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Eur J Cardiothorac Surg 2002;21:1128-1129
© 2002 Elsevier Science NL

Letter to the Editor

Reply to Maggi et al.

A.E. Martin-Ucar, J.G. Edwards, A. Rengarajan, S. Muller, D.A. Waller*

Department of Thoracic Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK

Received 20 March 2002; accepted 22 March 2002.

* Corresponding author. Tel.: +44-116-256-3959; fax: +44-116-236-7768
e-mail: debra.grew{at}uhl-tr.nhs.uk

The authors would like to thank Dr Maggi and his associates for their interest in our article recently published in the European Journal of Cardiothoracic Surgery [1].

We agree with some of their comments, especially related to findings during surgery. It is true that the majority of patients with malignant mesothelioma present at an advanced stage of the disease and only a limited proportion are suitable for radical surgery. However, patients present to the thoracic surgeon with symptoms, most frequently dyspnoea due to pleural effusion (100% in our series), and chest pain, probably of multifactorial cause (tumour infiltrating intercostals nerves, inflammatory reaction, effusion).

We believe that surgery has a role in the palliation of symptoms in patients with malignant mesothelioma, and that was the initial intention of our paper. Ideally we believe that this palliation by partially debulking the tumour to obtain pleural apposition should be performed by VATS as is potentially less traumatic than a formal thoracotomy. We were able to achieve pleurodesis by parietal pleurectomy alone by VATS in all patients (17) in whom the lung expanded after pleural drainage. However, what are the alternatives for patients with entrapped lung when during a VATS procedure fail to re-expand the lung even with positive pressure ventilation?

These, as Dr Maggi points out and is corroborated in our article, are the majority of patients (66%), and we agree that visceral decortication through VATS is difficult in these cases (only three out of 34 cases in our series), even in a surgical unit with expertise in thoracoscopic surgery that includes decortication of chronic empyemas as an indication for VATS [2].

In cases in whom limited thoracotomy was required, we agree that the operative side effects causes concerns and should not be routine in the group of patients with the worse prognosis as we pointed out in our series. However, we all are aware that a persistent air leak is nowadays a lesser complication than used to be in the past with the actual use of flutter valve drain systems [3] that allows earlier ambulation and even discharge from hospital with a drain in situ.

References

  1. Martin-Ucar A.E., Edwards J.G., Rengajaran A., Muller S., Waller D.A. Palliative surgical debulking in malignant mesothelioma. Predictors of survival and symptom control. Eur J Cardiothorac Surg 2001;20(6):1117-1121.[Abstract/Free Full Text]
  2. Waller D.A., Rengarajan A. Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema. Ann Thorac Surg 2001;71(6):1813-1816.[Abstract/Free Full Text]
  3. Waller D.A., Edwards J.G., Rajesh P.B. A physiological comparison of flutter valve drainage bags and underwater seal systems for postoperative air leaks. Thorax 1999;54(5):442-443.[Abstract/Free Full Text]




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