Ann Thorac Surg 2004;78:1228-1229
© 2004 The Society of Thoracic Surgeons
INVITED COMMENTARY
Robert McKenna, Jr, MD
Department of Thoracic Surgery, Cedars Sinai Medical Center, 8635 W 3rd St, Suite 975W, Los Angeles, CA 90048, USA
mckennar{at}cshs.org
AAlthough this article deals with a rare indication for pulmonary surgery, the report has much broader implications. The lessons from the study are relevant to thoracic procedures for other diseases; pulmonary resections after preoperative treatment, and the proper handling of the diaphragm on the side of a pneumonectomy if the phrenic nerve has been resected.
The authors present an impressive experience with major lung resections for germ cell tumors that have been treated with chemotherapy. Indiana University has been a leader in developing optimal management of fluids and oxygen when operating for germ cell tumors after the patient has been treated with bleomycin. Currently, thoracic operations after preoperative chemotherapy are now commonplace for lung cancer, esophageal cancer, malignant pleural effusions, stage III thymic cancer, and pulmonary mets from multiple malignancies. Pulmonary toxicity, including interstitial pneumonitis, postoperative ARDS, and pulmonary fibrosis, has now been reported after treatment with more than 20 chemotherapy drugs. Neoadjuvant treatment with carbo-platinum and Taxol (Bristol-Myers Squibb, New York, NY) increase the mortality for right pneumonectomy threefold. When operating upon any patient who has received neoadjuvant treatment, thoracic surgeons should follow the same precautions that we have learned from the Indiana University experience with bleomycin-treated patients. This article repots that major pulmonary resections can be performed with acceptable morbidity and mortality after preoperative chemotherapy.
The issue of how to handle the right diaphragm after a right pneumonectomy after resection of the right phrenic nerve is intriguing. The authors report a significant mortality in that subset of their patients. This may be in part related to the paradoxical movement of a paralyzed diaphragm. After a pneumonectomy, a normally functioning ipsilateral diaphragm is either fixed or moves towards the abdominal cavity with inspiration. If the diaphragm is paralyzed, then, especially in the early postoperative period before the hemithorax becomes filled with fluid, there will be paradoxical movement of the diaphragm. The mediastinum will shift towards the left lung during inspiration. The physiologic impact of that will be a compromise of the function of the left lung. Therefore, that raises the question of whether the ipsilateral diaphragm should be plicated when a pneumonectomy is done with resection of the ipsilateral phrenic nerve.
Related Article
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Short- and Long-Term Outcomes after Large Pulmonary Resection for Germ Cell Tumors After Bleomycin-Combination Chemotherapy
- Rafael S. Andrade, Kenneth A. Kesler, Jamison L. Wilson, Jo Ann Brooks, Brett D. Reichwage, Karen M. Rieger, Lawrence H. Einhorn, and John W. Brown
Ann. Thorac. Surg. 2004 78: 1224-1228.
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