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Ann Thorac Surg 1996;62:828-829
© 1996 The Society of Thoracic Surgeons
DR THOMAS R. J. TODD (Toronto, Ont, Canada): I cannot let the last comment go without amplifying it because my colleagues and I agree with you 100% about the use of lasers in otherwise resectable either tracheal or bronchial strictures. We have observed over the last several years that patients who have had laser therapy, particularly in the subglottic region, end up with much more complex lesions and prolonged management than they do just with simple dilation, and it certainly therefore in the end complicates the eventual operation. So I just rise to congratulate you on a very fine report and wonderful experience but also to amplify what you said about lasers and to fully support that conclusion.
DR THOMAS J. KIRBY (Cleveland, OH): Would you advocate or do you propose any role for stents in benign lesions?
DR BUENO: Stents may be useful in some situations, but they are not without complications. Given that we can achieve excellent outcome with very low morbidity, if the stenosis is technically resectable, I would advocate resecting it. There is that subgroup of patients with idiopathic stenosis in whom multiple stenoses are going to continue to develop in the airway after operation, and our group would favor being very cautious with those patients.
DR L. PENFIELD FABER (Chicago, IL): Doctor Bueno, on occasion mucoepidermoid carcinomas will contain positive hilar nodes. They are graded based on histology and the nodal involvement of the tumor, and some of the carcinoids turn out to be well-differentiated neuroendocrine cancers or atypical carcinoids and may have regional nodes involved as well. If indeed in dealing with these low-grade malignant type of tumors you find that hilar or mediastinal nodes are involved, do you abandon the sleeve procedure and go to pneumonectomy, or do you recommend the standard sleeve procedure in association with a lymphadenectomy?
DR BUENO: Four of the 54 or so carcinoids turned out to be atypical carcinoids. Two of them had positive lymph nodes. All of them required a sleeve lobectomy rather than a sleeve resection, and with a careful, complete lymph node dissection, especially hilar, we were happy with that extent of resection. I believe that with a sleeve resection you can get better bronchial margins than with just a straight pneumonectomy because you do not have the stump that is generated, and as long as you do a complete lymph node dissection, you are going to get the same result but with preservation of pulmonary parenchyma. As far as the mucoepidermoid carcinomas, all were either intermediate or benign grade, and we did not have any with positive lymph nodes.
DR JULIO POPOVSKY (Cleveland, OH): Have you done any sleeve resection after neoadjuvant therapy, like in stage IIIa?
DR BUENO: We have, but his report only pertains to tumor other than the usual lung cancers, so I did not discuss them here.
DR KIRBY: I was interested that you recommend proceeding with sleeve resection even in the face of obstructive pneumonia with just 4 or 5 days of preoperative antibiotic coverage. Even though you had no reported morbidity or mortality with resections in this group, I am wondering if it might be more prudent to operate when the pneumonia has been adequately treated.
DR BUENO: It is true that many of the lesions are benign or low-grade malignancies, but they are going to continue to be obstructive. As long as we could clear most of the symptoms with antibiotics and, if necessary, drain the patient with bronchoscopy once or twice, we have been able to do sleeve resections successfully without any serious complications. For this reason we continue to advocate this treatment for postobstructive pneumonia as a subgroup as well. Bound volumes available to subscribers Bound volumes of the 1995 issues of The Annals of Thoracic Surgery are available only to subscribers from the Publisher. The cost is $99.00 (outside US add $25.00 for postage) for volumes 59 and 60. Each bound volume contains a subject and author index, and all advertising is removed. The binding is durable buckram with the name of the journal, volume number, and year stamped on the spine. Payment must accompany all orders. Contact Elsevier Science Inc, 655 Avenue of the Americas, New York, NY 10010; or telephone (212) 633-3950 (facsimile: (212) 633-3990).
Related Article
Ann. Thorac. Surg. 1996 62: 824-828.
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