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J Thorac Cardiovasc Surg 2005;129:1202-1203
© 2005 The American Association for Thoracic Surgery

Letters to the Editor

Reply to the Editor

Lambros Zellos, MD, David J. Sugarbaker, MD

Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA 02115-6195

The primary goal of extrapleural pneumonectomy in mesothelioma is to perform a complete macroscopic cytoreduction. Routine pericardiectomy is an important step in achieving this goal. The issue of pericardial resection and reconstruction from the morbidity standpoint is a higher atrial fibrillation rate, the risk of cardiac herniation from a poorly constructed patch, tamponade from a tight patch, and epicarditis.

Our high rate of atrial fibrillation compared with that seen in other reports that use similar resection of the pericardium stems from our policy of monitoring all patients with telemetry until discharge from the hospital. Opening the pericardium is only one of the multiple causes of atrial fibrillation. Entry into the pericardium with multiple random biopsies would also result in a higher atrial fibrillation rate or at least not a significant decrease in those rates.

Cardiac herniation or tamponade from a poorly done pericardial reconstruction would be avoided by not resecting the pericardium. These are not common events, however, and were more prevalent during our earlier experience. However, from an oncologic perspective, it would not be prudent to risk a good cytoreduction, even in the setting of a few negative random biopsy specimens. It is this group of patients with early disease that would benefit the most from the most aggressive surgical intervention.

The operative time it takes to reconstruct the pericardium is not significant, and the diaphragmatic reconstruction is not facilitated in our experience by leaving the pericardium in.

Finally, we agree that personal experience with chylothorax should guide each surgeon as to whether prophylactic thoracic duct ligation should be used routinely.





This Article
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Lambros Zellos
David J. Sugarbaker
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Right arrow Articles by Zellos, L.
Right arrow Articles by Sugarbaker, D. J.
Related Collections
Right arrow Lung - cancer
Right arrow Pleura
Right arrow Chest wall
Right arrow Diaphragm

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