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J Thorac Cardiovasc Surg 2003;126:608-609
© 2003 The American Association for Thoracic Surgery
Letter to the editor |
a Department of Surgical, Anaesthesiological, and Radiological Sciences, University of Ferrara, Ferrara, Italy
To the Editor:
In response to the article by Saito and colleagues,1 "Indication for Preoperative Localization of Small Peripheral Pulmonary Nodules in Thoracoscopic Surgery," we would like to express our opinion about indications for preoperative localization techniques during thoracoscopic operations. First, we congratulate our colleagues on the results obtained in their study. The localization of small pulmonary nodules still remains an unsolved problem and an open question in thoracoscopic surgery.
We know that localization techniques are necessary for small nonperipheral pulmonary nodules, and in 1999 nodules with smaller dimensions and greater depths from the pleural surface were established as least susceptible to accurate evaluation by computed tomographic scan and thus most likely to require other localization techniques to avoid conversion from thoracoscopy to thoracotomy.2 We believe, however, that preoperative localization techniques have some negative aspects. First, the use of a needle wire can provoke pneumothorax and lung hemorrhages or parenchymal damage in a high number of patients.3 We are sure that in most cases these complications are without symptoms, but they can influence the operation and the compliance of a patient. Second, according to the international literature,3 the needle wire and other preoperative techniques, such as vital dye or radio-guided imaging, do not have optimal sensitivity. In light of these negative aspects, we prefer intraoperative localization techniques, such as intrathoracoscopic ultrasonography.4-5
For us, ultrasonography is the most effective method to localize pulmonary nodules without side effects. It is useful not only for the localization of the nodules, providing 100% localization in our small but we think meaningful record of cases (13 cases) and in another case series (18 cases),4 but also for the study of near structures surrounding the nodule, such as vessels, bronchi, and lymph nodes. It may also, because of different ultrasound patterns, provide some marginal information about the histologic character of a nodule. In experienced hands the technique is low risk and does not involve an excessive loss of time (12 minutes in our case series). The second positive aspect of ultrasonography is the possibility of an intraoperative scan of lung to detect nodules not visible on thoracic computed tomography. In fact, we know that in some cases computed tomographic scan can mistake the real dimension of pulmonary nodule. With ultrasonography, it is not necessary to use mathematic formulas to determine which nodules must be localized because it is not necessary to preoperatively limit localization techniques to nodules of a predetermined dimension or depth.
Moreover, ultrasonography is applicable for patients with more than one nodule, whereas is difficult to position two or three needles. We also are concerned about the possibility that the needle wire during the pulmonary exclusion and the positioning of the patient may become dislodged. Finally, we think that intrathoracoscopic ultrasonography is better than the other intrathoracoscopic techniques, such as finger palpation and indirect palpation, because it provides objective data, whereas direct or indirect palpation provides only subjective data.
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