| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 1996;62:979-980
© 1996 The Society of Thoracic Surgeons
DR L. PENFIELD FABER (Chicago, IL):
I compliment Agasthian and associates on an excellent presentation and a very well written manuscript. In their study, they emphasize the need for preoperative bronchoscopy, and I strongly support this recommendation. It is very important to rule out benign or malignant causes of obstruction and to determine the degree of inflammation in the bronchial wall itself. Severe inflammation may negate resection until better infection control has been achieved.
The preoperative diagnosis of bronchiectasis today can be somewhat of a problem. Dionosil is no longer available, and now we rely on thin-cut computed tomographic scan to define bronchiectasis. In the present series, a bronchogram was done in 66 patients, and computed tomographic scan made the diagnosis in 44. However, in 24 the apparent diagnosis was made on the plain chest roentgenogram. Doctor Agasthian, how could you define true bronchiectasis on a plain chest roentgenogram? My mentor, Dr Hiram Langston, emphatically taught us that bronchiectasis could be diagnosed only with the bronchogram. In that same vein, it would be helpful for Dr Agasthian to explain how the computed tomographic scan is used to define the true anatomic extent of bronchiectasis. In other words, does the computed tomographic scan tell us if the superior segment of the lower lobe is involved, and can we plan an anatomic resection based on this scan alone?
The surgical resections reported in this series are somewhat unusual for bronchiectasis. The majority were lobectomies and pneumonectomies, with very few segmentectomies. There was only one bilateral resection out of the 134 procedures done, and 26 patients had bilateral disease. Segmentectomy is the ideal procedure for bronchiectasis. Doctor Agasthian, how would you handle a symptomatic patient with saccular bronchiectasis of the basal segments of the left lower lobe and the right lower lobe? This series suggests that you would perform a lobectomy on the worst side. The basic guidelines for the operative therapy of bronchiectasis are: (1) infection control, (2) preoperative bronchoscopy, (3) precise anatomic diagnosis, and (4) precise anatomic resection. I am not certain that Agasthian and associates have met the last two guidelines in this series of patients.
DR AGASTHIAN:
Thank you, Dr Faber, for your comments. With regard to your first question, in 24 patients, the diagnosis of bronchiectasis was made on chest roentgenogram because they presented acutely with hemoptysis and recurrent infections. The diagnosis was confirmed postoperatively by pathologic examination.
High-resolution computed tomographic scan has now replaced bronchography in our practice for the diagnosis and anatomic localization of bronchiectasis.
Regarding the management of bilateral disease confined to the basilar segments, we would probably start on the worse side and do a bilateral basal segmentectomy so as to preserve the superior segments on both sides, thus relieving symptoms while preserving as much lung function as possible.
DR DAVID S. HUBBELL (Tampa, FL):
I enjoyed this paper very much, and it is interesting to see a collected series of patients with bronchiectasis. I was moved to compare it with our analysis of 215 cases published some years ago [1] in which we found multilobar disease in two thirds of the patients; in one third it was unilobar, in about one third it was on both sides, and in another third it was multilobar but on the same side. In our series, we analyzed 165 resections in 138 patients, and we also found that complete resection was important. Those who had remaining disease had about twice the postoperative complications. Late follow-up a year or more later showed that of those with complete resection, 93% considered themselves improved, compared with 74% of those who had remaining disease.
I would like to know a little more about the negative predictive value of high-technique computed tomographic scans of the lungs in diagnosing bronchiectasis. Did any of your patients have bronchography as well as computed tomographic scans, so that one might compare the accuracy of the two?
DR AGASTHIAN:
Our series ranged over a 17-year period, from 1976 to 1993, and although bronchography was used in the earlier part of the series, high-resolution computed tomography became the investigation of choice for localization of disease in the latter years. As to the efficacy of high-resolution computed tomography as compared with bronchography, the number of patients in our series who had both computed tomographic scan and bronchography was too small to derive any significant conclusion.
DR LEWIS WETSTEIN (Freehold, NJ):
I also congratulate Agasthian and associates on their clear and lucid presentation. It was disconcerting, however, that when the indication for operation was hemoptysis, more than 20% of the patients either were unimproved or continued to have hemoptysis.
I have two questions. First, why do you think this rate was so high? Second, how do you manage these patients after resection when they continue to bleed postoperatively?
DR AGASTHIAN:
One of the problems in the management of bronchiectasis is accurate preoperative localization. One of the possible reasons for the higher incidence of unimproved cases among those presenting with hemoptysis is that frequently, operation was performed in an emergent or semiemergent situation, precluding detailed preoperative localization studies.
For patients who return after previous resection for bronchiectasis, procedures such as angiography and bronchial artery embolization should be attempted before reoperation.
DR A. ALAN CONLAN (Worcester, MA):
I enjoyed your paper and congratulate you. There are two questions I want to ask. First, your three deaths occurred after completion pneumonectomy for bronchiectasis. Do you continue to recommend this procedure for patients with bronchiectasis? Presumably they have had previous lobar resection for bronchiectasis and it remains uncontrolled.
Second, some of your patients were children as young as 4 years. Separation of the airway and control of secretions during the resection by double-lumen tube are easy enough in adults, but what methods did you use in children? Clearly some of your patients required bronchoscopy for secretions and atelectasis postoperatively. What was the common method of bronchial separation for your resections?
DR AGASTHIAN:
Completion pneumonectomy for bronchiectasis should be avoided whenever possible, as the mortality rate is rather high. There was a total of three deaths after the seven completion pneumonectomies performed in our series. The procedure should be attempted only in cases of life-threatening symptoms and in those with a nonfunctioning, destroyed lung.
We use bronchial blockers for isolation of the airway to prevent spillage of secretions when performing an operation for bronchiectasis in children.
DR JOSEPH LoCICERO III (Boston, MA):
The radiology literature now is full of reports on the use of high-resolution computed tomography for bronchiectasis. I have done a lot of bronchography in the past, and I have become convinced that it is no longer necessary. However, for Dr Faber, the lipid-based contrast is still available, and it is used in patients who get chemoembolization.
In terms of this presentation, we at New England Deaconess Hospital had a large experience with bronchiectasis in the past, but we do very few resections today for non–life-threatening conditions. We believe that patients must have some debilitating problem with their life-style because of their bronchiectasis, and we now operate only on patients who have more than six pneumonias per year. What is your usual indication for patients who have no life-threatening condition?
DR AGASTHIAN:
We totally agree with your comments that the operative indication in bronchiectasis is mainly confined to patients with life-threatening symptoms. Operation should be offered to those with severe, chronic, disabling symptoms only if their disease is rather localized and the chances of cure are good. We defined disabling symptoms as those that affect the quality of life by causing frequent hospitalizations, interfering with work or school, and requiring frequent medication.
Reference
Related Article
| ||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
