CORRESPONDENCE
Ann Thorac Surg 1991:51:3448
4. Lawrie GM, DeBakey ME, Morris GC Jr, Crawford ES, Wagner WF, Glaeser DH. Late repair of coarctation of the descending thoracic aortic in 190 patients. Arch Surg 1981;116:1557-60. 5. Nanton MA, Olley PM. Residual hypertension after coarctectomy in children. Am J Cardiol 1976;37:769-72. 6. Shinebourne EA, Tam ASY, Elseed AM, et al. Coarctation of the aorta in infancy and childhood. Br Heart J 1976;38:375-80. 7. Campbell DB, Waldhausen JA, Pierce WS, Fripp R, Whitman V. Should elective repair of coarctation of the aorta be done in infancy? J Thorac Cardiovasc Surg 1984;88:929-38. 8. Sciolaro C, Copeland J, Cork R, Barkenbush M, Donnerstein R, Goldberg S. Long-term follow-up comparing subclavian flap angioplasty to resection with modified oblique end-to-end anastomosis. J Thorac Cardiovasc Surg (in press). 9. Sinha SN, Kardatzke ML, Cole RB, Muster AJ, Wessel HU, Paul MH. Coarctation of the aorta in infancy. Circulation 1969;40:385-98.
Staging Lung Cancer With Computed Tomography To the Editor: I found the recent article by Lewis and associates [l]of great interest, and thought it a valuable addition to the literature on this subject. Their results further emphasize the importance of careful intraoperative assessment of the mediastinum at thoracotomy. We [2] have shown that such a dissection (we prefer the term "sampling") will disclose unsuspected nodal metastasis in 25% of thoracotomies, even after careful preoperative staging with computed tomography with or without mediastinal exploration by mediastinoscopy, supplemented by left anterior mediastinoscopy for tumors of the left upper lobe and left main bronchus. The concordance between the stage derived by computed tomography and that following such a careful intraoperative assessment, 45.4%, should not discourage our radiological colleagues. This figure is remarkably similar to the figure we found, 46.5%, in a recent publication (31 reporting the variance between the T and N stages determined preoperatively, using all investigations including computed tomography with or without mediastinal exploration, and careful intraoperative staging along the lines used by Lewis and associates. These figures should encourage all surgeons to add mediastinal node sampling to their operative routine. The IASLC has recently endorsed this technique as part of its recommendations on "minimal pre-treatment staging," to be published as part of the proceedings of the Bruge Workshop (June 21-27). We surgeons should recognize that thoracotomy is the final staging investigation, before proceeding with the treatment-pulmonary resection. I would ask Lewis and associates to clarify one point. They found the computed tomographic scan falsely negative in 19 patients, and yet later we were told that mediastinal node deposits were found in 69 patients at thoracotomy. Are we to assume that the other 50 patients proceeded to thoracotomy despite a positive scan? Was this checked preoperatively by mediastinal exploration? Peter Goldstraw, FRCS Royal Brompton and National Heart Hospital Fulham Rd London SW3 6HP England
345
References 1. Lewis JW Jr, Pearlberg JL, Beute GH, et al. Can computed tomography of the chest stage lung cancer?-yes and no. Ann Thorac Surg 1990;49:591-6. 2. Gaer JAR, Goldstraw P. Eur J Cardiothorac Surg 1990;4: 207-10. 3. Fernando HC, Goldstraw P. Cancer 1990;65:2503-6.
Reply
To the Editor:
Mediastinal lymph node sampling before resection in lung cancer patients is performed in many centers. Some authors feel that documentation of N2 disease contraindicates potential curative resection. Our center pursues an aggressive approach to stage IIIa patients (enlarged mediastinal lymph nodes by computed tomographic scan) with neoadjuvant chemotherapy followed by exploration [l].Those patients who cannot be resected for cure are treated by aggressive intraoperative brachytherapy 121. The additional 50 patients mentioned by Mr Goldstraw were part of this surgical subset.
loseph W . Lewis, jr, M D Division of Cardiac and Thoracic Surgery Henry Ford Hospital 2799 W Grand Blvd Detroit, MI 45202
References 1. Chapman R, Lewis J, Kvale P, et al. Preoperative chemotherapy in stage I1 and IIIA non-small cell lung cancer [Abstract]. Chest 1990;98:55S. 2. Lewis JW Jr, Ajlouni M, Kvale P, et al. Role of brachytherapy in the management of pulmonary and mediastinal malignancies. Ann Thorac Surg 1990;49:728-32.
Single Drain (Pleura, Pericardium, Mediastinum) After Open Heart Operations To the Editor: A fascinating facet of cardiac surgery is the never-ending scope for fresh thinking on "standard" practices. Postoperative chest drainage is an example. Smulders and associates [ l ] refer to the high incidence of postoperative pericardial effusion, sometimes leading to tamponade and probably related to ineffective drainage. They accept postoperative pericardial effusion as inevitable in some patients and advocate early removal of the drains because of discomfort, mechanical irritation to the heart and pericardium, and increased risk of infection. One of our patients who underwent closure of an atrial septa1 defect proved to have a large congenital pericardial window in the left side. A single pleural drain inserted after opening the left pleural cavity proved effective. This led us to adopt the following procedure as a routine in subsequent patients. A large pericardial window is created by an incision parallel and 1cm anterior to the right phrenic nerve from the superior to the inferior vena cava. The lower end of the incision is continued forward parallel to the diaphragm for about 3 cm. The pericardium is closed in the midline using three or four interrupted stitches. The right pleura is widely opened. Thus the mediastinum and the pericardial and pleural spaces form a common space that is effectively drained by a single pleural tube. In patients undergoing internal mammary
Ann Thorac Surg 1991:51:3448
4. Lawrie GM, DeBakey ME, Morris GC Jr, Crawford ES, Wagner WF, Glaeser DH. Late repair of coarctation of the descending thoracic aortic in 190 patients. Arch Surg 1981;116:1557-60. 5. Nanton MA, Olley PM. Residual hypertension after coarctectomy in children. Am J Cardiol 1976;37:769-72. 6. Shinebourne EA, Tam ASY, Elseed AM, et al. Coarctation of the aorta in infancy and childhood. Br Heart J 1976;38:375-80. 7. Campbell DB, Waldhausen JA, Pierce WS, Fripp R, Whitman V. Should elective repair of coarctation of the aorta be done in infancy? J Thorac Cardiovasc Surg 1984;88:929-38. 8. Sciolaro C, Copeland J, Cork R, Barkenbush M, Donnerstein R, Goldberg S. Long-term follow-up comparing subclavian flap angioplasty to resection with modified oblique end-to-end anastomosis. J Thorac Cardiovasc Surg (in press). 9. Sinha SN, Kardatzke ML, Cole RB, Muster AJ, Wessel HU, Paul MH. Coarctation of the aorta in infancy. Circulation 1969;40:385-98.
Staging Lung Cancer With Computed Tomography To the Editor: I found the recent article by Lewis and associates [l]of great interest, and thought it a valuable addition to the literature on this subject. Their results further emphasize the importance of careful intraoperative assessment of the mediastinum at thoracotomy. We [2] have shown that such a dissection (we prefer the term "sampling") will disclose unsuspected nodal metastasis in 25% of thoracotomies, even after careful preoperative staging with computed tomography with or without mediastinal exploration by mediastinoscopy, supplemented by left anterior mediastinoscopy for tumors of the left upper lobe and left main bronchus. The concordance between the stage derived by computed tomography and that following such a careful intraoperative assessment, 45.4%, should not discourage our radiological colleagues. This figure is remarkably similar to the figure we found, 46.5%, in a recent publication (31 reporting the variance between the T and N stages determined preoperatively, using all investigations including computed tomography with or without mediastinal exploration, and careful intraoperative staging along the lines used by Lewis and associates. These figures should encourage all surgeons to add mediastinal node sampling to their operative routine. The IASLC has recently endorsed this technique as part of its recommendations on "minimal pre-treatment staging," to be published as part of the proceedings of the Bruge Workshop (June 21-27). We surgeons should recognize that thoracotomy is the final staging investigation, before proceeding with the treatment-pulmonary resection. I would ask Lewis and associates to clarify one point. They found the computed tomographic scan falsely negative in 19 patients, and yet later we were told that mediastinal node deposits were found in 69 patients at thoracotomy. Are we to assume that the other 50 patients proceeded to thoracotomy despite a positive scan? Was this checked preoperatively by mediastinal exploration? Peter Goldstraw, FRCS Royal Brompton and National Heart Hospital Fulham Rd London SW3 6HP England
345
References 1. Lewis JW Jr, Pearlberg JL, Beute GH, et al. Can computed tomography of the chest stage lung cancer?-yes and no. Ann Thorac Surg 1990;49:591-6. 2. Gaer JAR, Goldstraw P. Eur J Cardiothorac Surg 1990;4: 207-10. 3. Fernando HC, Goldstraw P. Cancer 1990;65:2503-6.
Reply
To the Editor:
Mediastinal lymph node sampling before resection in lung cancer patients is performed in many centers. Some authors feel that documentation of N2 disease contraindicates potential curative resection. Our center pursues an aggressive approach to stage IIIa patients (enlarged mediastinal lymph nodes by computed tomographic scan) with neoadjuvant chemotherapy followed by exploration [l].Those patients who cannot be resected for cure are treated by aggressive intraoperative brachytherapy 121. The additional 50 patients mentioned by Mr Goldstraw were part of this surgical subset.
loseph W . Lewis, jr, M D Division of Cardiac and Thoracic Surgery Henry Ford Hospital 2799 W Grand Blvd Detroit, MI 45202
References 1. Chapman R, Lewis J, Kvale P, et al. Preoperative chemotherapy in stage I1 and IIIA non-small cell lung cancer [Abstract]. Chest 1990;98:55S. 2. Lewis JW Jr, Ajlouni M, Kvale P, et al. Role of brachytherapy in the management of pulmonary and mediastinal malignancies. Ann Thorac Surg 1990;49:728-32.
Single Drain (Pleura, Pericardium, Mediastinum) After Open Heart Operations To the Editor: A fascinating facet of cardiac surgery is the never-ending scope for fresh thinking on "standard" practices. Postoperative chest drainage is an example. Smulders and associates [ l ] refer to the high incidence of postoperative pericardial effusion, sometimes leading to tamponade and probably related to ineffective drainage. They accept postoperative pericardial effusion as inevitable in some patients and advocate early removal of the drains because of discomfort, mechanical irritation to the heart and pericardium, and increased risk of infection. One of our patients who underwent closure of an atrial septa1 defect proved to have a large congenital pericardial window in the left side. A single pleural drain inserted after opening the left pleural cavity proved effective. This led us to adopt the following procedure as a routine in subsequent patients. A large pericardial window is created by an incision parallel and 1cm anterior to the right phrenic nerve from the superior to the inferior vena cava. The lower end of the incision is continued forward parallel to the diaphragm for about 3 cm. The pericardium is closed in the midline using three or four interrupted stitches. The right pleura is widely opened. Thus the mediastinum and the pericardial and pleural spaces form a common space that is effectively drained by a single pleural tube. In patients undergoing internal mammary
