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Ann Thorac Surg 2000;70:251-252
© 2000 The Society of Thoracic Surgeons
DR LEWIS WETSTEIN (Freehold, NJ): Doctor Potaris, I would like to congratulate you on a very nice study, and your results are excellent. I am confused, however, with your methodology. How did you decide on which patients to operate? Your study began with 118 patients, but you only operated on, or addressed 47. For those of us who do not see this problem that often, have you developed an algorithm to assist in their management? For example, how does one decide which patients can safely be observed? Conversely, when should we be more aggressive?
DR POTARIS: Thank you. In this paper we presented only the 47 patients who underwent operations. We did not present data from the other two groups of patients. The decision on whether or not to operate on patients with a broncholithiasis is based on the development of complications of the disease. We would not recommend resection in an asymptomatic patient. We did not compare the three different groups that I mentioned in the beginning because this had been done in a previous paper from our institution.
DR CHRISTOPHER J. KNOTT-CRAIG (Oklahoma City, OK): I enjoyed the paper very much and compliment you on your results. Is there anything that you do in the postoperative period that you believe may diminish the recurrence of broncholithiasis?
DR POTARIS: Thank you. I would like to say that this disease is incessant, and it depends on the host’s immune system and if total eradication of the disease was achieved. A recurrence cannot be predicted or be prevented. It happens depending on the extent of the disease and the immunity of the host.
DR DANIEL L. MILLER (Rochester, MN): I just want to add something. We did not have a good idea on which patients would recur, and actually looking at those 6 patients that did, they were all negative for histoplasmosis. The 13 that were treated with antifungal agents, none of them recurred. So I think it was just progression of the disease. The ones that did recur had a tremendous amount of caseous necrosis at the time of their original operation. So we do not know from debulking the nodes if we caused more of a problem or not, but it seemed like they did have more extensive broncholithiasis at the time of operation.
DR CAROLYN E. REED (Charleston, SC): I would like to ask you one question, that is, of your original 118 patients, I believe there were a number of patients that had bronchoscopic removal. Would you tell us what your guidelines are for bronchoscopic removal?
DR POTARIS: Thank you, Dr Reed. Bronchoscopic removal usually takes place when the broncholith is particularly small and is located in a position that the bronchoscopist can decide whether he or she can take it out. Usually a broncholith inside the tracheobronchial tree seems to be something like the tip of the iceberg, and sometimes, as is reported in the literature, massive bleeding has occurred from bronchoscopic removal of the broncholiths. So I would like to say that experience of the surgeon or the pulmonary medicine doctors who are doing the bronchoscopies sometimes is important for the decision whether or not to pull out this broncholith. Of course, it all depends on how the chest roentgenogram or, better, the computed tomographic scan of the patient looks to make this decision.
DR REED: I guess I would just say that I would shudder to tell my pulmonologist to even attempt to pull out a broncholith, and I think he or she should leave that alone.
DR MILLER: Let me just comment on that point. The one patient that went for emergency operation was one that one of our pulmonologists attempted to remove. When Dr Trastek presented our original series in 1985 at the AATS, they did comment on a bronchoscopic series. Of the 12 that were removed bronchoscopically, eight of them had to go on to surgical intervention because of bleeding. At the present less attempts are performed at our institution for bronchoscopic removal unless they are very loose and friable, but otherwise they will send them to us.
DR JOSEPH I. MILLER (Atlanta, GA): Being in the South with histoplasmosis, we have had a fair amount of experience with broncholithiasis. In those patients who are not candidates for resective operation and in whom a broncholithectomy is not possible, and these seem to be a lot, as you say, on the right side in the bronchus intermedius and in the right lower lobe main bronchus, we have used the neodymium:yttrium aluminum garner laser in 3 patients, turning up the wattage to around 90 W, and it has been successful in all 3 patients, and being able to laser those in whom you cannot do a lithectomy on and in whom operation is absolutely contraindicated, older patients with a lot of comorbidities, but it is another modality. You can laser it back to the bronchial wall with a very successful result, and we have had no problems in those 3 patients, and they have all been followed up a number of years.
DR POTARIS: Thank you. With regard to laser shattering or destruction of the broncholith, there are a few reports in the literature presenting satisfactory data; however, the experience of the bronchoscopist and the nature of the stone is crucial for a decision whether or not to attempt bronchoscopic removal.
Related Article
Ann. Thorac. Surg. 2000 70: 248-251.
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