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Ann Thorac Surg 1997;64:326-327
© 1997 The Society of Thoracic Surgeons
DR STEPHEN R. HAZELRIGG (Springfield, IL): I enjoyed your presentation very much. We have had a relatively large experience with some unilateral procedures and bilateral procedures. And we actually had 40 patients we staged with unilateral thoracoscopic procedures, and our results have not been quite the same as yours.
When we look at the improvement with respect to FEV1, for example, the improvement has been identical with each unilateral procedure, so that it is essentially doubled. We did not see a big improvement with one and a lesser improvement with the second side. And that also has been true with the physiologic measurements that we have seen. The dyspnea index measures dyspnea. And I think you found what we found, that that is quite different from the physiologic measurements and there are a lot of things we do not quite understand, so improvement in terms of the patients' questionnaires and their dyspnea often does not correlate with improvements with their FEV1 and with physiologic measurements such as 6-minute walks.
Our complication rates were pretty much the same when we did a unilateral procedure versus a median sternotomy and bilateral procedure, other than a slightly lower incidence of postoperative air leaks in our unilateral approach. And some of that may be that our patient population, as I looked at your group, may be a little bit better, a little bit healthier; they walked a little further on average in their 6-minute walk. And it is possible that the sicker the patient the more appropriate a unilateral approach may be. However, I think for the standard patients who we are selecting now, our approach has been that the unilateral approach did not have fewer complications but in the end resulted in longer hospital stays when we added two hospitalizations versus one. We would suggest that a unilateral approach is good in specific settings where there is unilateral disease or reasons to want to stay out of one of the chest cavities. But in the typical patient we think a bilateral approach makes more sense.
DR ARGENZIANO: I thank you for your comments and for sharing your experience with us. I think I would agree with you, in that if you look at our patient population, the majority of our patients who received unilateral lung volume reduction were either patients with markedly asymmetric disease or prior thoracotomy, and so I would agree that we did not apply this procedure to patients who did not meet one of those two criteria. We would then agree that although a bilateral operation is probably the procedure of choice when indicated, we are all going to see more and more patients who do not fit that mold and who may require unilateral targeting of the procedure.
With respect to thoracoscopy, we have done only one thoracoscopic procedure. But one of the reasons we are most excited about our data is that we really do think that this may actually lend strength to the thoracoscopic movement in the sense that if you can prove that a unilateral procedure can effect similar functional improvements then you might be able to justify thoracoscopy a little more easily.
DR DANIEL L. MILLER (Louisville, KY): I enjoyed your presentation; however, I am a little concerned about a few things.
First of all, in regard to your sternal dehiscence rate, was that in the group of median sternotomy patients or was that in the clamshell patients? You are the only group that I know of who are using the clamshell incision for your bilateral approach. I know your mentor, Dr Ginsburg, prefers that, and I would just like your comments about that approach and your results.
Second, in one of your conclusion points you said that you would favor a unilateral procedure in a patient who would be a candidate for lung transplantation later on because you would like to save one side that is clean. Of the 110 patients who we have operated on at the University of Louisville, 50 were either transplant eligible or on the transplant list. Only 1 of those patients has gone on to transplantation 19.5 months later. We do not believe that this is a problem for transplantation. And especially because of the prolonged waiting time for transplantation, you cannot wait for that "clean" lung that has not been violated. Also, with the use of aprotinin we have been able to minimize bleeding with reoperative procedures.
DR ARGENZIANO: I thank you for your comments, Dr Miller. With respect to our sternal dehiscence rate, in fact only 1 of 4 was in the median sternotomy group, the other 3 actually corresponding to breakdown of the sternal closure of the clamshell incision. For that reason these sternal dehiscences were not actually as morbid as they might have been for the median sternotomy patients.
With respect to the clamshell, we have in fact done about half of our bilateral procedures via the clamshell incision. And although Dr Ginsburg and our group do believe that it is an option in patients, especially in those in whom posterior and lower lobe access is important, we are currently using the median sternotomy for patients with biapical disease because we have not been that impressed with the differences in wound morbidity.
With respect to the application of this in lung transplant patients, although your results and those of Dr Cooper, as well as our own, have shown that there seems to be a fair amount of permanence to the results of lung reduction, long-term results are still lacking. And so it is not unreasonable to postulate that a number of these lung reduction patients may return with recurrence of disease in the future. We have reoperated on two lung volume reduction patients for transplantation, and they have been very long and very bloody operations.
DR RICHARD W. ZOLLINGER II (Charlotte, NC): Just a comment. I think in support of your conclusions we might all enjoy redressing the 1959 article by Dr Brantigan that comes to quite similar conclusions.
DR ARGENZIANO: Thank you very much.
DR LEWIS WETSTEIN (Freehold, NJ): I would like to raise a concern that I previously addressed in a presentation this morning. Based on your problem with persistent or prolonged air leaks, would you modify your methodology in your next group of patients, ie, employing some form of pleurodesis?
DR ARGENZIANO: We have not used pleurodesis, although in patients in whom we have performed extensive apical resections we have used pleural tents with some success. We have begun now to use the Heimlich valve in patients with persistent air leaks with success, allowing them to be more mobile and to be rehabilitated a little more easily. But we have not used pleurodesis.
Although air leaks do tend to prolong hospital stay, they are really not associated with much more difficulty than that. In fact, with use of the Heimlich valves, we have found that our patients can get out of the hospital relatively quickly without too much trouble.
Related Article
Ann. Thorac. Surg. 1997 64: 321-326.
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