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J Thorac Cardiovasc Surg 2005;129:1202
© 2005 The American Association for Thoracic Surgery

Letters to the Editor

Extrapleural pneumonectomy for malignant mesothelioma: Should pericardium be resected routinely?

Loïc Lang-Lazdunski, MD, PhD, FRCS, Carol Tan, MRCS, Tom Treasure, MD, MS, FRCS

Department of Cardiothoracic Surgery, Guy’s Hospital, London, United Kingdom

To the Editor:

We read with interest the article by Sugarbaker and colleagues1 in the July issue of the Journal. This study reports their extensive experience with the management of complications occurring after extrapleural pneumonectomy (EPP) done mainly for malignant mesothelioma. It is clear from the Sugarbaker article that technical complications might arise from the resection and replacement of the pericardium with a patch, such as size mismatch, improper insertion and suturing, or inadequate fenestration. Three percent of their patients had cardiac arrest, 2.7% had constrictive physiology caused by inflammatory epicarditis, 3.6% had tamponade, and 44.2% had atrial fibrillation.

Although we recognize the importance of Sugarbaker’s work in studying specific complications of EPP and reporting the largest series to date, we would like to emphasize a particular technical point that might prove useful in some patients. Recently, we have been surprised that some patients with stage I or II malignant mesothelioma receiving induction chemotherapy before EPP presented at the operation with a pericardium macroscopically free of disease. In those patients we have taken random biopsy specimens of the pericardium and have preserved them. Histopathology confirmed the absence of pericardial invasion in all patients. In such patients with a macroscopically normal pericardium, we suggest taking frozen sections of the pericardium and preserving them if the frozen sections are negative. Although we do agree that pericardium has to be resected in most patients with malignant pleural mesothelioma, it is likely that with the adoption of induction chemotherapy before EPP2 and refinement of diagnostic techniques, such as positron emission tomography and computed tomography, more patients will be operated on with the possibility of preserving their native pericardium, thereby reducing the incidence of cardiac complications, reducing the operative time, and facilitating the anchorage of the diaphragmatic patch.

We would also like to mention that chylothorax is another potential complication of EPP, with a recent article reporting an 18.7% incidence.2 Although no postoperative chylothorax has been reported in the series by Sugarbaker et al,1 we would like to re-emphasize the importance of prophylactic thoracic duct ligation during right-sided procedures.

References

  1. Sugarbaker DJ, Jaklitsch MT, Bueno R, Richards W, Lukanich J, Mentzer SJ, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg. 2004;128:138-146.[Abstract/Free Full Text]
  2. Weder W, Kestenholz P, Taverna C, Lardinois D, Jerman M, Stahel RA. Neoadjuvant chemotherapy followed by extrapleural pneumonectomy in malignant pleural mesothelioma. J Clin Oncol. 2004;22:3451-3457.[Abstract/Free Full Text]




This Article
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