Ann Thorac Surg 1999;67:344
© 1999 The Society of Thoracic Surgeons
Commentary
Ryosuke Tsuchiya, MDa
a Division of Thoracic Surgery, National Cancer Center Hospital, 1-1, 5-Chome, Tsukiji, Chuo-ku, Tokyo 104 Japan
Invited commentary
I congratulate the success of Klepetko and colleagues in performing combined resection of T4 lung tumors infiltrating the thoracic aorta in 7 cases. The results of reported cases including those in this manuscript demonstrate favorable morbidity and mortality even in selected cases. Therefore, most of the technical problems seem to be solved for selected patients with lung tumor infiltrating the aorta. How to apply the cardiopulmonary bypass depends on the status of the patients and the nature of the lung tumor as the authors indicated. Covering the bronchial stump is widely accepted to prevent bronchovascular fistula after bronchovasculoplasty (sleeve lobectomy and sleeve resection of pulmonary artery) and combined resection of sleeve pneumonectomy and superior vena cava. Bronchopleural fistula occurs more frequently after pneumonectomy and lower lobectomy than other procedures. Covering the bronchial stump after combined resection of the thoracic aorta and major pulmonary resection is reasonable because bronchopleural fistula is a fatal complication.
Patient selection is the most important point to get a better long-term result. Accurate preoperative diagnosis of the extent and degree of infiltration of the aorta is essential. Thin-section computed tomography, 3-dimensional computed tomography, ultrasound, and magnetic resonance imaging demonstrate useful information to make a plan of operative procedure and arrangement. Ruling out distant metastases is also required, especially in the cases of N2 disease. Positron emission tomography will give us good information about occult metastases incapable of being detected by other conventional examinations.
Preoperative chemotherapy or chemoradiotherapy to stage IIIB lung tumors are expected to increase the number of cases to be objects of the combined resection of the thoracic aorta. However, these induction therapies also increase the possibility of occurrence of postoperative complications, such as bronchopleural fistula, pyothorax, pneumonia, interstitial pneumonitis and adult respiratory distress syndrome. Perioperative management, including the method of anesthesia, should be improved to prevent these complications, and operative procedures also should be improved. Prophylactic omentopexy may be one of the choices to prevent complications.
Related Article
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T4 lung tumors with infiltration of the thoracic aorta: is an operation reasonable?
- Walter Klepetko, Wilfried Wisser, Tudor Bîrsan, Peter Mares, Shahrokh Taghavi, Natascha Kupilik, and Ernst Wolner
Ann. Thorac. Surg. 1999 67: 340-344.
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