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Ann Thorac Surg 1992;54:394400
399
References Bronchial Stump Closure To the Editor: Staple closure of the bronchus is now widely accepted and, although the superiority of the technique over conventional suture closure has not been convincingly shown, the convenience factor will assure its increasing use. Suture closure will, however, always be required in some cases. We think it is appropriate to bring two points to the attention of our colleagues: (1) Of the standard texts, not even those dedicated to the usage of staplers [l, 21 specify the exact orientation of the stapling device relative to the bronchus. Vester and associates [3] refer to transverse placement of the bronchial stapler relative to the long axis of the bronchus, and recommend that ”the stapler be parallel to the mucous membrane.” We suspect that the intended meaning places the anvil of the stapling device parallel to the membranous part of the bronchus, and have used staplers this way in the expectation that, should the cartilaginous part tend to resume its original C shape, it will pull the softer membranous part with it. Two apposing curved pieces of cartilage with the same tendency will tend to pull apart. Steichen (personal communication) confirms this and adds that orientation for smaller bronchi without C-shaped rings of cartilage does not matter. (2) Ideal suture closure of a large bronchus is not achieved by following the techniques depicted in the paper by Vester and associates [3], which are of historical interest only or place more emphasis on coverage than on the creation of a properly closed stump. Optimal technique involves cutting the bronchus to tailor a flap of posterior membranous wall as advocated by Scannell [4] wherever possible (Fig 1). This, combined with meticulous dissection and suture technique to avoid tension and devascularization, should produce secure bronchial closure. All thoracic surgeons should be familiar with the correct execution of both suture and staple techniques for bronchial closure.
D a r y l Hoffman, FRCS Robert W. M . Frater, M D Department of Cardiothoracic S u r g e y The Albert Einstein College of Medicine of Yeshiva University 1300 Morris Park Ave Bronx, NY 10461
Fig 1 . Suture closure of the bronchus with a flap of posterior membranous wall.
1. Ravitch MM, Steichen FM. Atlas of general thoracic surgery. Philadelphia: W. 8. Saunders, 1988. 2. Ravitch MM. The current practice of surgical stapling. Malvern, PA: Lea & Febiger, 1991. 3. Vester SR, Faber LP, Kittle FC, Warren WH, Jensik RJ. Bronchopleural fistula after closure of bronchus. Ann Thorac Surg 1991;52:1253-8. 4. Scannell JG. Pulmonary resection-anatomy and techniques. In: Glenn WWL, Baue AE, Geha AS, Hammond GL, Laks H, eds. Thoracic and cardiovascular surgery. Norwalk, CT: Appleton-Century-Crofts, 1983:214.
Better Salvage in Non-Small Cell Lung Cancer To the Editor: Two topics in the January 1992 issue of The Annals of Thoracic Surgery on surgery and lung cancer point up the impasse or dilemma we surgeons face in the 1990s. Richard Feins’ editorial [l] on the demise of funding for the Lung Cancer Study Group after 12 years listed the accomplishments of that group: “set standards for surgical staging of lung cancer . . ., determined survival by TNM classification . . ., and compiled modern morbidity and mortality statistics for lung resection . . . Important questions about the role of radiation therapy in selected postoperative situations . . ., the efficacy of limited lung resection . . ., and tolerance and benefit of postoperative chemotherapy . . . were answered.” These are modest successes. The unanswered questions (rather, unasked questions) are probably more important than the answered ones and may suggest why the funding is no longer available. Questions such as: 1. Can neoadjuvant (preoperative) modern radiotherapy be combined
with modern resective surgery with a reasonable morbidity and mortality? Modern radiotherapy has defined the parameters that have led to an improved 5-year survival rate in locally advanced non-small cell lung cancer (continuous course small fractions to a therapeutic dose of 55 to 65 Gy using molded fields and computerized dosimetry). Surgeons have prided themselves in improved preoperative and postoperative care as well as strategies to reduce space problems, bronchopleural and pulmonopleural fistulas, and infectious complications (use of staples, stump coverage, use of pleural sclerosants, and high suction where needed to minimize postoperative pneumothorax). However, they have been disinterested in using these modern strategies to blend with the preoperative improvements in radiotherapy. For example, most protocols at the surgeon’s request have used only a small dose of preoperative radiotherapy (40 Gy, for example). This dosage is unacceptable to radiotherapists striving for cures. Surgeons have not had any idea of what preoperative dosage they are comfortable with but tend to think “the lower the better.” Is our answer to question 1 really that we do not know and are not really interested in finding out whether we can operate after modern radiotherapy with a reasonable morbidity or mortality? Is that what we really believe? 2. Can noninvasive staging in non-small cell lung cancer, by minimizing traumatic tumor spread, enhance salvage? I suppose surgeons who make their living wielding the scalpel find it difficult to acknowledge that trauma plays an important part in tumor spread. Have you noticed many surgeons insist on invasive (traumatic) staging to separate “negative” mediastinoscopy, anterior thoracotomy, and larger thoracotomy cases to have a try at primary surgery instead of preoperative radiotherapy? I believe our medical colleagues intuitively sense that rooting
400
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around in the mediastinum or elsewhere in the chest could contribute to tumor spread through the bloodstream or lymphatics [Z]. Do they also sense that surgeons like to operate even if the staging operation really is not helping the patient, for example, does not alter the treatment? My point is that noninvasive staging for the majority of patients with locally advanced disease followed by preoperative radiotherapy would probably salvage more patients than invasive staging (surgical staging is not an exact science) in selecting primary surgery cases. This question could be answered with trials but it has not been considered. Shouldn‘t we surgeons really be interested in abandoning surgical staging before preoperative radiotherapy and opt for restaging and salvage resection later? We have thus presented the radiotherapist with a virtually untraumatized patient for preoperative radiotherapy. 3. Have we answered the question of whether preoperative modern radiotherapy alone or in conjirnction with chemothcrapy is better? Ruckdeschel and Holmes [3], regarding a preoperative regimen with 5-fluorouracil, cisplatinum, and radiotherapy, stated “one could compare this regimen either with radiotherapy alone with 5WO Gy or with the same dose of radiation preceded by chemotherapy. It is our opinion that the community standard remain radiotherapy alone . . . We feel it is imperative that such a study be undertaken before preoperative therapy becomes a standard component of the armamentarium.” Shouldn‘t a combination in the theoretically correct order of, in themselves, curative agents (radiotherapy and surgery) be checked out before adding chemotherapy and immunotherapy (noncurative agents in themselves)? How many surgeons would be happy operating after 50 to 60 Gy of radiotherapy? How many surgeons have tried to operate (resect) after this dosage? Feins [ l ] perhaps understates it when he writes, ”The National Cancer Institute has created a considerable challenge for thoracic surgeons.” Haven’t the surgeons created the problem themselves by hesitating to let their medical colleagues know exactly what they can accomplish operating after modern radiotherapy? Even if funds are filtered through radiotherapy and chemotherapy colleagues, we the surgeons should answer the above questions. Shouldn’t we surgeons be at the forefront of finding what the role of preoperative radiotherapy is before combining it with chemotherapy and immunotherapy? Shouldn’t we find out first what radiotherapy alone as neoadjuvant treatment can dwradiotherapy, a potentially curative modality? The answers could determine the future of surgery in locally advanced non-small cell lung cancer. I happen to believe that all patients with locally advanced non-small cell lung cancer after a therapeutic dose (for cure) of radiotherapy should routinely be considered for resective surgery for residual disease, restagng and surgical risk factors permitting of course. If such patients were told before preoperative radiotherapy that surgery later were a possibility and why, clinical management of the patient would be facilitated. The surgeon must believe in this approach, push for
such an approach, and show salvage results of such an approach to be considered credible by the pessimistic medical colleagues who control not only the patients but the trial pursestrings. Are surgeons ready for this outlined strategy? If not, then haven’t we lost out by default? The second article in The Annals, the review by Miller, Gorenstein, and Patterson [4], is a beautifully written summation of the state of the art in non-small cell lung cancer as treated primarily by one curative modality-resective surgery. The prognosis decreases with the increasing extent of the disease so that it becomes harder to employ primary surgery with locally advanced cancer. Thus, the use of primary resection in more advanced cases becomes harder to justify. Employing the other curative modality in combination with resective surgery is hardly mentioned in the review, the other modality being of course preoperative high-dose modern radiotherapy. The review states that “there are no prospective, randomized trials that show survival benefit using neoadjuvant therapy for patients with locally advanced [non-small cell lung cancer]” [4]. None have been tried using modern radiotherapy! This blind spot in the surgeon’s approach to locally advanced non-small cell lung cancer is also obvious in the already discussed editorial [ l ] decrying the demise of the Lung Cancer Study G r o u p a surgery-friendly cancer study group. If one analyzes the six accomplishments of this group during its 12 years in operation, not one study was undertaken employing, in the theoretically correct order, the two modalities that are in themselves curative. Are these two ostensibly unrelated articles not an illustration of what ails the surgical approach to lung cancer? Are we surgeons only interested in primary surgery? Have we failed to keep up with our radiotherapy colleagues in defining the parameters in cooperating in best using bimodality therapy? Should I be optimistic in thinking that we, thoracic surgeons, will face the challenge of locally advanced non-small cell lung cancer? Will we face the challenge of exploring first bimodality therapy and perhaps later multimodality therapy as better drugs are found?
John S . Chambers, M D 550 Washington St, #211 San Diego, C A 92103
References 1. Feins RH. Thoracic surgery participation in cooperative group studies of cancer therapy. Ann Thorac Surg 1992;53:9-10. 2. Scanlon E, Murthy S. Basic science overview: the process of metastasis. CA 1991;41:301-5. 3. Ruckdeschel JC, Holmes E. Preoperative chemotherapy for locally advanced non small cell lung cancer. Chest Surg Clin North Am 1991;l:l-12. 4. Miller JD, Gorenstein LA, Patterson GA. Staging: the key to rational management of lung cancer. Ann Thorac Surg 1992; 53:170-8.
Ann Thorac Surg 1992;54:394400
399
References Bronchial Stump Closure To the Editor: Staple closure of the bronchus is now widely accepted and, although the superiority of the technique over conventional suture closure has not been convincingly shown, the convenience factor will assure its increasing use. Suture closure will, however, always be required in some cases. We think it is appropriate to bring two points to the attention of our colleagues: (1) Of the standard texts, not even those dedicated to the usage of staplers [l, 21 specify the exact orientation of the stapling device relative to the bronchus. Vester and associates [3] refer to transverse placement of the bronchial stapler relative to the long axis of the bronchus, and recommend that ”the stapler be parallel to the mucous membrane.” We suspect that the intended meaning places the anvil of the stapling device parallel to the membranous part of the bronchus, and have used staplers this way in the expectation that, should the cartilaginous part tend to resume its original C shape, it will pull the softer membranous part with it. Two apposing curved pieces of cartilage with the same tendency will tend to pull apart. Steichen (personal communication) confirms this and adds that orientation for smaller bronchi without C-shaped rings of cartilage does not matter. (2) Ideal suture closure of a large bronchus is not achieved by following the techniques depicted in the paper by Vester and associates [3], which are of historical interest only or place more emphasis on coverage than on the creation of a properly closed stump. Optimal technique involves cutting the bronchus to tailor a flap of posterior membranous wall as advocated by Scannell [4] wherever possible (Fig 1). This, combined with meticulous dissection and suture technique to avoid tension and devascularization, should produce secure bronchial closure. All thoracic surgeons should be familiar with the correct execution of both suture and staple techniques for bronchial closure.
D a r y l Hoffman, FRCS Robert W. M . Frater, M D Department of Cardiothoracic S u r g e y The Albert Einstein College of Medicine of Yeshiva University 1300 Morris Park Ave Bronx, NY 10461
Fig 1 . Suture closure of the bronchus with a flap of posterior membranous wall.
1. Ravitch MM, Steichen FM. Atlas of general thoracic surgery. Philadelphia: W. 8. Saunders, 1988. 2. Ravitch MM. The current practice of surgical stapling. Malvern, PA: Lea & Febiger, 1991. 3. Vester SR, Faber LP, Kittle FC, Warren WH, Jensik RJ. Bronchopleural fistula after closure of bronchus. Ann Thorac Surg 1991;52:1253-8. 4. Scannell JG. Pulmonary resection-anatomy and techniques. In: Glenn WWL, Baue AE, Geha AS, Hammond GL, Laks H, eds. Thoracic and cardiovascular surgery. Norwalk, CT: Appleton-Century-Crofts, 1983:214.
Better Salvage in Non-Small Cell Lung Cancer To the Editor: Two topics in the January 1992 issue of The Annals of Thoracic Surgery on surgery and lung cancer point up the impasse or dilemma we surgeons face in the 1990s. Richard Feins’ editorial [l] on the demise of funding for the Lung Cancer Study Group after 12 years listed the accomplishments of that group: “set standards for surgical staging of lung cancer . . ., determined survival by TNM classification . . ., and compiled modern morbidity and mortality statistics for lung resection . . . Important questions about the role of radiation therapy in selected postoperative situations . . ., the efficacy of limited lung resection . . ., and tolerance and benefit of postoperative chemotherapy . . . were answered.” These are modest successes. The unanswered questions (rather, unasked questions) are probably more important than the answered ones and may suggest why the funding is no longer available. Questions such as: 1. Can neoadjuvant (preoperative) modern radiotherapy be combined
with modern resective surgery with a reasonable morbidity and mortality? Modern radiotherapy has defined the parameters that have led to an improved 5-year survival rate in locally advanced non-small cell lung cancer (continuous course small fractions to a therapeutic dose of 55 to 65 Gy using molded fields and computerized dosimetry). Surgeons have prided themselves in improved preoperative and postoperative care as well as strategies to reduce space problems, bronchopleural and pulmonopleural fistulas, and infectious complications (use of staples, stump coverage, use of pleural sclerosants, and high suction where needed to minimize postoperative pneumothorax). However, they have been disinterested in using these modern strategies to blend with the preoperative improvements in radiotherapy. For example, most protocols at the surgeon’s request have used only a small dose of preoperative radiotherapy (40 Gy, for example). This dosage is unacceptable to radiotherapists striving for cures. Surgeons have not had any idea of what preoperative dosage they are comfortable with but tend to think “the lower the better.” Is our answer to question 1 really that we do not know and are not really interested in finding out whether we can operate after modern radiotherapy with a reasonable morbidity or mortality? Is that what we really believe? 2. Can noninvasive staging in non-small cell lung cancer, by minimizing traumatic tumor spread, enhance salvage? I suppose surgeons who make their living wielding the scalpel find it difficult to acknowledge that trauma plays an important part in tumor spread. Have you noticed many surgeons insist on invasive (traumatic) staging to separate “negative” mediastinoscopy, anterior thoracotomy, and larger thoracotomy cases to have a try at primary surgery instead of preoperative radiotherapy? I believe our medical colleagues intuitively sense that rooting
400
CORRESPONDENCE
Ann Thorac Surg 1992;54:394400
around in the mediastinum or elsewhere in the chest could contribute to tumor spread through the bloodstream or lymphatics [Z]. Do they also sense that surgeons like to operate even if the staging operation really is not helping the patient, for example, does not alter the treatment? My point is that noninvasive staging for the majority of patients with locally advanced disease followed by preoperative radiotherapy would probably salvage more patients than invasive staging (surgical staging is not an exact science) in selecting primary surgery cases. This question could be answered with trials but it has not been considered. Shouldn‘t we surgeons really be interested in abandoning surgical staging before preoperative radiotherapy and opt for restaging and salvage resection later? We have thus presented the radiotherapist with a virtually untraumatized patient for preoperative radiotherapy. 3. Have we answered the question of whether preoperative modern radiotherapy alone or in conjirnction with chemothcrapy is better? Ruckdeschel and Holmes [3], regarding a preoperative regimen with 5-fluorouracil, cisplatinum, and radiotherapy, stated “one could compare this regimen either with radiotherapy alone with 5WO Gy or with the same dose of radiation preceded by chemotherapy. It is our opinion that the community standard remain radiotherapy alone . . . We feel it is imperative that such a study be undertaken before preoperative therapy becomes a standard component of the armamentarium.” Shouldn‘t a combination in the theoretically correct order of, in themselves, curative agents (radiotherapy and surgery) be checked out before adding chemotherapy and immunotherapy (noncurative agents in themselves)? How many surgeons would be happy operating after 50 to 60 Gy of radiotherapy? How many surgeons have tried to operate (resect) after this dosage? Feins [ l ] perhaps understates it when he writes, ”The National Cancer Institute has created a considerable challenge for thoracic surgeons.” Haven’t the surgeons created the problem themselves by hesitating to let their medical colleagues know exactly what they can accomplish operating after modern radiotherapy? Even if funds are filtered through radiotherapy and chemotherapy colleagues, we the surgeons should answer the above questions. Shouldn’t we surgeons be at the forefront of finding what the role of preoperative radiotherapy is before combining it with chemotherapy and immunotherapy? Shouldn’t we find out first what radiotherapy alone as neoadjuvant treatment can dwradiotherapy, a potentially curative modality? The answers could determine the future of surgery in locally advanced non-small cell lung cancer. I happen to believe that all patients with locally advanced non-small cell lung cancer after a therapeutic dose (for cure) of radiotherapy should routinely be considered for resective surgery for residual disease, restagng and surgical risk factors permitting of course. If such patients were told before preoperative radiotherapy that surgery later were a possibility and why, clinical management of the patient would be facilitated. The surgeon must believe in this approach, push for
such an approach, and show salvage results of such an approach to be considered credible by the pessimistic medical colleagues who control not only the patients but the trial pursestrings. Are surgeons ready for this outlined strategy? If not, then haven’t we lost out by default? The second article in The Annals, the review by Miller, Gorenstein, and Patterson [4], is a beautifully written summation of the state of the art in non-small cell lung cancer as treated primarily by one curative modality-resective surgery. The prognosis decreases with the increasing extent of the disease so that it becomes harder to employ primary surgery with locally advanced cancer. Thus, the use of primary resection in more advanced cases becomes harder to justify. Employing the other curative modality in combination with resective surgery is hardly mentioned in the review, the other modality being of course preoperative high-dose modern radiotherapy. The review states that “there are no prospective, randomized trials that show survival benefit using neoadjuvant therapy for patients with locally advanced [non-small cell lung cancer]” [4]. None have been tried using modern radiotherapy! This blind spot in the surgeon’s approach to locally advanced non-small cell lung cancer is also obvious in the already discussed editorial [ l ] decrying the demise of the Lung Cancer Study G r o u p a surgery-friendly cancer study group. If one analyzes the six accomplishments of this group during its 12 years in operation, not one study was undertaken employing, in the theoretically correct order, the two modalities that are in themselves curative. Are these two ostensibly unrelated articles not an illustration of what ails the surgical approach to lung cancer? Are we surgeons only interested in primary surgery? Have we failed to keep up with our radiotherapy colleagues in defining the parameters in cooperating in best using bimodality therapy? Should I be optimistic in thinking that we, thoracic surgeons, will face the challenge of locally advanced non-small cell lung cancer? Will we face the challenge of exploring first bimodality therapy and perhaps later multimodality therapy as better drugs are found?
John S . Chambers, M D 550 Washington St, #211 San Diego, C A 92103
References 1. Feins RH. Thoracic surgery participation in cooperative group studies of cancer therapy. Ann Thorac Surg 1992;53:9-10. 2. Scanlon E, Murthy S. Basic science overview: the process of metastasis. CA 1991;41:301-5. 3. Ruckdeschel JC, Holmes E. Preoperative chemotherapy for locally advanced non small cell lung cancer. Chest Surg Clin North Am 1991;l:l-12. 4. Miller JD, Gorenstein LA, Patterson GA. Staging: the key to rational management of lung cancer. Ann Thorac Surg 1992; 53:170-8.
