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Ann Thorac Surg 2004;78:285-286
© 2004 The Society of Thoracic Surgeons

Invited commentary

Yale-New Haven Hospital, 5 Landmark Terrace, Woodbridge, CT 06525, USA

e-mail: rbponn{at}aol.com

The approach to fibrinous-gelatinous material in the pleural space that cannot be drained by tubes and catheters is an issue about which only a thoracic surgeon can get excited. Further, it regrettably seems that, with some exceptions, only thoracic surgeons understand the nuances of "space problems" and "trapped lung." The potential consequences of undrained material are pleural space infection due to the original process or to our interventions, and parietal or visceral diminution of the pleural space (fibrothorax, trapped lung) that prevents lung expansion to a degree that interferes with breathing. This subject is a good example of the art of medicine, as it is greatly case-dependent and is difficult to quantify. The result is that spaces are often termed pneumothoraces, radiographs rather than patients become the focus of well-intentioned discussion, and clinical decisions are thereby muddled by terminology and technology.

The report of Navsaria and colleagues examines their experience with VATS assessment and treatment of one source of retained pleural collections—posttraumatic hemothorax. Although the lessons from this paper are not unique, the findings deserve emphasis. The main points are interrelated. Most importantly, the authors found that an early "window" period for successful video-assisted thoracoscopic surgery (VATS) is not universally applicable. Second, infection often, but not always, correlates with the need for open treatment. The conclusion at this point is that infected collections require an incision. However, the authors reconfirmed that the decision to proceed with an open approach can be made expeditiously at the time of VATS. The operation can then proceed appropriately. There is no delay in treatment and no need for a second trip to the operating room. Thus, with no "downside," no patients are hurt, and some patients are treated less invasively than would be the case if operative decisions were based on adherence to a supposed universally applicable therapeutic timetable. More broadly, much of the appeal of VATS is that it often provides us a single-procedure diagnostic and potentially therapeutic approach, thereby obviating the necessity to commit preoperatively to a major intervention. The present report again demonstrates this benefit.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ronald B. Ponn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ponn, R. B. Search for Related Content PubMed Articles by Ponn, R. B. Related Collections Pleura