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Eur J Cardiothorac Surg 2005;28:360-361
© 2005 Elsevier Science NL
Letter to the Editor |
Department of Cardiac Surgery, Royal Hospital for Sick Children, Dalnair Street, Glasgow G3 8SJ, UK
Received 30 March 2005; accepted 28 April 2005.
* Tel.: +44 141 201 0269. (Email: sgunpat{at}hotmail.com).
Key Words: Congenital Cystic adenomatoid malformation • Lobectomy
The article on congenital cystic adenomatoid malformation (CCAM) [1], fails to provide new insights into surgical strategy or surgical timing in CCAM.
(a) The authors contend that macrocystic lesions (based on the Adzick classification), enlarge and require surgical excision, while microcystic lesions resolve and can be simply followed-up. This is an erroneous statement. In actual fact, microcystic lesions have a poor prognosis, and are associated with mass effects requiring prenatal intervention!
(b) The authors state that an exact Stocker's type can be assigned at 18–20 weeks of gestation. An exact Stocker's classification can only be confirmed on the histopathological examination of a resected specimen! Perhaps the authors would care to comment, on how this determination is made antenatally?
Currently, there is no controversy as to the surgical indication for CCAM. The only question is of timing, which the authors attempt to address but fail to answer.
Appropriate surgical timing is determined by the prenatal behaviour of CCAM, the development of mass effects, and postnatal presentation. Given the variable natural history, it is the clinical presentation and not the mere antenatal diagnosis that dictates surgical timing.
What was the incidence of air leaks in the lobectomy or segmentectomy groups? This is important because seven patients had segmental resections.
Immaterial of the mode of presentation, immediate postoperative outcomes are good following CCAM surgery, at all age in most series [2]. This is established fact. The risk factors for poor outcome include bilateral and multilobar CCAM, and the presence of pulmonary hypoplasia, which the authors have not alluded to.
The expectation of respiratory distress during subsequent follow-up was one of the authors' indications for emergency surgery. Does this constitute a true indication for an emergency procedure? The inclusion of this category under ‘emergency‘ procedures confounds the statistical analysis.
Barring a mention of normal physical activity in survivors, there is no mention of symptoms, lung function tests, or details pertaining to late outcomes. Yet the authors conclude that long-term outcomes were good.
The management strategy for prenatally diagnosed lesions is not based on hard science.
Many patients will have antenatally diagnosed CCAM in future. Why would all patients require Intensive care, especially if they are asymptomatic and clinically stable? Transfer to a neonatal unit is dictated by clinical symptoms in conjunction with the antenatal findings—not solely on the basis of an antenatal diagnosis.
The recommendation for emergency surgery in respiratory distress is obvious and not new.
I wonder how many patients with large lesions and mediastinal shift would be asymptomatic, which is the author's indication for an urgent operation?
How did the authors arrive at the 2–3 months time frame to operate on these patients? While they established that neonatal surgery is safe, there is no basis to operating on these children at the age of 2–3 months, from an analysis of their data, which does not lend credence to this conclusion.
Unfortunately, the authors have not answered the question that they set out to answer.
References
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