Ann Thorac Surg 2006;82:767
© 2006 The Society of Thoracic Surgeons
Correspondence
Reply
David Waller, BM, BS, FRCS(CTh)
Department of Thoracic Surgery, Glenfield Hospital, Leicester, LE3 9QP, UK
(Email: david.waller{at}uhl-tr.nhs.uk).
To the Editor:
On behalf of all of the authors I would like to thank our British colleagues, Hunt and Lang-Lazdunski [1] for their interest in this subject [2], which is becoming so important in the United Kingdom.
With respect to their technical concerns about this approach, I can reassure them that with an increasing experience of greater than 25 of these operations per year the pitfalls can be overcome. Improved selection criteria have excluded patients with widespread chest wall involvement, particularly in the costophrenic recess, and this, together with the retraction techniques described in the article, has obviated our necessity to add a thoracotomy to the sternotomy.
Regarding the nodal management in these cases, we aim to perform a systematic nodal dissection as we do for lung cancer, and we have not found this to be a problem [3]. It is true that the patient must be able to withstand retraction of the heart medially, but in order to clear the posteromedial extent of the pleural tumor rather than for nodal dissection. This emphasizes the importance of excluding patients with cardiac dysfunction in the preoperative workup. Hemostasis from the azygos system is addressed by routine ligation at an early stage of the dissection.
We would take issue with the comments that complete resection is the only factor affecting long-term survival and suggest that it is naive of the correspondents to assume that this operation is any more than "maximal debulking." All we can assure them is that the percentage of reported R0 resections is similar in the thoracotomy and sternotomy groups.
We stress that the reason for developing this median sternotomy approach for extrapleural pneumonectomy was to reduce the significant morbidity and mortality associated with the right thoracotomy approach, which may increase the acceptability of this controversial treatment.
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References
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- Hunt I, Lang-Lazdunski L. Is median sternotomy an appropriate approach to right extrapleural pneumonectomy for mesothelioma?(letter) Ann Thorac Surg 2006;82:767.[Free Full Text]
- 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]
- Edwards JG, Stewart DJ, Martin-Ucar AE, Muller S, Richards C, Waller DA. The pattern of lymph node involvement influences outcome after extrapleural pneumonectomy for malignant pleural mesothelioma J Thorac Cardiovasc Surg 2006;131:981-987.[Abstract/Free Full Text]
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