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Ann Thorac Surg 1996;62:1247-1248
© 1996 The Society of Thoracic Surgeons
Division of Cardiac Surgery, University of Verona, OCM Piazzale Stefani 1, Verona 37126, Italy
Division of Cardiothoracic Surgery, Childrens Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027
To the Editor:
We read with interest the article by Moritz and associates [1] on the application of the bilateral thoracosternotomy to patients with pulmonary atresia, ventricular septal defect, and multiple aortopulmonary collateral arteries (PA/VSD/MAPCA). As our group has reported the surgical application of the clamshell approach to infants and children with a variety of complex congenital lesions, including conotruncal malformations [2–4], we believe a few aspects of this technique should be further reported.
Similarly to other groups dealing with PA/VSD/MAPCA [5], we became disappointed with multiple-stage approaches at complete repair. Unlike previously reported series in which a midline incision was used to achieve complete unifocalization and repair in one stage, at The Childrens Hospital Los Angeles we were initially faced with a population of previously palliated patients, which presented unusual management problems. In particular, 9 of 10 patients operated on between October 1993 and December 1995 had undergone a mean of three procedures per patient, including systemic–pulmonary shunts (12 operations) and right heart homograft conduit placement (7 operations). Consequently, both the problem of the "frozen pulmonary hilum," due to scarring from previous procedures, and that of the "egg-shell conduit," intimately adhered to the sternal table, were commonly encountered in our patients. Pleased with the experience in our pediatric lung transplant population, we began extending the clamshell approach to children with PA/VSD/MAPCA.
However, as for the introduction of any novel or revisited surgical approach, not only its efficacy but also its safety need to be demonstrated. As only half of the patients reported by Moritz and associates had undergone previous palliative procedures, one could contend that for at least 3 of their patients a midline incision, as reported by Reddy and associates [5], may have proved as effective in dealing with the disease. Furthermore, although the description of the technical aspects of each of the 6 cases reported was relatively detailed, the evaluation of the clamshell incision in terms of postoperative complications was incomplete and may not per se justify the optimism of the concluding remarks. In contrast, we presented data [3, 4] showing that this approach is as effective in dealing with PA/VSD/MAPCA as a midline approach, and particularly more effective when faced with the problem of pleural and mediastinal adhesions, which may preclude extensive mobilization of the hilar posterior mediastinal structures as described by Hanley's group [5]. In addition, our experience suggests that the clamshell is safe, in that the prevalence of postoperative hemorrhage (10%) and pulmonary morbidity (10%) was comparable with previously reported series [5]. We found that routine use of epidural analgesia in infants and children greatly aided control of incisional pain, allowing for extubation after a median duration of 2 days and discharge from the intensive care unit after a median duration of 4 days.
Unlike Moritz and associates [1], who could not find disadvantages for the clamshell incision, we could. Certainly, the sacrifice of both internal thoracic arteries, the possibility of soft tissue denervation (particularly in women), as observed with the submammary incisions, and the cosmetic considerations of patients who have previously received a midline incision do represent concerns. We agree with Moritz and colleagues [1], however, that reentry can be more easily performed using one intercostal space higher, making dissection less difficult. While advising caution in the critical assessment of this new surgical technique, we do believe that the overall advantages of the clamshell approach for PA/VSD/MAPCA, particularly in children who have undergone a previous operation, far outweigh the potential disadvantages. Thus, we continue to support use of this surgical approach in selected infants and children with conotruncal malformations and are greatly pleased that other groups are successfully reproducing this experience.
References
Department of Cardiothoracic Surgery, J. W. Goethe Universität, Theodor Stern Kai 7, D-60590 Frankfurt, Germany
To the Editor:
I thank Drs Luciani and Starnes for their remarks concerning our article. I make no priority claims but note that we published our first results with this technique in 1994 [1].
Certainly many operations can be done by various methods and incisions. I agree that it would have been possible to operate on 1 or 2 of our patients through a midline sternotomy as well. Still the wide access to all hilar, pulmonary, and cardiac structures makes this complex operation easier. We do not think that sacrificing the two mammary arteries is that much of a disadvantage, especially when other arterial conduits seem to work out pretty well, and we do not know if coronary vascular surgery will exist in 40 years and what type of conduits we will be using at that time.
The amount of soft tissue denervation, which might be a problem for female patients, will not be the same as observed with the submammary incisions, because a wide dissection of the subcutaneous tissue from the fascia is avoided. By using a subpectoral approach [2], one can avoid decreased sensitivity or permanent anesthesia of the lower part of the breast.
We are honored that such a renowned group of surgeons as Drs Luciani and Starnes agree with our conclusion that the advantages of the clamshell incision for correcting complex cases of PA/VSD by far outweighs all potential disadvantages.
References
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