J Thorac Cardiovasc Surg 2005;130:1732-1733
© 2005 The American Association for Thoracic Surgery
Reply to the Editor:
Guven Olgac, MD, FETCS
a
,
Cemal Asim Kutlu, MD, FETCS
b
a Department of Thoracic Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center
b Department of Thoracic Surgery, Sureyyapasa Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey
We thank Dr Pramesh and his colleagues for their comments on our recently published article.
1
As clearly indicated in their letter, the authors agreed with our conclusion that the low perfusion rate alone is not an indication for lung resection under certain circumstances. However, they were also concerned about the approach we used for decortication and raised another issue, which has entirely different conceptual and technical aspects.
We have been using video-assisted thoracoscopic surgery (VATS) decortication for stage 3 postpneumonic empyemas and reported our technique recently.
2
The response of the pleura is very much similar, regardless of the underlying cause (tuberculosis or nonspecific infection), in the third stage of the empyema. Calcified pleural plaques might also occur in some cases during the long and chronic course of tuberculous empyemas. Other treatment options, like deloculation and use of fibrinolytic agents, are only effective in the fibrinopurulent phase (stage 2) of the disease, and therefore their usefulness to decrease hospital stay are out of consideration for such cases that were reported in our article.
It is certain that the increased and ongoing experience with VATS will replace most of the conventional techniques and will allow us to perform more sophisticated procedures in the near future. Although Pramesh and colleagues did not mention whether they have had any experience using VATS in such cases, we think the procedure is not as easy as they stated in their letter. Because of extreme narrowing of the intercostal spaces and thickened parietal peel, introducing the thoracoports and manipulating the endoscopic instruments through these ports might be very difficult. In addition, one might have to remove a rib to enter the chest in some cases, and this could also be troublesome if conversion to an open thoracotomy as a result of severe bleeding emerges. With the gained experience over the years, we almost always know that complete expansion of the lung cannot be achieved after decortication in such cases. Thus assessment of and judgment as to whether an optimal peeling has been gained without causing undue excessive air leak is difficult via thoracoscope and consequently requires extreme experience.
Therefore we would have agreed with the authors' statement that VATS might be preferred over open thoracotomy for stage 3 tuberculous empyemas only if there was enough evidence supporting this proposal.
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References
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- Olgac G, Yilmaz MA, Ortakoylu MG, Kutlu CA. Decision-making for lung resection in patients with empyema and collapsed lung due to tuberculosis. J Thorac Cardiovasc Surg 2005;130:131-135.[Abstract/Free Full Text]
- Olgac G, Fazlioglu M, Kutlu CA. VATS decortication in patients with stage 3 empyema. Thorac Cardiovasc Surg. 2005;53:318-20..
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