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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Efstratios Apostolakis Christos Prokakis Efstratios Koletsis Dimitrios Dougenis Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Apostolakis, E. Articles by Dougenis, D. PubMed Articles by Apostolakis, E. Articles by Dougenis, D. Related Collections Lung - cancer Coronary disease

Letters to the Editor

Median sternotomy for combined coronary artery bypass grafting and lung tumor resection: is it valid or not?

Cardiothoracic Surgery Department, University of Patras, School of Medicine, Aisxylou Street 3, 26442 Patras, Greece

Received 6 February 2009; accepted 11 March 2009.

^_* Corresponding author. Tel.: +30 61452854; fax: +30 61999847. (Email: xristosprokakis{at}gmail.com).

Key Words: Lung resection • Coronary • Lung cancer • Combined surgery • Lymph node dissection • Sternotomy

We have read with interest your manuscript on the combined management of coronary artery disease and lung cancer [1]. However, we need to delineate that your results cast some doubt on the validity of median sternotomy as the approach for the management of these patients. The issue in question is whether this approach is performed at the expense of the radical resection required for the treatment of lung cancer. Access to the lung hilum through median sternotomy is easily carried out in cases of bilateral lung transplantation [2] or surgical treatment of pulmonary emphysema [3]. In cases of malignant disease this approach may compromise the extent of resection, mostly in terms of adequate mediastinal lymph node dissection, lead to a significant burden for the cardiac function and increase the risk of cancer cell's dissemination. Considering the advantages of sternotomy on the postoperative pulmonary function of those patients we are not reluctant to use this approach for the treatment of both heart disease and lung cancer as it is shown by our published experience [4]. Nevertheless we believe that only tumors of the right upper lobe and the corresponding mediastinal lymph node dissection can be safely carried out via median sternotomy. In all other cases the management of these diseases must be performed through a staged approach (PCI or CABG followed by lung resection) or combined approach via T-incision, which includes median sternotomy and anterolateral extension of the incision through the 5th intercostal space. The best sequence in performing the combined management should be that of pulmonary resection followed by the heart procedure unless the last one is intended to be performed off-pump [4]. The combined surgical approach of thoracotomy-sternotomy (T-incision) carries several advantages: first, ideal approach for coronary artery bypass grafting whether the operation is performed on- or off-pump: second, excellent and safe approach for pulmonary resection with better control of the lung hilum and less risk for postoperative bleeding; third, safe and accurate lymph node dissection which is a well-established parameter related to the long-term survival of lung cancer patients [5]; fourth, reduced risk for lung cancer cells’ dissemination since the manipulation of the pulmonary lobe during pulmonary resection is less violent; fifth, less complications related to sternal over-distension (brachial plexus injury, sternal fracture, laryngeal nerve paresis) while attempting to achieve better access for lung resection, and finally avoidance of mechanical stress on the cardiac chambers during the maneuvers for access to the lung hilum with significantly less risks for hemodynamic compromise, arrhythmias and graft injury. Your high rate of local recurrence may depend on the inability to perform radical lymph node dissection. It would be of help for us to know the sites of primary lung tumor in those patients who experience local recurrence of the disease. In addition your 5-year survival of 30%, which is lower than the one reported in the series of isolated lung resection, may be related to both incomplete lymph node dissection and the dissemination of cancer cell during the tumor's manipulation.

References

1. Dyszkiewicz W, Jemielity M, Piwkowski C, Kasprzyk M, Perek B, Gasiorowski L, Kaczmarek E. The early and late results of combined off pump coronary artery bypass grafting and pulmonary resection in patients with concomitant lung cancer and unstable coronary heart disease. Eur J Cardiothorac Surg 2008;34:531-535.[Abstract/Free Full Text]
2. Sheikh A, Pelletier M, Robbins R. Heart-lung and lung transplantation. In: Cohn L, editor. Cardiac surgery in the adult. 3rd ed.. MacGraw Hill; 2008. pp. 1579-1608.
3. Klepetko W. Surgical aspects and techniques of lung volume reduction surgery for severe emphysema. Eur Respir J 1999;13:919-925.[Abstract]
4. Prokakis Ch, Koletsis E, Apostolakis E, Panagopoulos N, Charoulis N, Velissaris D, Filos K, Dougenis D. Combined heart surgery and lung tumor resection. Med Sci Monit 2008;14:CS17-CS21.[Medline]
5. Miller DL, Orszulak TA, Pairolero PC, Trastek VF, Schaff HV. Combined operation for cancer and cardiac disease. Ann Thorac Surg 1994;58:989-993.[Abstract]

This article has been cited by other articles:

				W. Dyszkiewicz and C. Piwkowski Reply to Apostolakis et al. Median sternotomy for combined coronary artery bypass grafting and lung tumor resection: is it valid or not? Eur. J. Cardiothorac. Surg., June 1, 2009; 35(6): 1117 - 1118. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Efstratios Apostolakis Christos Prokakis Efstratios Koletsis Dimitrios Dougenis Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Apostolakis, E. Articles by Dougenis, D. PubMed Articles by Apostolakis, E. Articles by Dougenis, D. Related Collections Lung - cancer Coronary disease