| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1997;63:1825-1826
© 1997 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, University of Cape Town, South Africa, e-mail: mdegroot{at}thoracic.cts.uct.ac.za
To the Editor:
We read with interest the article entitled "Pneumonectomy for Chronic Infection is a High-Risk Procedure" by Massard and colleagues [1]. This article essentially reinforces the sentiments expressed in an earlier article by Reed [2] that pneumonectomy for inflammatory lung disease is exceptionally hazardous and often results in a high percentage of postoperative complications. These series have in common a low annual incidence (2 per year and 1 per year respectively), heavy intraoperative blood loss (1,983 ± 1,424 mL and 2,083 ± 519 mL, respectively), and a high incidence of bronchial stump dehiscence (32% and 23%, respectively). In addition, Reed [2] records an average operative time of 5.7 hours and Massard and colleagues [1] report an empyema rate of 32%. Their sentiments regarding this operation appear reflected in their titles, "high risk procedure" and "fraught with danger."
In South Africa, which reflects much of the developing world, the majority of lung resections are performed for sequelae of pulmonary tuberculosis or other inflammatory lung disease. In our institution more than 100 major procedures of this type are performed annually. Consequently, and as a matter of necessity, skills and strategies have evolved that help to minimize the risks associated with these difficult resections. We have recently reviewed our experience over the last 3 years (Jan 1, 1993, to Dec 31, 1995) with pneumonectomy for inflammatory lung disease. During this time 82 pneumonectomies (left = 55, right = 27) were performed. The indications were complications of old tuberculosis in 51 (62.2%), multi-drug-resistant tuberculosis in 14 (17.1%), life-threatening hemoptysis in 7 (8.5%), bronchiectasis in 7 (8.5%), and aspergilloma in 3 (3.7%). The average time of the procedure was 159 ± 54 minutes (range, 65 to 290 minutes). The average intraoperative transfusion was 1.2 ± 1.7 units, with 40 patients (48.8%) requiring no blood products at all. Intrapericardial dissection was not required in any case, nor was any muscle flap transposition used. Seventeen patients had a total of 20 complications including empyema in 8 (9.8%), bleeding requiring rethoracotomy in 7 (8.5%), postoperative pneumonia in 4 (4.9%), wound infection in 2 (2.4%), and bronchial stump leak in 1 (1.2%). No patient required postoperative ventilation, and the perioperative mortality was nil. The average postoperative stay was 8.6 ± 3.5 days for uncomplicated cases and 12.6 ± 7.1 days for complicated ones.
In our opinion the practice of surgery for inflammatory lung disease is a "lost art" and related to one's exposure to the entity. Reports from the "olden days" of surgery for complications of tuberculosis frequently quote mortality rates of less than 10% and empyema rates of 6% to 21% [3, 4]. More recently Conlan and associates [5] reported an empyema rate of 15.3% and a mortality rate of 2.4%, the latter comparing favorably with that of pneumonectomy for lung cancer. Of note, this was another series based on a high-volume experience with inflammatory lung disease.
Our technique involves numerous "tricks of the trade" but centers on basic principles: (1) adherence to extrapleural and extrafascial planes for initial mobilization, (2) avoidance of particular pitfalls of dissection in the mediastinal and apical areas, (3) avoidance of thermal injury by injudicious overuse of diathermy, and (4) care not to devascularize bronchial stumps. Two thirds of our resections are undertaken primarily by surgical trainees who bear witness to the ease of assimilation of these skills. In summary, we disagree with the conclusions of Dr Massard and associates and Dr Reed and suggest that initiatives be directed toward developing education in particular nuances of technique.
References
Division of Cardiothoracic Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston Sc 29425-2279
To the Editor:
Doctors De Groot and Fulton's experience with 82 pneumonectomies for inflammatory lung disease is certainly exemplary, and I agree that careful surgical technique aided by experience is important. I would like to correct a misunderstanding that some readers have had regarding my article. I certainly agree that one must adhere to extrapleural and extrafascial planes for mobilization. I pointed out in my article that even with extrapleural dissection, inflammation can extend into the extrathoracic fascia, making even this difficult. Clearly, pneumonectomies for chronic infection should be done by surgeons who adhere to the principles outlined by Drs De Groot and Fulton. However, in America, it is doubtful that any surgeon will see the number of patients that Dr De Groot and his colleagues have treated.
Department of Thoracic Surgery, Hôpitaux Universitaires de Strasbourg, F-67091 Strasbourg, France
To the Editor:
We thank Drs De Groot and Fulton for sharing their experience with pneumonectomy for chronic inflammatory lung disease. In our recently published experience, we have made some admonitions against this type of procedure because of a major risk of serious complications. More particularly, the incidence of empyema was 32% [1], which exceeds the anticipated incidence of 20% to 25% in high-risk subgroups [2–4]. The rate of 10% reported by Drs De Groot and Fulton compares favorably with these results, although it exceeds four times the empyema rate we have observed with standard pneumonectomy during the past 7 years (unpublished data). Doctors De Groot and Fulton should be commended on this achievement.
However, we do not entirely suscribe to their hypothesis that operative time and intraoperative bleeding are indicators of surgical skill; in agreement with Reed [3], we merely consider that these parameters describe the level of technical difficulty. Particular situations such as pneumonectomy for aspergilloma and completion pneumonectomy have been shown to convey a major operative risk. In our previously published series of aspergilloma patients, we showed that pneumonectomy resulted most often in empyema [5]; McGovern and colleagues [6] reported on 29 completion pneumonectomies for benign disease, complicated by an empyema rate of 20.7%, a 17.2% incidence of bronchopleural fistulas, and a mortality rate of 27.6%. There is no doubt that postoperative complications are related to intraoperative difficulties. We demonstrated a statistically significant relation between intraoperative blood loss and occurrence of empyema: intraoperative blood loss was highest in patients with aspergilloma and sequelae of tuberculosis. On the other hand, such complications have developed in only 1 patient of 9 (11%) with neither sequelae of tuberculosis nor aspergilloma [1].
For these reasons, we would like to know more about the patients described by Drs De Groot and Fulton. Were the latter patients comparable with the series referenced below? Obviously, the most difficult patients in their series were those with "old tuberculosis" and those presenting with aspergilloma. We may hypothesize that empyema and bronchopleural fistula occurred with preference in these patients, which equals an incidence close to 17%. It seems that two thirds of the operations were relatively straightforward cases, as they could be committed to the care of surgical trainees; if we consider that complications have occurred in the remaining third of difficult operations, the incidence would be 9 of 21, or 43%. We clearly need some more information, such as duration of disease before the operation, rationale of surgical indication, and intraoperative presentation.
It is the responsibility of academic surgeons to publish not only their very best, but also to report on failures. It would not be wise for patients' security to banalize a procedure that may lead to major complications. Therefore, regarding their large experience, Drs De Groot and Fulton should be encouraged to analyze further their series to identify those factors that herald postoperative complications. This work would be an invaluable contribution, establishing some guidelines for all surgeons dealing with these challenging patients.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
