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Ann Thorac Surg 2003;76:185-186
© 2003 The Society of Thoracic Surgeons
a Head Section General Thoracic Surgery, Virginia Mason Clinic, 1100 Ninth Avenue, Seattle, WA 98111-0900, USA
e-mail: donald.low{at}vmmc.org
The paper by Greason and colleagues reviews the important issue of minimizing complications and costs in the management of patients receiving neoadjuvant radiotherapy prior to surgical resection for advanced lung cancer. This review is pertinent due to increasing indications that neoadjuvant therapy, either chemotherapy alone or chemoradiotherapy, can impact outcomes, including resectability and survival, in patients with III-A, III-B, and localize stage IV disease. The current review suffers from being a nonrandomized comparison of outcomes in patients undergoing lobar resection following neoadjuvant radiotherapy. The authors go to great lengths to demonstrate that the three comparative groups, ie no bronchial coverage, coverage with mediastinal tissue, and coverage with serratus anterior, are similar in presentation and radiation dosage. However, in each individual patient’s case, the ultimate decision regarding bronchial coverage was left to surgical judgment. There are multiple factors that can lead to the decision to reinforce bronchial closure. Although it did not reach statistical significance, preoperative median dose of radiotherapy was higher in the muscle coverage group. In addition, the majority of bronchopleural fistulas occurred in the muscle coverage group, although these two patients also had associated muscle flap necrosis. This indicates that experienced surgeons were able to identify "bronchial closures at risk" and respond accordingly.
The results indicate a benefit in the muscle coverage group with respect to decreasing air leaks and prolonged chest tube drainage, as well as hospital stay. The vast majority of air leaks following standard resections are parenchymal rather than associated with bronchopleural fistulas. The authors point out that improvement in these parameters in the muscle group may be associated with eliminating dead space and thereby decreasing chest tube drainage and speeding the resolution of standard air leaks.
Bronchial stump reinforcement should be a routine consideration in complex pulmonary resections. The authors have limited their assessment specifically to lobar resection, but the issues are even more important in sleeve resections and pneumonectomies (particularly right pneumonectomies). Thoracic surgical incisions in general should be based on the concept of preserving all potential resources for buttressing and reconstruction whenever feasible. Appropriate exposure with a standard posterolateral thoracotomy rarely requires division of the serratus anterior. In addition, particularly complex procedures should utilize either a muscle preserving approach or incision of latissimus dorsi very low to maintain its availability for reconstruction if required. The authors describe some personal perceptions of the drawbacks to utilizing intercostal muscle for buttressing. Many surgeons believe intercostal flaps to be a good additional alternative in selected patients.
The authors indicate that they rely on their plastic surgical colleagues to harvest the serratus anterior. Although this is no doubt the ideal situation, thoracic surgeons should be comfortable and prepared to mobilize and utilize these muscles at any time without the need for additional subspecialty assistance. This concept is particularly important because of the implication that the threshold for utilizing muscle reinforcement during these cases should be decreasing in patients receiving neoadjuvant radiotherapy prior to anatomic resection.
Examining the potential physical sequelae of muscle harvest in these patients is appropriate. All patients were reviewed with a telephone interview, which did not demonstrate any significant problems of utilizing the serratus anterior. However, objective measurements would be much more meaningful as subjective assessment alone, especially with respect to range of motion and strength, can be misleading.
Greason and colleagues have provided important supportive information that muscle bundle reinforcement is likely underutilized and may lead to a decrease in postoperative pulmonary complications, hospital stay, and costs. Results from national neoadjuvant trials suggest that it is unlikely that every patient undergoing lobar resection following radiotherapy requires bronchial stump reinforcement. Surgical judgment will remain the most important factor in individual patient selection, although more routine utilization of various options for bronchial stump reinforcement and obliteration of dead space is likely appropriate. This issue is worthy of a randomized controlled trial possibly comparing routine utilization of serratus anterior to intercostal muscle in previously irradiated patients and including postoperative objective assessment of strength, range of motion, and affect on activities of daily living.
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