| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2000;70:946-947
© 2000 The Society of Thoracic Surgeons
Discussion
DR WALTER Weder (Zurich, Switzerland): Congratulations for bringing this interesting concept to our attention.
I was wondering how the patients tolerated the pneumoperitoneum in terms of dyspnea. Did you measure dyspnea scores?
Additionally, would you recommend performing this technique in a patient with a limited lung function especially with restrictive disease?
DR CERFOLIO: The answer to your first question is, no, we did not measure dyspnea scores.
The answer to your second question, is it actually was not in a conclusion or a summary slide but rather a slide entitled "Future Study." That slide suggested that perhaps there may be some role to create a pneumoperitoneum in the patient with poor pulmonary function. I don’t know about restrictive disease, but certainly in patients who have emphysema. Some surgeons I know will create a pneumoperitoneum to see if the patient is a candidate for lung volume reduction surgery. They believe that if you can temporarily elevate the hemidiaphragm, and their dyspnea resolves, they may do well with lung volume reduction surgery.
I appreciate your questions. Thank you.
DR DANIEL S. RENNER (Cleveland, OH): Have you had any experience doing this after an upper and middle lobectomy? In my experience, I’ve had just as much problem with that type of bilobectomy as with the lower and middle.
DR CERFOLIO: Well, for this particular study we have not. I cognitively divide the pleural space into two compartments, an upper and a lower. I treat space problems in the upper with a pleural tent and in the lower with a pneumoperitoneum. I think for prolonged air leaks we have used pneumoperitoneum for any type of pulmonary resections (patients sent to us from other institutions). If we have to go back in for empyema we’ll use a muscle flap. A muscle flap on the lung is a great way to stop an air leak, but reoperation is rarely needed for just an air leak. We only use it for an empyema with an air leak. In this paper we didn’t do that, but I suspect it would work just as well. I mean the goal of any manuever to treat a space problem is to obliterate the pleural space, to encourage visceral and parietal pleural apposition. You can encourage that via a pneumoperitoneum and/or a pleural tent. You accomplish the same goal with these two separate weapons available in your armamentarium in the operating room.
DR RAYMOND A. DIETER, JR (Glen Ellyn, Illinois): I enjoyed your paper very much. We were trained to use pneumoperitoneum (p.p.) in the ’60s in the V.A. We have used p.p. repeatedly for more than what you have utilized p.p. for in your paper. We have used p.p. for any reason for which we felt we would have a decreased lung volume, and therefore a space concern, whether it be resection of huge blebs, a large increased AP diameter chest, or in someone we are performing just a single lobectomy. We have been hesitant to put in quite as much air as you have utilized. Therefore, I would like to ask you, first, if you have had any problems with having too much air inserted under the diaphragm, and, second, if you have had any experience in any other areas besides bilobectomies.
DR CERFOLIO: To answer your first question about too much air, I think the advantage of doing this in the anesthetized patient at the time of thoracotomy is you don’t get any complaints of pain like you may get when you have them awake and do it at the bedside with a diagnostic peritoneal lavage catheter. At the bedside, you are slowly injecting air, but they can complain of pain. We haven’t had complaints of pain afterwards. If we had, we have attributed it to the thoracotomy, and I can’t tell you that these patients have had more pain or less pain in one group versus the other. We have really noticed no difference in postoperative pain but the numbers are small.
In terms of have we used it in other groups of patients, yes, we have. It’s part of our armamentarium that we use in blebectomies and in lung volume reduction surgery. We can’t prove it and we haven’t studied it, but my belief is, as you’ve suggested, that I think it helps obliterate the pleural space, helps decrease the incidence of air leak, and perhaps improves pulmonary function temporarily for 14 days. We believe you may get adhesions between the lung and the diaphragm, and as the air gets absorbed, the diaphragm pulls the lung down with it. Then when the air is absorbed the pleural space is obliterated and the air leaks are long gone.
DR MILTON SAUTE (Haifa, Israel): I enjoyed your paper very much. We have indeed been using this same technique that you presented here for at least 20 years, together with the Group of Porto Alegre, Brazil, where I started my practice, with very good results. But we put more air than you do. We use 20 cc of air for each patient’s kilogram. For a 70-kilo patient we go to 1,400 cc and even more than that. And we use this technique whenever we think that the amount of lung tissue that remains is not adjustable for the volume of the pleural cavity. I think that the use of pneumoperitoneum should be encouraged. Congratulations on the paper.
DR CERFOLIO: I appreciate your comments. I think you’re right. We tried to do this scientifically. We picked a group, specifically middle and lower lobe bilobectomy, that would be at increased risk. We tried to give everyone the same amount of air. I think what you have been doing is great and it works. I’m just trying to prove that you’re right, in a prospective randomized control model scientifically.
As for the amount of air, I don’t know the right answer. I will say that on the X-rays it’s interesting to note that some patients have significant elevation of their hemidiaphragm and other patients do not. It’s probably multifactorial based on the compliance of the lung, the compliance of the diaphragm, whether the peritoneal space is loculated or not, or how much air leaks out doing injection. Different patients do have different levels of diaphragmatic elevation, however, despite using the same volume.
Related Article
Ann. Thorac. Surg. 2000 70: 942-946.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
