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Ann Thorac Surg 1995;60:1459-1460
© 1995 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, The Killingbeck Hospital, York Road, Leeds Ls14 6uq, United Kingdom
To the Editor:
We read with interest the report by Miles and associates [1] documenting the use of ductus arteriosus occlusion without insertion of a thoracostomy tube, a procedure we have routinely used for 16 years. The group of patients reported possessed demographic characteristics similar to that of groups of neonates commonly encountered by surgeons treating this problem. This philosophy thus lends itself to consideration for general use by pediatric surgeons. In addition the group of infants described includes a cohort who have very low birth weights and gestational ages, and are thus most likely to experience failure of medical therapy and require surgical duct occlusion [2]. These infants are, however, also most prone to acquiring bacterial infections. It is therefore necessary to employ surgical methods that reduce the amount of foreign material such as a chest tube implanted, albeit temporarily, and thus minimize the possibility of an infective complication. This aim is met by the methods described.
We have in this institute actively pursued a protocol in which the insertion of a thoracostomy tube after the ligation of the duct has been avoided. In 1991 we reported the results of a similar study, which was one of the largest documented, and in which the outcome of a group of 122 infants was evaluated [3]. In that study a similar incidence of postoperative pneumothorax was identified (6/122; 4.9%) as was reported by Miles and associates. We also found that operative hemorrhage was almost universally minimal and did not require drainage. The mortality in our study was 12%, the etiology of which was related to the problems of prematurity. We have therefore had sufficient confidence regarding the safety of this procedure to treat this population of infants as ``day cases.'' The infants have been transported from referring neonatal intensive care units immediately before operation, some from 130 km away. After clinical stability was achieved postoperatively and full expansion of the lung confirmed by chest roentgenography, the patients were returned to the neonatal unit. Since our report a further 44 premature infants have had their ductus ligated at this institute using the same protocol.
We note the aspirations of this surgical unit to institute earlier duct occlusion and thus facilitate reduced periods of ventilation. The age at duct ligation may, however, be determined more by the management protocol favored by the responsible physician rather than by a surgeon's desire or will to provide a prompt service. A feature of medical treatment that is known to determine the pattern of referral is the administration of indomethacin. In the population reported by Miles and associates all but 2 infants had been treated with indomethacin. By contrast, in our own study only 43.4% of infants had been previously treated with indomethacin. The postnatal age at the time of duct ligation in this cohort was a median of 23 days (range, 3 to 48 days), a value similar to that recorded by Miles and associates. In infants who had not received indomethacin, however, the postnatal age at operation was 15 days (range, 5 to 63 days) (p < 0.001). The subsequent interval from the time of operation to extubation was not, however, influenced by the age at operation.
In summary, the high quality of results presented concur with our own experience. We have also concluded that the method is safe.
References
Loyola University Medical Center, 2160 S First Ave, Maywood, Il 60153
To the Editor:
We appreciate the letter from Satur and colleagues regarding the safety of patent ductus arteriosus closure in premature infants without tube thoracostomy [1]. We note and acknowledge their claim that they have routinely used a similar procedure in the last 16 years [2].
Their study concentrated on the preoperative state of those premature infants and the safety of their transfer to the surgical center on the day of operation. Although they mentioned that chest tube drainage was not used routinely, it was not noted how many patients actually needed chest tube insertion and its implication, especially in babies who had hemorrhages that required reexploration, 1 of whom died later of rapidly progressive respiratory failure. There was also no mention of how soon after the ligation the patients were transferred back to the referring institution. Satur and colleagues have ligated the patent ductus arteriosus through the posterolateral approach. We have emphasized the use of the transaxillary approach and clip closure of the ductus because of its friable nature.
In essence, Satur and colleagues are in agreement with us in terms of the safety and attractiveness of closure of patent ductus arteriosus without chest tube drainage. This philosophy lends itself to consideration for the general use by pediatric surgeons.
References
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