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Ann Thorac Surg 2006;82:767
© 2006 The Society of Thoracic Surgeons

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Correspondence

Is Median Sternotomy an Appropriate Approach to Right Extrapleural Pneumonectomy for Mesothelioma?

Department of Cardiothoracic Surgery, Guy's Hospital, St Thomas' Street, SE1 9RT London, UK

(Email: ian.hunt{at}gstt.nhs.uk).

To the Editor:

We read with interest the article of Martin-Ucar and associates [1], and we congratulate their efforts in improving radical surgery for malignant mesothelioma. However we have some concerns regarding the use of a median sternotomy for achieving an extrapleural pneumonectomy.

There is little doubt a median sternotomy provides good exposure for the control and stapling of the right pulmonary veins and artery. The lung apex is also reasonably well exposed through this approach. However, having performed lobectomies or pneumonectomies through a median sternotomy, we found it extremely difficult to access the costophrenic angle and paravertebral sulcus. This is usually where bulky disease is found in the malignant mesothelioma, and it is the most difficult area to resect completely after talc pleurodesis. We note the authors' admission that two cases required additional limited lateral thoracotomies to aid resection.

In addition, performing a complete mediastinal lymphadenectomy through this approach represents a real surgical challenge. The pre-tracheal and right paratracheal lymph nodes are presumably approached between the innominate artery and the superior vena cava (SVC), and also the subcarinal station between the SVC and ascending aorta once the posterior pericardium is opened. The paraoesophageal and inferior pulmonary ligament lymph nodes presumably would be approached laterally, but would require traction on the heart to gain access to the esophagus, although no doubt placement of an esophageal bougie would aid in its identification. The authors mention a case regarding the need for additional exposure due to severe hemodynamic instability after manipulation of the pericardium to obtain adequate exposure. Was this preceded by lymph node dissection of these stations? We are also concerned that hemostasis from bleeding of the azygos vein or a collateral may be difficult to achieve through this approach.

As complete resection is the key to long-term survival [2], it seems difficult to justify the risk of an incomplete resection through a median sternotomy, although we accept that this approach may carry less morbidity than a standard posterolateral thoracotomy. We welcome an opportunity for further comment on how lymph node dissection was achieved to ease our concerns regarding this aspect of the authors approach.

	References

Top References

 

1. Martin-Ucar AE, Stewart DJ, West KJ, Waller DA. A median sternotomy approach to right extrapleural pneumonectomy for mesothelioma Ann Thorac Surg 2005;80:1143-1145.[Abstract/Free Full Text]
2. Sugarbaker DJ, Flores RM, Jaklitsch MT, et al. Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesotheliomaresults in 183 patients. Thorac Cardiovasc Surg 1999;117:54-63.

This article has been cited by other articles:

				D. Waller Reply Ann. Thorac. Surg., August 1, 2006; 82(2): 767 - 767. [Full Text] [PDF]

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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ian Hunt Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hunt, I. Articles by Lang-Lazdunski, L. Search for Related Content PubMed PubMed Citation Articles by Hunt, I. Articles by Lang-Lazdunski, L. Related Collections Pleura Related Article