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Ann Thorac Surg 1996;61:280
© 1996 The Society of Thoracic Surgeons
Montreal Chest Institute, 3650 Ste Urbain St, Montreal, Que H2X 2p4, Canada
To the Editor:
On first reading the article on pneumonectomy for chronic infection [1] we had the impression that this represented the learning curve of an inexperienced surgeon, which resulted in reinvention of the wheel. On rereading the article it was evident that Dr Reed was aware of recent reports of a high mortality rate when pneumonectomy was done for inflammatory disease, which has led some authors to question the advisability of pneumonectomy in this situation. Based on 13 pneumonectomies over 13 years Dr Reed indicated that a lower mortality of 7.6% was obtained by following certain precepts that she outlines.
In 1960 Padhi and Lynn [2] reported on the use of a median sternotomy or parasternal thoracotomy with intrapericardial ligation of the pulmonary vessels as an initial step in pneumonectomy for difficult bronchopleural fistulas. Based on our own experience of 738 consecutive resections in 700 patients for tuberculosis from 1950 to 1961 (Paper presented to The Royal College of Surgeons of Canada in 1960 and as a poster presentation to the XVI International T.B. Congress 1961; unpublished), the 30-day operative mortality was 2.7% for 111 pneumonectomies and 0.6% for the remaining resections. The indications for pneumonectomy were thoracoplasty failure, destroyed lung, bronchial stenosis, and tuberculosis bronchiectasis. Forty-three percent of the patients had positive sputum tests for tuberculosis at the time of operation, of which a third had drug-resistant organisms. If endobronchial tuberculosis was present, operation was postponed until it had healed. Most of the operations were difficult, requiring painstaking dissection to mobilize the lung. At the apex, where visibility was limited and adhesions particularly dense, the sharp dissection plane was just beyond the black lung; at times, discretion being the better part of valor, a small amount of lung was left on the subclavian vessels rather than the reverse situation. Blood loss was controlled with the cautery. The volume was carefully recorded, and we believed it was important to replace blood loss with blood as loss occurred. Special filters were used if more than 2 units were to be transfused. Postoperative bleeding was managed conservatively as long as the vital signs were stable. The divided pulmonary vessels were oversewn. Four bronchopleural fistulas and two empyemas in the absence of a bronchopleural fistula occurred. Complete dehiscence of the bronchus as is seen in the stapled bronchus after pneumonectomy for lung cancer was not seen in suture closure of the bronchus. Bronchopleural fistulas were successfully treated by resuture of healthy bronchus covered by a pedicled muscle flap and, if needed, a space-reducing thoracoplasty.
Even though her article evoked a strong response, Dr Reed deserves credit for a timely report and recommendations that are absolutely correct and can be expected to produce improved results in the future.
References
Division of Cardiothoracic Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, Sc 29425-2279
To the Editor:
I thank Drs Munro and Wilson for relating their experience with 111 pneumonectomies for complications of tuberculosis. It is a noteworthy series. They are correct in that I was outlining an alternative approach and precepts to help avoid the difficulties they have discussed. I appreciate their comments.
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