communications to the editor Commw1ications for this section will be Jmblished as space tmd priorities pennit. The comments shcmld not excenl .3.50 rcords in length , with a rru1ximum of jive rrfercnces; one jigurr or table can be printed. Exceptions may occur undt•r particular circumstances. Contributions rru1y include comments on articles 1mblished in this periodical, or they nUly be rrports of unique t•ducational character. Specific pennission to publish should be cited in a covering letter or appended as a JJOStscript.
enee d in the procedure ) would he intrinsically more dangerous to the patient than these other procedures. I do believe that the performance of such procedures is bt>tter suited to a hospital that has on-site coverage hy a qualified thoracic surgeon. I urge your organization to issue a statement regarding the use of this procedure by trained pulmonologists and, if appropriate, to perhaps define suggested guidelines for such use. This would also he an excellent topie for discussion at the next naticntal rnee ting.
Thoracoscopy Forum: Continuing Dialogue
john G. Byers, jr., M.D. , FC .C.P. ( PulmmUlry Dismse and Critical Care Medicirw) Bristol. Tennessee
To tht• f:ditor: I am surt> that you are well aware that thorat"st"PY has a long history and was originally a procedure mmmonly perlimned by internists in the prechemotherapy era of tuberculosis therapy. This has been a well-acceptt•d procedure in Europe for a number of years, and some of the most respected thorat,>scopists are internists. I recently had the pleasure of meeting Dr. Christian Boutin of Marseilles and Dr. Robe rt Lodenkemper of Berlin. Thest> gentlemen are pulmonologists and have a vast experience in thorat,>st,>py. and both have published e xcellent texts on the subject. They both ent,mraged mt• to develop a program for thoraseopy to be performed by pulmonologists at my institution. I personally believe that there is a role for pulmnnnlogists in performing diagnostic thoracoscopy. Most pulmnnologists, including myself. have no designs on performing video-assisted thoracie surgery, hut I do feel there is a role for pulmnnologists in performing thoracoscopy for diagnosis and management of pleural diseases. There was a similar l'>neern approximate ly 10 years ago, whPn there was some fet>ling that laser bronchoscopy was too dangt>rous for pulmonologists to pe rform . Time has shown this not to ht> the case, and in fact at this point the most respectt>d laser bronchost,>pists in this t'mntry are pulmonologists. I suspect that if the College muld he lp develop guide lines that ht>tter dt"flne diagnostic thoral,>smpy and video-assisted thoracic surgt>ry. somt> of the fears that our surgical t, >llt>agut>s may have concerning pulmonologists pt>rforming thoracic surgery can he alleviated . Thank you for your t'>ncern in this matte r.
john F. Beamis, jr. , M.D., EC .C .P., Section of Pulnwnary and Critical Carr Metliciru•, Lahey Clinic Medical Center; Burlington, .\fas.w ldwsetts
71> till' Editor:
I have reeently learned that the thoracic surgeons are trying to restrict the performance of thorat,>st,>py exclusively to thoracic surgeons. \Vhile some thoracoscopic procedures are certainly in the domain of thorack surgery, there are other procedures that are being performed 'l'ith a high degree of success and safety by pulmonologists. At the Medical College of Virginia. two of our pulmonary faculty have been performing thorat•>st,>py for more than 5 yt>ars with no significant mmplications. We use the technique to inspt>cl and obtain biopsy specimens from the parietal plt>ura. primarily in cases of undiagnosed pleural effusion. Our procedure is performed with local ant>sthesia (and intravenous sedation only if necessary) in our procedure nx>m. Thoracoscopy is rapidly taking ovt>r as the prt>ferred route for many thoracic surgical procedures involving mediastinal and pulmonary structures. proct>dures that are clearly the domain of the operating room and the thoracic surgeon. However, the present move to rest riel all thonlt,>St,>py to thoracic.· surgeons is not justified as it will rest riel the a\·ailahility of endosc.,>pic evaluation of parietal pleural lesions and dramatically increa~e the expense. since the surgeons fees. anesthesiology fees. and operating nx>m expenses cost about tlw same as a full thoracotomy. Our charges are similar to those for bronchoscopy. At our institution we have a thoracic surgeon doing thorat,>scopy and two pulmonologists also doing thoracoscopy. The surgeon does a full range of operative procedures on the lung and mediastinum, and the pulmonologists stick to the parie tal pleura. Our system works fine . and I would e nc.,mrage the Ame rican College of Chest Physicians to advocate this py praelke.
Kt•vin R. Cooper. .\f. D., EC .C.P., Didsiou of Pulmonary and Critical Can• JllediciriC,
To the Editor: I am a practitioner of pulmonary and critical eare medidne {hoard-certified in both areas) who has for many years performed invasive hronedle biopsies of the plt>ura (among many other invasive procedures). At bronchoscopy I often pe rform transbronchial biopsies and \Vang-needle biopsies. In addition. I do both diagnostic and tht>rapeutic percutaneous catheter drainage of pleural effusions, and, in emergencies. I place chest tubes. Under the circumstances, Ifail to see how diagnostil· thorat,>sd and expt>ri-
Medical College of Virginia, Richmond To the f:ditor: I have observed a l'msulting thoracic surgeon perform thorat,>st,>pk biopsies and havt' witnessed one situation in which a "simple" wedge resection was t'>mplicated by massive hltx> to rapidly intervt>ne hy "erashing" the chest. this patient would not have had an uneventful rec.,wery. CHEST I 102 I 6 I DECEMBER, 1992
1915
enee d in the procedure ) would he intrinsically more dangerous to the patient than these other procedures. I do believe that the performance of such procedures is bt>tter suited to a hospital that has on-site coverage hy a qualified thoracic surgeon. I urge your organization to issue a statement regarding the use of this procedure by trained pulmonologists and, if appropriate, to perhaps define suggested guidelines for such use. This would also he an excellent topie for discussion at the next naticntal rnee ting.
Thoracoscopy Forum: Continuing Dialogue
john G. Byers, jr., M.D. , FC .C.P. ( PulmmUlry Dismse and Critical Care Medicirw) Bristol. Tennessee
To tht• f:ditor: I am surt> that you are well aware that thorat"st"PY has a long history and was originally a procedure mmmonly perlimned by internists in the prechemotherapy era of tuberculosis therapy. This has been a well-acceptt•d procedure in Europe for a number of years, and some of the most respected thorat,>scopists are internists. I recently had the pleasure of meeting Dr. Christian Boutin of Marseilles and Dr. Robe rt Lodenkemper of Berlin. Thest> gentlemen are pulmonologists and have a vast experience in thorat,>st,>py. and both have published e xcellent texts on the subject. They both ent,mraged mt• to develop a program for thoraseopy to be performed by pulmonologists at my institution. I personally believe that there is a role for pulmnnnlogists in performing diagnostic thoracoscopy. Most pulmnnologists, including myself. have no designs on performing video-assisted thoracie surgery, hut I do feel there is a role for pulmnnologists in performing thoracoscopy for diagnosis and management of pleural diseases. There was a similar l'>neern approximate ly 10 years ago, whPn there was some fet>ling that laser bronchoscopy was too dangt>rous for pulmonologists to pe rform . Time has shown this not to ht> the case, and in fact at this point the most respectt>d laser bronchost,>pists in this t'mntry are pulmonologists. I suspect that if the College muld he lp develop guide lines that ht>tter dt"flne diagnostic thoral,>smpy and video-assisted thoracic surgt>ry. somt> of the fears that our surgical t, >llt>agut>s may have concerning pulmonologists pt>rforming thoracic surgery can he alleviated . Thank you for your t'>ncern in this matte r.
john F. Beamis, jr. , M.D., EC .C .P., Section of Pulnwnary and Critical Carr Metliciru•, Lahey Clinic Medical Center; Burlington, .\fas.w ldwsetts
71> till' Editor:
I have reeently learned that the thoracic surgeons are trying to restrict the performance of thorat,>st,>py exclusively to thoracic surgeons. \Vhile some thoracoscopic procedures are certainly in the domain of thorack surgery, there are other procedures that are being performed 'l'ith a high degree of success and safety by pulmonologists. At the Medical College of Virginia. two of our pulmonary faculty have been performing thorat•>st,>py for more than 5 yt>ars with no significant mmplications. We use the technique to inspt>cl and obtain biopsy specimens from the parietal plt>ura. primarily in cases of undiagnosed pleural effusion. Our procedure is performed with local ant>sthesia (and intravenous sedation only if necessary) in our procedure nx>m. Thoracoscopy is rapidly taking ovt>r as the prt>ferred route for many thoracic surgical procedures involving mediastinal and pulmonary structures. proct>dures that are clearly the domain of the operating room and the thoracic surgeon. However, the present move to rest riel all thonlt,>St,>py to thoracic.· surgeons is not justified as it will rest riel the a\·ailahility of endosc.,>pic evaluation of parietal pleural lesions and dramatically increa~e the expense. since the surgeons fees. anesthesiology fees. and operating nx>m expenses cost about tlw same as a full thoracotomy. Our charges are similar to those for bronchoscopy. At our institution we have a thoracic surgeon doing thorat,>scopy and two pulmonologists also doing thoracoscopy. The surgeon does a full range of operative procedures on the lung and mediastinum, and the pulmonologists stick to the parie tal pleura. Our system works fine . and I would e nc.,mrage the Ame rican College of Chest Physicians to advocate this py praelke.
Kt•vin R. Cooper. .\f. D., EC .C.P., Didsiou of Pulmonary and Critical Can• JllediciriC,
To the Editor: I am a practitioner of pulmonary and critical eare medidne {hoard-certified in both areas) who has for many years performed invasive hronedle biopsies of the plt>ura (among many other invasive procedures). At bronchoscopy I often pe rform transbronchial biopsies and \Vang-needle biopsies. In addition. I do both diagnostic and tht>rapeutic percutaneous catheter drainage of pleural effusions, and, in emergencies. I place chest tubes. Under the circumstances, Ifail to see how diagnostil· thorat,>sd and expt>ri-
Medical College of Virginia, Richmond To the f:ditor: I have observed a l'msulting thoracic surgeon perform thorat,>st,>pk biopsies and havt' witnessed one situation in which a "simple" wedge resection was t'>mplicated by massive hltx> to rapidly intervt>ne hy "erashing" the chest. this patient would not have had an uneventful rec.,wery. CHEST I 102 I 6 I DECEMBER, 1992
1915
