| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2004;77:1503
© 2004 The Society of Thoracic Surgeons
Thoracic Surgery Department, University Hospital of Nice, 30 Ave de la Voie Romaine 06000 Nice, France
e-mail: francescoleo{at}interfree.it
To the Editor:
We read with interest the report by Avendano and colleagues [1] on pulmonary complications after esophagectomy. We agree with the comments of Santos [2] on the importance of the type of procedure performed. In 1996 at the Thoracic Surgery Department of University Hospital of Nice, we retrospectively analyzed the results in our series of 70 patients who underwent esophagectomy. The analysis showed that the risk of pulmonary complications increases progressively from a transhiatal esophagectomy (6%) to a Santy-Lewis esophagectomy (19%) to an Akiyama procedure (43%).
However, there are two important issues that limit studies on pulmonary complications, including the study by Avendano and co-workers. First, the methodology is always the same. Starting from the "complication," investigators search for predictors of the event among preoperative, intraoperative, and postoperative variables. This approach is also used in prospective studies and does not reveal the chain of events leading up to the respiratory complication. In a word, we miss the natural history.
Second, the definition of "respiratory complication" is misleading. In the article by Avendano and associates, for example, respiratory complication is indirectly defined as everything that happens in the thorax after operation. This is not logical. Authors mix surgical complications (pleural effusions, chylothorax) with true respiratory complications (pneumonia, atelectasis, acute respiratory distress syndrome, respiratory failure requiring mechanical ventilation, pulmonary embolism). The analysis is compromised by the fact that the important differences between these two categories are not delineated. This simple consideration may explain why well-conducted studies can miss well-known relationships, such as the relationship between respiratory complications and postoperative predicted forced expiratory volume in 1 second after lung resection [3].
Moreover, in the list of true respiratory complications, two different categories are mixed. Pneumonia, atelectasis, acute respiratory distress syndrome and pulmonary embolism are causes. Respiratory failure requiring mechanical ventilation is the final outcome that can result from any of these causes. And again, we overlook what happens between the normal postoperative recovery and the onset of respiratory failure by focusing on events and not on patients.
To overcome these limitations, a prospective study was started at our institution in November 2002 to assess the daily respiratory status of patients with a scoring system. In the developed model, only two respiratory complications are used: respiratory stress and respiratory failure. Respiratory stress is defined as any impairment of respiratory function requiring the following maneuvers: class I—bronchoscopy, antibiotic therapy, steroids, diuretics, or heparin sodium infusion; and class II: continuous positive airway pressure or tracheostomy. Respiratory failure is defined as postoperative dependence on mechanical ventilation for 12 hours or more or reintubation.
Results from this study and validation of the scoring system are in progress. However, it is already evident that the cause of respiratory complications is multifactorial and that a binary analysis is insufficient to describe them.
The impact of respiratory complications after esophagectomy is well known and was recently confirmed by a large prospective study[4]. To address this problem, we have to overcome the classic old-fashioned attitude and develop a model that will allow better comprehension of the causes, which are often multifactorial, mechanisms, and natural history of such pulmonary complications.
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 |
