Ann Thorac Surg 1998;66:330
© 1998 The Society of Thoracic Surgeons
Original articles: general thoracic
Invited commentary
Marvin Pomerantz, MDa
a General Thoracic Surgery Section, Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center, 4200 E 9th Ave, #C310, Denver, CO 80262, USA
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Invited commentary
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 Invited commentary
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This article by Nelson and associates illustrates the increasing number of patients infected with Mycobacterium avium complex who will benefit from operation. The experience of myself and my colleagues now totals 106 patients undergoing operation for Mycobacterium avium complex disease. Although the majority of Nelson and associates’ patients were male, we did not find this in our patients, the majority of whom were female. The nutritional status of our patients was similar to that of those reported by Nelson and associates, and the indications for operation of a destroyed lung or cavitary disease with persistent positive sputum were similar. We used similar drugs but based therapy on specific sensitivities and, if operation was needed, kept giving patients these specific antibiotics for 1 to 3 months before the operation.
Nelson and associates’ incidence of persistent air leaks (6 of 28 patients) is too high. We routinely use muscle if space problems are expected after less than a pneumonectomy is performed and also use muscle in situations where the sputum is positive or there is preexisting polymicrobial infection before the operation. We prefer to use the latissimus dorsi as the muscle of choice. Because it is a more bulky muscle, it fills more space and leaves little disability. The use of a large Hemovac for the seroma that routinely occurs is important, and the Hemovac should not be removed until the drainage has ceased. The need for five thoracoplasties at a second operation can probably be eliminated with the use of a latissimus muscle flap at the time of lobectomy. In our recent patients, the rate of bronchopleural fistulas has been very low, and as Nelson and associates point out, when fistula occurs, it is more common on the right side than on the left.
In summary, Dr Nelson and his colleagues have added another article demonstrating the morbidity of Mycobacterium avium complex infections in primarily white patients. I recommend that latissimus dorsi muscle flaps be used with procedures less than pneumonectomies if the sputum is positive, there is a preexisting bronchopleural fistula, there is polymicrobial contamination, or space problems are expected. With use of these guidelines, the need for a second operation (thoracoplasty) will be markedly diminished.
