| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 1995;60:934-935
© 1995 The Society of Thoracic Surgeons
DR JOSEPH I. MILLER, JR (Atlanta, GA): Doctor Cole, I appreciate your asking me to discuss your paper and the opportunity of receiving the manuscript before presentation. I rise mainly to second your conclusions. Basically when VATS became available at a national level in 1991, enthusiasm was quite high in the utilization of this technique, potentially in the role of spontaneous pneumothorax, and I, like a number of other people around the country, employed this initially in our practice. However, it was in the calendar year 1992 I received my first, not my own but a recurrence, and then during the calendar year I reoperated on 7 patients from outside the Emory system with the conventional techniques who had failed VATS done in the state of Georgia. That led to my own conviction that VATS was probably not better than the usual axillary thoracotomy for this situation.
During 1992 and 1993 I had the opportunity to give the talk at the World Congress on Thoracoscopy on complications of VATS, and Dr Steven Hazelrigg provided me access to data from the VATS study bank. The national failure rate of VATS is around 7%, with up to a 10% failure rate reported.
In this particular application of VATS, it was hard for me to see where three 1
-cm incisions were any different than, say, a 7
- to 9-cm incision through the standard axillary approach. In a personal operative experience at Emory over a 20-year period I had 176 patients either through axillary thoracotomy or limited thoracotomy with no recurrence rate and no operative mortality.
It is hard for me to think that we should take an operation that has essentially a 100% success rate, that is, when done by conventional methods by either of the other two approaches, and convert it into an operation with a 7% national failure rate done with many individuals. I think the standard of care in most places would be an axillary thoracotomy in the young patient, and in the more complicated, older patient, you might need to go to a limited posterolateral thoracotomy where you have better access, and then combine that with a pleurodesis or pleurectomy or whatever seems appropriate.
DR KEITH S. NAUNHEIM (St. Louis, MO): I always hesitate to state an opinion opposite to that of Dr Miller; I do admire his judgement and know he has a phenomenal clinical experience. However, I think I have to take a stance as one of the young turks who thinks that VATS is actually an advance in thoracic surgery. I would say that if you looked at the early results for atrial septal defect closure on pump bypass, mitral commissurotomy, open mitral commissurotomy, or any of those procedures we would think of as significant advances in the evolution of cardiothoracic surgery, the morbidity and the mortality of the earliest experience was excessive and, when compared with the experience from prior surgeons who were not using that technique, suggested prohibitive morbidity and mortality. I think that Dr Cole has made an excellent point. His 30 patients do represent the learning curve for three different institutions, an average of 10 per institution.
We recently presented at the meeting of the Western Thoracic Surgical Association the combined series from Rodney Landreneau, Steven Hazelrigg, myself, Mark Ferguson, and Michael Mack. We found a 4% recurrence rate in 120 procedures; that was the early learning curve, if you will, for even those surgeons who have the greatest experience. I believe that VATS can be performed with equal efficacy once the experience is gained. I believe that the incidence of pain immediately postoperatively is less, even than with an axillary thoracotomy. I think the routine patient can be discharged within 48 hours of operation, and I think VATS well serves the vast majority of patients.
One important point is that VATS allows visualization of the entire pleural space and the entire lung including the diaphragmatic surfaces. This is impossible through an axillary thoracotomy without the use of a thoracoscope. As I say, I hesitate ever to contradict Dr Miller, but hopefully he will not hold it against me after this session.
DR COLE: Thank you for those remarks. I certainly do not disagree with them. I also like the VATS technique, but we were somewhat struck by our results. I must say that our length of stay is something I need to go home and improve. As one who has been married for 29 years and has raised three teenagers, I did not need more humility, but when I learned yesterday that Dr Treasure's posttuberculosis pneumonectomy patients go home quicker than some of my chest tube patients, I was very humbled.
DR SAFUH ATTAR (Baltimore, MD): I felt compelled to stand and oppose the views propagated by Dr Cole and Dr Miller in presenting the data from my colleague, Dr Mark Krasna. He is quite experienced in video thoracoscopy, and I think this bears a lot of importance on the results. Doctor Krasna has had experience with 400 thoracic videoscopies so far, including 29 cases of video-assisted treatment of spontaneous pneumothorax between February 1991 and October 1994.
There are two points in which we disagree with Cole and associates. First, there is no indication to operate on a patient with spontaneous pneumothorax at the initial presentation with direct operation or VATS. I think a tube thoracotomy should be enough. Therefore all our procedures were done for recurrent or persistent air leaks and none were done for initial spontaneous pneumothorax. We had only 2 patients who had recurrence postoperatively, and this was due to a learning curve. One of them had metastatic carcinoma to the lung that presented as a spontaneous pneumothorax. The second patient had the same thing, and had a cautery pleurodesis rather than pleurectomy. These two were the only failures.
Our pleurectomy extended from the first to seventh rib, and below this level, pleurodesis was performed. The mean chest tube duration was 1.7 days. There were no recurrences in all these cases. The causes of failure we believe are due to missing the source of the leak, and there are certain tricks that can be used to detect the leak: by submerging the lung between air and fluid, and by injection of methylene blue. I wonder whether these tricks were used in localizing the site of the air leak. I enjoyed the presentation very much.
DR LYNN H. HARRISON (Marrero, LA): I think that there are two learning curves that are involved in the implementation of this technique. One of them is the technical learning curve, but the other one is learning to which patients to apply the technique. In a somewhat smaller series of 23 patients with pneumothorax in whom we have applied the technique, only 7 had what I would refer to as primary spontaneous pneumothorax occurring in an asthenic, young individual; in that group the eldest patient in our series was 28 years. I notice that 30% in your series were older than 50 years and at least 1 had bullous disease of the lung. I think if you are going to start taking on that kind of patient, then your success rate is indeed going to plummet.
I think a more useful segregation of your patients is not simple and complex but those with and without acquired parenchymal disease of the lung. If you look just at the young patient who has congenital apical blebs either in the apical or in the superior segments, then your success rate will be very good. We have had no ipsilateral recurrences and one contralateral recurrence in those 7 patients in whom we have applied the technique in that group.
I second your cautionary note regarding the use of talc in young patients. Some of those patients will come back with a primary lung neoplasm at some point in their lives, and I only wish that the surgeon who applied the talc could be the one who has to deal with that operative procedure.
DR JOHN R. BENFIELD (Sacramento, CA): We started with VATS among the earliest in the country, and we have used it enthusiastically for pneumothorax treatment. Nonetheless, we have found a certain degree of frustration in not being able to approach the pleura as directly with VATS as through traditional axillary thoracotomy. We also learned that when one applies the argon beam laser to the pleura, one may cause a good deal of pain, and we have stopped using the argon beam to cause pleural scarring for pleurodesis.
We have reached a compromise position, somewhere between what Dr Naunheim has said and what Dr Miller has said. We now use the axillary thoracotomy, usually without rib spreading, as a small access incision. This gives direct access, and then we use the telescope to see those areas of the pleura that we were not able to see with the traditional axillary thoracotomy.
So I come as someone from the West hoping to serve as arbitrator and to suggest a compromise here in the South.
DR COLE: I thank the discussants for their remarks. Obviously I think we have two separate issues. The first issue is whether it is reasonable to begin invasive therapy for primary pneumothorax. In favor of that are the 40% to even 60% recurrence rate after the initial primary pneumothorax and the substitution of a general anesthetic for a local anesthetic procedure. I think that certainly Murray's group recommends primary axillary thoracotomy in a fairly small series, and also Interbitzi has actually recommended primary VATS. The second issue is, whatever your indications for invasion are, is one going to do an axillary thoracotomy or a video-assisted procedure? I think in our own hands we simply need to work on our patient selection and length of stay a little bit more, and this is probably an unsettled issue.
Related Article
Ann. Thorac. Surg. 1995 60: 931-933.
| ||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
