Operative Closure of Patent Ductus

CORRESPONDENCE

Pancoast‘s Tumor To the Editor: I wish to comment on the article entitled ”Pancoast’s Tumor” by Dr. Robert R. Shaw that appeared in the Classics in Thoracic Surgery section in the April, 1984, issue of The Annals [l]. The author states, “Until 1956, surgical attempts to remove a Pancoast tumor had proven futile . . .” and ”Postoperative irradiation proved incapable of eradicating the residual neoplasm.” In 1956, his colleagues and he successfully treated a patient believed to have a nonresectable Pancoast tumor by preoperative irradiation followed by resection. This chronology does not fully reflect the record of the literature. Successful surgical removal of a Pancoast tumor due to bronchogenic carcinoma was performed in 1950 by Dr. James D. MacCallum and myself. The involved roots of the brachial plexus were sacrificed and postoperative irradiation (6,528 rads) was delivered. The case was reported in The Iournal of Thoracic Surgery in 1953 [2] and again in 1956 (31, shortly after the patient had died-of an unrelated cause-almost 6 years after the operation. No residual tumor was found at autopsy. Dr. Shaw cites our 1956 report, but the statements just quoted conflict with the data we published. Up to the publication of our article in 1953, only seven explorations of similar lesions had been reported and in no instance had the tumor been removed. A few weeks after operation, our patient complained of pain in the arm and hand, albeit of a different type from that experienced prior to resection. Radiotherapy up to then had been uniformly unsuccessful, but we thought that since all gross tumor and the overlying bony structures had been removed, there was a chance of eradicating remaining or recurring foci of a highly undifferentiated tumor. In preparation for our second report in 1956, we uncovered three publications (1952 through 1954) dealing with irradiation of Pancoast tumors and reporting varying degrees of shrinkage of the lesion, or symptomatic relief, or both, although no authenticated cure had been obtained. Since in our patient the operation followed by irradiation was successful, we speculated that the combination might be more potent than either method alone, although obviously the point could not be proven. The experience of Dr. Shaw and his associates with preoperative irradiation suggests that their approach represents a further improvement in dealing with this distressing lesion, pending the advent of a cancericidal agent. William M . Chardack, M.D. 547 Golfvim Dr Gulfstream, FL 33444

References 1. Shaw RR: Pancoast’s tumor. Ann Thorac Surg 37:343, 1984 2. Chardack WM, MacCallum JD: Pancoast syndrome due to bronchiogenic carcinoma: successful surgical removal and postoperative irradiation. J Thorac Surg 25:402, 1953 3. Chardack WM, MacCallum JD: Pancoast tumor: five-year survival without recurrence of metastases following radical resection and postoperative irradiation. J Thorac Surg 31:535, 1956

Reply To the Editor: Dr. Chardack is correct in pointing out that the statement, “Until 1956, surgical attempts to remove a Pancoast tumor had 96

proven futile. . .” is in error. This statement in the abstract that led off the article was added by the Editorial Office of The Annals. In the original article on this subject in the Annals of Surgery in 1961 and in the essay that appeared in the April, 1984, issue of The Annals of Thoracic Surgery, I gave credit to Drs. Chardack and MacCallum for having cured a patient with such a tumor by surgical resection carried out in 1950. Based on my own experience and the literature, I find no evidence that irradiation following resection is of proven value in treating a Pancoast tumor. There is growing evidence that presurgical irradiation is capable of ”localizing” the neoplasm, making curative resection possible in one-third of the patients in whom this therapy can be applied.

Robert R. Shaw, M.D. 7403 Villanova Dallas, TX 75225

Operative Closure of Patent Ductus To the Editor: Regarding the article by Kron and colleagues (Ann Thorac Surg 37422, 1984) on a rapid technique for ligaclip ligation of a patent ductus arteriosus (PDA) in the premature infant, we wish to add a note of caution. Using the technique described by the authors, we have performed more than 100 ligations of a PDA in premature infants with no deaths and no major morbidity. After moderate use, however, ligaclip appliers often become somewhat sticky and the clips tend to adhere to the applier when released. If the ductus is clipped and the applier is removed but the clip remains adherent to the side of the applier, the ductus may tear apart with catastrophic hemorrhage. We are aware of one such instance. It is therefore imperative to perform a test application first to ensure that the clip releases properly from the applier prior to actual clip ligation of the PDA. In this way, a potentially lethal complication may be avoided.

James R. Skinner, M.D. Chamnahn Kongtahworn, M . D. Steven I. Phillips, M.D. Robert H . Z e f , M.D. Richard S . Toon, M . D . Cardiac Surgey Associates, P.C. 94418th St Des Moines, IA 50314

Operative Closure of PDA To the Editor: The article by Kron and colleagues entitled “A Simple, Rapid Technique for Operative Closure of Patent Ductus Arteriosus in the Premature Infant” (Ann Thorac Surg 37:422,1984) describes a technique that we have employed for the last 2% years in a comparable patient population. I wish to offer a few words of caution regarding this technique. We have found the specific metal clip recommended by the authors to be inadequate in some instances in which the duct was too large; therefore, we routinely use the Ethicon LC 200 clip. We also have found that in large ducts, it is not safe to perform limited dissection, as this does not ensure that the entire duct is closed. We therefore pass a small, right-angled clamp underneath the duct and raise it gently before inserting