal transversectomy allowed intrathoracic access to the tumor with or without pleural breach. This approach has been shown to be safe, particularly in resecting smaller lesions. We note that the largest lesion in Osada and associates' series was 5.5 cm in diameter. Ricci and colleagues [3] have warned about the potential difficulties in resecting larger lesions using this approach. They have recommended a Grillo type of procedure for the resection of lesions of 4 cm or more or where multiple-level laminectomies were needed. The potential need for thoracotomy in resecting larger lesions was also mentioned by Osada and associates in 1991 [2]. Two of the four lesions in our series were more than 6 cm in diameter.
In their original report, Osada and associates argue in favor of costotransversectomy over thoracotomy, citing cosmetic advantages and a reduction in postoperative pain. Stability of the laminectomized thoracic spine is also said to be possibly superior if costotransversectomy instead of thoracotomy is added. (We disagree with this latter argument, and in fact estimate stability of the laminectomized spine to be possibly inferior after the addition of a costotransversectomy.)
We estimate thoracoscopy to be superior to both costotransversectomy and thoracotomy on all three counts. The incisions are smaller, only a small amount of bone is excised, and postoperative discomfort is dramatically reduced. Both asymptomatic patients in our series were discharged home within 2 to 4 days after operation.
The needs to reposition the patient and reintubate are slight inconveniences of our technique which, we believe, most of us can accept when doing few of these resections in a year. With the rarity of such tumors, cost-analysis comparison of one technique over the other is less important.
In resecting these rare tumors, one must adhere to the established principles of single-stage operation and use the procedure one is most comfortable with to be safe and to avoid neurologic catastrophes. In our hands, the adjunct of video-assisted thoracic resection to microneurosurgical laminectomies has proved to be safe and effective in the resection of posterior mediastinal dumbbell tumors.
References
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