182
Ann Thorac Surg
CORRESPONDENCE
1992;53:18&2
Fig 1. Bronchoscopy 6 weeks postoperatively shows a well-healed bronchial anastomosis with hyperemia of the donor bronchial mucosa. of acute rejection manifested by right pleural effusion and leakage from the thoracotomy wound. The effectiveness of the paravertebral block allowed exploration and resuturing of the thoracotomy wound without further analgesia or anesthesia. This episode resolved with intravenous doses of prednisolone. Bronchoscopy at 2 weeks postoperatively confirmed satisfactory healing. Transbronchial biopsy showed no evidence of rejection. Bronchoalveolar lavage did not reveal evidence of infection. Oral prednisolone was commenced. His condition was stabilized with low-dose prednisolone, cyclosporine, and azathioprine, and he was discharged home 3 weeks after operation. He remained very well with improved exercise tolerance and excellent respiratory function parameters. Routine bronchoscopy at 6 weeks showed a well-healed bronchial anastomosis (Fig 1) with hyperemia of the donor bronchial mucosa distal to the ridged appearance of the anastomosis. The lack of rejection was confirmed by transbronchial biopsy and lack of infection by bronchoalveolarlavage. A repeat bronchoscopicexamination at 3 months confirmed the same picture, with the patient remaining in excellent condition. We believe that the hyperemia has resulted from sympathetic denervation of the bronchial vasculature. This should not be misinterpreted as evidence of rejection, and this report should serve as a cautionary tale for the unwary. Rejection should be confirmed by transbronchial biopsy.
Jibah Eng, FRCS Sabaratnam Sabanathan, DM, FRCS Duncan A . G. Newton, MRCP Department of Thoracic Surgery Bradford Royal lnfirma ry Duckworth Lane Bradford BD9 6RJ England
Reference 1. Eng J, Sabanathan S. Site of action of continuous extrapleural intercostal nerve block. Ann Thorac Surg 1991;51:387-9.
Fine-Needle Aspiration Biopsy To the Editor: Based on 188 patients with suspected pulmonary malignancy who underwent fine-needle aspiration biopsy, Colquhoun and
associates [l] conclude that "although accuracy can be quite high, the actual influence on patient management may be much less." Their conclusions resulted in part from obtaining nondiagnostic specimens from fine-needle aspiration biopsy in 53 (28.2%) of their 188 patients. What eventually happened to the 38 patients with nondiagnostic biopsies who did not undergo thoracotomy is not stated. The yield of positive aspiration .biopsies is related to the methods used as well as to the experience of the operator. Several suggestions to improve the yield of fine-needle aspiration biopsy may be helpful. The cytologist should examine the aspirate near the operating suite (5 to 10-minute wait) so that a nondiagnostic yield can be followed by repeated aspirations until diagnostic material is obtained. The needle, under suction, may be manipulated with both hands if an assistant holds the suction syringe. The needle should be "jabbed" several times into the suspect area during aspiration. Biplane fluoroscopy with a single image intensifier that can be rotated for anteroposterior and lateral visualization leaves adequate room for the operator to position himself or herself efficiently [2]. The plea is worth repeating that all personnel in the suite wear aprons and dosimeter badges that are monitored monthly by the Radiology Department.
Rodman E . Taber, M D 1140 LaPalma Ct Punta Gorda. FL 33950
References 1. Colquhoun SD, Rosenthal DL, Morton DL. Role of percutaneous fine-needle aspiration biopsy in suspected intrathoracic malignancy. Ann Thorac Surg 1991;51:3903. 2. Taber RE, Lupovitch A, Kantzler P. Fine needle aspiration biopsy of lung tumors. Ann Thorac Surg 1986;42(Suppl): 544-7.
Reply To the Editor: We appreciate Dr Taber's comments with regard to our results and agree that the technique of needle biopsy is most important and is well described in his letter. The method used in our study was essentially the same as that described by Dr Taber. Furthermore, Dr Rosenthal is a very experienced cytopathologist. Thus, despite the best efforts of an experienced team, the results of percutaneous fine-needle aspiration biopsy failed to establish a correct diagnosis on many occasions. For this reason, we believe percutaneous fine-needle aspiration biopsy adds little to the preoperative workup of a patient who is otherwise a surgical candidate. In such cases, either a positive diagnosis or a negative diagnosis requires confirmation or therapy by thoracotomy. Therefore, in our opinion, percutaneous fine-needle aspiration biopsy might best be reserved for establishing a diagnosis of malignancy so that nonoperative therapy can be instituted in patients who are not surgical candidates or in patients with suspected infectious disease.
Donald L. Morton, M D Steven D. Colquhoun, M D Dorothy L. Rosenthal, M D John Wayne Cancer lnstitute Saint John's Hospital and Health Center 1328 22nd St Santa Monica, C A 90404
Ann Thorac Surg
CORRESPONDENCE
1992;53:18&2
Fig 1. Bronchoscopy 6 weeks postoperatively shows a well-healed bronchial anastomosis with hyperemia of the donor bronchial mucosa. of acute rejection manifested by right pleural effusion and leakage from the thoracotomy wound. The effectiveness of the paravertebral block allowed exploration and resuturing of the thoracotomy wound without further analgesia or anesthesia. This episode resolved with intravenous doses of prednisolone. Bronchoscopy at 2 weeks postoperatively confirmed satisfactory healing. Transbronchial biopsy showed no evidence of rejection. Bronchoalveolar lavage did not reveal evidence of infection. Oral prednisolone was commenced. His condition was stabilized with low-dose prednisolone, cyclosporine, and azathioprine, and he was discharged home 3 weeks after operation. He remained very well with improved exercise tolerance and excellent respiratory function parameters. Routine bronchoscopy at 6 weeks showed a well-healed bronchial anastomosis (Fig 1) with hyperemia of the donor bronchial mucosa distal to the ridged appearance of the anastomosis. The lack of rejection was confirmed by transbronchial biopsy and lack of infection by bronchoalveolarlavage. A repeat bronchoscopicexamination at 3 months confirmed the same picture, with the patient remaining in excellent condition. We believe that the hyperemia has resulted from sympathetic denervation of the bronchial vasculature. This should not be misinterpreted as evidence of rejection, and this report should serve as a cautionary tale for the unwary. Rejection should be confirmed by transbronchial biopsy.
Jibah Eng, FRCS Sabaratnam Sabanathan, DM, FRCS Duncan A . G. Newton, MRCP Department of Thoracic Surgery Bradford Royal lnfirma ry Duckworth Lane Bradford BD9 6RJ England
Reference 1. Eng J, Sabanathan S. Site of action of continuous extrapleural intercostal nerve block. Ann Thorac Surg 1991;51:387-9.
Fine-Needle Aspiration Biopsy To the Editor: Based on 188 patients with suspected pulmonary malignancy who underwent fine-needle aspiration biopsy, Colquhoun and
associates [l] conclude that "although accuracy can be quite high, the actual influence on patient management may be much less." Their conclusions resulted in part from obtaining nondiagnostic specimens from fine-needle aspiration biopsy in 53 (28.2%) of their 188 patients. What eventually happened to the 38 patients with nondiagnostic biopsies who did not undergo thoracotomy is not stated. The yield of positive aspiration .biopsies is related to the methods used as well as to the experience of the operator. Several suggestions to improve the yield of fine-needle aspiration biopsy may be helpful. The cytologist should examine the aspirate near the operating suite (5 to 10-minute wait) so that a nondiagnostic yield can be followed by repeated aspirations until diagnostic material is obtained. The needle, under suction, may be manipulated with both hands if an assistant holds the suction syringe. The needle should be "jabbed" several times into the suspect area during aspiration. Biplane fluoroscopy with a single image intensifier that can be rotated for anteroposterior and lateral visualization leaves adequate room for the operator to position himself or herself efficiently [2]. The plea is worth repeating that all personnel in the suite wear aprons and dosimeter badges that are monitored monthly by the Radiology Department.
Rodman E . Taber, M D 1140 LaPalma Ct Punta Gorda. FL 33950
References 1. Colquhoun SD, Rosenthal DL, Morton DL. Role of percutaneous fine-needle aspiration biopsy in suspected intrathoracic malignancy. Ann Thorac Surg 1991;51:3903. 2. Taber RE, Lupovitch A, Kantzler P. Fine needle aspiration biopsy of lung tumors. Ann Thorac Surg 1986;42(Suppl): 544-7.
Reply To the Editor: We appreciate Dr Taber's comments with regard to our results and agree that the technique of needle biopsy is most important and is well described in his letter. The method used in our study was essentially the same as that described by Dr Taber. Furthermore, Dr Rosenthal is a very experienced cytopathologist. Thus, despite the best efforts of an experienced team, the results of percutaneous fine-needle aspiration biopsy failed to establish a correct diagnosis on many occasions. For this reason, we believe percutaneous fine-needle aspiration biopsy adds little to the preoperative workup of a patient who is otherwise a surgical candidate. In such cases, either a positive diagnosis or a negative diagnosis requires confirmation or therapy by thoracotomy. Therefore, in our opinion, percutaneous fine-needle aspiration biopsy might best be reserved for establishing a diagnosis of malignancy so that nonoperative therapy can be instituted in patients who are not surgical candidates or in patients with suspected infectious disease.
Donald L. Morton, M D Steven D. Colquhoun, M D Dorothy L. Rosenthal, M D John Wayne Cancer lnstitute Saint John's Hospital and Health Center 1328 22nd St Santa Monica, C A 90404
