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J Thorac Cardiovasc Surg 1994;108:595
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Physiologic evaluation of pulmonary function in the candidate for lung resection

Alon Yellin, MD, David Simansky, MD

Department of Thoracic Surgery
Sheba Medical Center
Tel Hashomer 52621, Israel

To the Editor:

We read with interest the recent publication by Dr. Miller Go 1 regarding pulmonary function in candidates for lung resection. As in other studies of a similar nature, its thrust is to find more accurate selection criteria that would minimize mortality while denying curative operation to as few patients as possible.

The study seems to encompass the entire pulmonary surgical experience at the participating hospitals. This obviously influences results, because more young and"healthy" patients are included. Most patients with benign diseases would tend to be younger, have better pulmonary function, and undergo less extensive resections. Twenty-six percent of the patients with benign disease underwent exploratory thoracotomy. What is the meaning of exploratory thoracotomy in benign diseases?

Patients with malignant diseases comprised about two thirds of the cases. Judging from the high number of wedge resections, it is our understanding that patients operated on for lung metastases were also included. The surgeons performing the resections were conservative—only 10% of their patients underwent pneumonectomy. On the other hand, an alarmingly high proportion (19.5%) had exploration only, whereas the commonly reported rate is close to 10%. Although only 39 patients (which is close to 2% and not less than 1%, as mentioned in the abstract) were denied surgical treatment, overall 22% of the patients with malignant tumors had no resection. I suspect that more than half of these patients were rejected on the basis of physiologic considerations and not because of unresectability.

We analyzed our experience at the Sheba Medical Center in Israel since 1978 (when general thoracic surgery was separated from cardiac surgery) with patients with bronchogenic carcinoma only (GoTable I). Thus we excluded a group of almost equal size with benign diseases, metastases, and uncommon neoplasms.


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  		Table I. Type of operation and mortality (in parentheses, morality rate)
 
Since 1985 we have done thoracic computed tomographic scans on all patients undergoing thoracotomy. This may have led to the slight reduction in the exploration rate from 10.3% before 1985 to 8.4% thereafter. Thoracotomy without resection was due in most cases to miliary pulmonary or pleural spread or to unexpected lymphatic spread. In a minority of cases it was due to vital organ involvement. In patients with a compromised pulmonary reserve who otherwise require pneumonectomy, we perform sleeve lobectomy, lobectomy plus segmentectomy, or combined bilobar segmentectomy (usually superior segment lower lobe plus posterior segment upper lobe). In no case was lobectomy denied during the operation because of compromised lung function, and only three patients in whom pneumonectomy alone could emcompass the entire tumor were denied resection.

The overall mortality in the recent 8 years of our experience was 2.6% and was essentially identical for all types of operation. Although this mortality is higher than the extremely low overall mortality reported by Miller, we believe that our less rigorous selection allowed many more patients to benefit from the best therapeutic modality for their tumor.

We dare say that the more precise method of selecting patients practiced by Miller has indeed resulted in lower mortality while denying operationto very few patients, but in reality it failed because a high proportion of patients may have been denied a curative operation.

References

  1. Miller JI. Physiologic evaluation of pulmonary function in the candidate for lung resection. J THORAC CARDIOVASC SURG 1993;105:347-52.[Abstract]




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