- Email: [email protected]
About the surgical treatment of pulmonary mycetoma
260
CORRESPONDENCE
dium and epicardium involved by tumor, attempts to repair the defect were unsuccessful and the patient exsanguinated in the operating room. The “effusions” referred to by Ohri and associates may not be truly so, although the blood associated with angiosarcomas may be clinically and grossly confused with effusions. Rosai [2] describes angiosarcomas in numerous body sites as “grossly . . . highly hemorrhagic.” The large amounts of blood (and it is frank blood, and not just a transudate or exudate with blood staining) associated with many of these lesions in other organs and tissues would not be described as “effusions,” nor should they properly be so when the pericardium is involved by such neoplasms. The association of large amounts of blood with these angiosarcomas may make them clinically confused with effusions (which are much more common), but after pathologic examination the correct assignation should be made. A gross photograph from the autopsy of our patient (Fig 1) emphasizes this point. The 4 or 5 cm of what appears to be simply loculated blood filling the pericardial cavity, and which might be described as ”effusion” by echocardiography, is, in fact, all hemorrhagic tumor. Perhaps the same comments could apply to the case of Ohri and associates, whose patient is described as having normal intracardiac anatomy with tumor obliterating the pericardial cavity, compressing the right heart, and apparently growing from outside into ventricle and atrium. No rupture of large vascular structures would be necessary to explain the presence of the large amounts of blood, a feature integral to the diagnosis of many angiosarcomas. The hemorrhage associated with pericardial angiosarcomas may be diffuse or localized over only parts of the pericardial space, and is often sufficient to allow successful pericardiocentesis of it. Demonstration of this phenomenon can be found in other references, for instance the article by Herrmann and colleagues [3], which illustrates that even intracavitary angiosarcomas may eventually grow into pericardium and be complicated by hemopericardium mixed with tumor, the pericardial hemorrhage without rupture as its basis.
Ann Thorac Surg 1994;5725&64
For these reasons, in cases like those of Ohri and associates, there may be no need to invoke preoperative ”cardiac rupture” to explain the blood in the patient’s pericardial cavity. Instead, it may be that the defect in right atrium of their patient arose at the time of operation. Opening the pericardium and trying to take down these tumoral adhesions, particularly when the tumor invades thin-walled structures such as the right atrium and superior vena cava, may be fraught with great technical difficulties, and ultimately with patient death as illustrated in our case. Many of these same comments might apply to 2 of the cases from the literature compiled by Ohri and associates [4, 51. In them no preautopsy or preoperative substantiation for “rupture” is given. Parenthetically, it should be said that the autopsy separation of the heart may be complicated by right atrial tears in just the same way, and for just the same reasons, as it occurs at operation. Resultant defects, whether at operation or autopsy, should not be overdiagnosed and need not necessarily be invoked to explain cases of tumor-associated hemopericardium. Two other cases discussed by Ohri and associates [6, 71 are distinct, with flow of blood from right atrium to the pericardial cavity clearly demonstrated by echocardiography, color Doppler echocardiography, or contrast echocardiography.
Virginia M . Walley, M D Roy G. Masters, M D Anatomical Pathology, Department of Laboratory Medicine and Cardiac Surgery, Department of Surgery University of Ottawa Heart Institute Ottawa Civic Hospital 1053 Carling Ave Ottawa, Ont, KlY 4E9 Canada References 1. Ohri SK, Nihoyannopoulos P, Taylor KM, Keogh BE. Angiosarcoma of the heart causing cardiac rupture: a rare cause of hemopericardium. Ann Thorac Surg 1993;55:5258. 2. Rosai J. Soft tissue. In: Ackerman‘s surgical pathology. Toronto: Mosby, 1989:1586. 3. Herrmann MA, Shankerman RA, Edwards WD, Shub C, Schaff HV. Primary cardiac angiosarcoma: a clinicopathologic study of six cases. J Thorac Cardiovasc Surg 1992;103:65W. 4. Lob0 AJ, Butland RJ, Stewart S, Shneerson JM. Primary cardiac angiosarcoma causing rupture of the heart and spontaneous bilateral pneumothorax. Thorax 1989;44:78-9. 5. Lantz DA, Dougherty TH, Lucca MJ. Primary angiosarcoma of the heart causing cardiac rupture. Am Heart J 1989;118:186-8. 6. Lutas EM, Stelzer P. Echocardiographic demonstration of right atrial rupture in a patient with right-sided cardiac tumor. Chest 1983;83:921-2. 7. Satou Y, Nakagawa Y, Miki H, Suzuki H, Takahashi M. Cardiac angiosarcoma with ruptured right atrium diagnosed by echocardiography. Chest 1991;100:274-5.
About the Surgical Treatment of Pulmonary Mycetoma To the Editor:
Fig 1. This gross photograph is of the left and right ventricles with the apex of the heart removed at autopsy, and is an equivalent of an echocardiogram short-axis view of the heart. Marked expansion of the pericardial space is seen. Although the material in the pericardial space bears a resemblance to loculated sanguineous effusion or hematoma, it is, in fact, all angiosarcoma with large amounts of associated blood.
We read with much interest the article by Massard and associates [l] concerning the results of surgical treatment of pleuropulmonary aspergllloma. Between January 1979 and December 1991,77 patients with parenchymal mycetomas have been resected in our division, located in a former sanatorium in northern Italy. Clinical features, type of operation, and results are summarized in Tables 1 and 2. We agree with Massard and co-workers that asymptomatic patients should be subjected to operation to avoid catastrophic
CORRESPONDENCE
Ann Thorac Surg 1994:5725W
Table 1. Clinical Features of Patients Undergoing Operation for Pulmonary Mycetoma (January 1979-December 1991) Variable Observed Resected Major symptoms Hemoptysis Massive hemoptysis Chronic cough Dyspnea Asymptomatic Underlying diseases Tuberculosis Bronchiectasis Bullous emphysema Abscess Silicosis Lung cancer (excavated) None (primary)
No. of Patients 104 77
Percentage 74
91 9 89 48 12
87.5 8.6 85.6 46.1 11.5
55 18 11 7 6 2 4
52.9 17.3 10.6 6.7
5.8 1.9 3.8
complications. In addition, whenever possible, resections wider than lobectomies should be avoided because the postoperative course can be difficult for these often very debilitated patients. We would like to emphasize three points of major concern in scheduling operation for mycetoma:
Table 2. Type of Operation and Results of Surgical Treatment of Pulmonary Mycetoma in 77 Patients (January 1979-December 1991) Variable Treatment Conservative Surgical Segmental resection” Lobectomy” Bilobectomy” Pneumonectomy” Other Results of operation Healing Complications Postoperative morbidity Air space problems Recurrent tuberculosis Bronchopleural fistula Late morbidity Air space problems Deaths Postoperative mortality Massive hemoptysis Respiratory failure Late mortality Empyema a
Often via an extrapleural approach.
(1) Preoperative diagnosis should be aimed at evaluating the anatornosurgical features of pulmonary involvement of Aspergillus. Essential to correct surgical treatment is the fundamental distinction between simple (ie, cavitation with thin walls and minimal associated pleuroparenchymal sequelae) and complex mycetomas (ie, connected to the thoracic wall through thick and extremely vascularized pleural adhesions). If correctly interpreted, these features may guide the surgeon to predict the potential for postoperative complications, such as bleeding and pleural space problems with subsequent evolution to empyema and bronchopleural fistula. Diagnosis is made by conventional radiologic and endoscopic procedures: chest computed tomography and selective bronchography may at times be added to determine the actual extension of the pathologic involvement. Even in asymptomatic patients, a thorough evaluation of the anatornosurgical situation is mandatory in the event of a possible emergency treatment and to provide a reference stage in the evolution of the disease. (2) A careful evaluation of the costhenefit ratio must be made when a surgical option is contemplated. This is especially true for those patients presenting with mycetoma and recurrent episodes of hemoptysis. Functional and nutritional status must be weighed against the anticipated extension of the resection, keeping in mind that hemoptysis can turn into a fatal hemorrhage in up to 30% of patients with pulmonary mycetoma [2]. Based on these considerations, we share the aggressive approach toward patients with pulmonary mycetomas independent of their symptoms. (3) A conservative surgical approach is preferable based on the observation that mycetomas often develop in heavily compromised lungs. Major intraoperative and early postoperative bleeding (up to a total of 2,000 mL) is the rule when the lungs are manipulated for the removal of complex mycetomas. Furthermore, the chance of development of disseminated intravascular coagulation in the early postoperative period should not be underestimated. In addition, care should be taken in not causing disruption of the cavitation while attempting pneumolysis. In fact, Aspergillus empyema represented the only cause of late mortality in our series. Accordingly, a liberal use of additional procedures for the obliteration of the pleural cavity is recommended. Further investigations are needed to define the possible role of “adjuvant” medical treatments (itraconazole)in reducing the risk of postoperative Aspergillus empyema. In conclusion, Dr Massard and his colleagues should be commended for their effort in recalling the attention of thoracic surgeons to this increasingly challenging surgical disease.
No. of Patients
Percentage
27 77 30 35 2 8 2
26 74 39 45.4 2.6 10.4 2.6
57 15 7 2 2 3 8 8 5 3 1
74 19.5 9.0
Gaetano Rocco, M D Adriano Rizzi, M D Mario Robustellini, M D Gerolamo Rossi, M D Claudio Della Pona, M D Fabio Massera, M D
10.5
Division of Thoracic Surgery ” E . Morelli“ Regional Hospital Via Zubiani, 33 23039 Sondalo, Italy
6.5
261
2
References
2 2
1. Massard G , Roeslin N, Wihlm JM, Dumont P, Witz JP, Morand G . Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment. Ann Thorac Surg 1992;54: 1159-64.
262
CORRESPONDENCE
2. Garvey J, Crastnopol P, Weisz D, Khan F. The surgical treatment of pulmonary aspergillomas. J Thorac Cardiovasc Surg 1977;74:542-7.
Reply
To the Editor:
We wish to congratulate Dr Rocco and colleagues on their extensive surgical experience with pulmonary aspergilloma, as well as on their excellent postoperative results. Although we totally agree with their comments, we would like to take the opportunity to stress some points of interest, and to focus especially on the contribution of thoracoplasty to the treatment of mycetomas. The prognostic significance of the clinical and radiologic presentation cannot be overemphasized. The “simple mycetoma” (cavitation of limited volume with thin walls in a normal lung) [ l ] occurs in otherwise healthy patients, with a normal respiratory function, and may be addressed to with a conventional lobectomy or segmentectomy without major surgical risk. Nevertheless, even in these favorable cases, the dissection of the pedicle may be hazardous, and we recommend routine taping of the main pulmonary artery to control quickly any arterial injury. We speculate that the majority of Dr Rocco’s patients presented with this type of lesion, as 65 of 77 patients (84%) treated with surgical means were amenable to segmentectomy or lobectomy. This would explain the lower overall mortality (6.5% versus 9.5% in our experience). Comparatively, if we refer to the patients we treated with lobectomy or segmentectomy, the mortality was 5.8% [2]. The lower incidence of pleural space problems (7.4% versus 47%) may be interpreted to suggest that the underlying lungs were less diseased and less fibrosed, and were thus able to reexpand more easily. In contrast, the “complex mycetoma” (cavitation with thick walls in a sequellary lung) [ l ] occurs in symptomatic patients, who usually have a long history of pulmonary disease and have impaired functional values. It is specifically this group of patients who represent the real problem. One cannot afford to decide for a no-treatment option, because the symptoms seriously disable the patient, and because there is a major risk for catastrophic spontaneous complications. Whenever both the extent of the disease and the respiratory function studies allow the surgeon to plan for lobectomy, the surgeon will have to face a challenging procedure. Major bleeding is to be expected from adhesions to the chest wall vascularized by the intercostal vessels as well as during dissection of the pedicle. Furthermore, with large lesions, the major risk is being constrained to decide on a pneumonectomy intraoperatively-either because of the extent of the disease, or because of an injury to the pulmonary artery. However, pneumonectomy is the type of operation that should be avoided as far as possible. First, many patients will have an obvious functional contraindication. Second, in our experience with aspergillomas, pneumonectomy has regularly led to major complications. Among 6 attempts at pleuropneumonectomy, 1 patient died intraoperatively with a laceration of the pulmonary artery. All 5 survivors bled extensively, and empyema thoracis developed postoperatively in 4 of 5 [2]. Although an attempt at resection should be avoided in these difficult cases, we believe that conservative management with intracavitary injections or even speleotomy and removal of the fungus ball is not satisfactory, and is acceptable only for very debilitated patients. All these conservative treatments do not remove the cavitation, and relapse of the Aspergillus infection is likely as long as the cavitation persists. It is in this setting that we
Ann Thorac Surg 1994;5725664
recommend thoracoplasty. This procedure achieves (1)removal of the fungus ball and (2) obliteration of the cavitation without removing functional lung tissue. The number of ribs to be resected is planned on a standard posteroanterior chest view, the lowest rib to be resected being tangential to the inferior border of the cavity. We routinely resect the first rib to assure a total collapse of the apex, with a complete release of the superior sulcus. The anterior part of the lowermost rib may be left in situ. Next the cavity is entered through a pneumonotomy and the fungus ball is removed; a 16F catheter is inserted into the cavity for postoperative irrigations with amphotericin. The extrapleural space is drained with two 24F chest tubes connected to strong suction. However, we have to admit that thoracoplasty carries a considerable mortality and morbidity, which is the price to pay for a definite cure [2]. This same treatment has been effective for management of aspergillus empyema. Fifteen patients were operated on with thoracoplasty between 1976 and 1991 (14 first choice, 1 after a failed decortication). There was one postoperative death. One patient has been lost to follow-up. The remaining 13 were all considered to be cured on clinical, radiologic, and serologic examinations, with follow-up ranging from 1 to 15 years. Muscle plombage might be an alternative to thoracoplasty. We have no extensive experience with intrathoracic muscle transfers. Muscle plombage in any case requires uninjured chest wall muscles and was not feasable in our cases before 1990, when we started to use muscle-sparing incisions routinely. However, as the muscles of the chest wall are actively implicated in the motility of the shoulder girdle, the question arises whether the functional sequelae of a muscle transfer procedure are less than those of a thoracoplasty. The answer to this question requires further expertise. Again, we wish to compliment Dr Rocco and colleagues on their impressive experience.
Gilbert Massard, M D Norbert Roeslin, M D Jean-Marie Wihlm, M D Pascal Dumont, M D Georges Morand, M D Department of Thoracic Surgery H6pitaux Uniuersitaires de Strasbourg F-67091 Strasbourg, France
References 1. Daly RC, Pairolero PC, Piehler JM, Trastek VF, Payne WS, Bernatz PE. Pulmonary aspergilloma. Results of surgical treatment. J Thorac Cardiovasc Surg 1986;92:981-8. 2. Massard G, Roeslin N, Wihlm JM, Dumont P, Witz JP, Morand G. Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment. Ann Thorac Surg 1992;54: 1159-64.
Autotransfusion in Routine Cardiac Operations To the Editor: We were delighted to see the article by Ward and associates [l]in the July issue of The Annals of Thoracic Surgery. Their study notes, as have others, that autotransfusion of unprocessed mediastinal shed blood after cardiac operations does not benefit the patient. We have been convinced of this for several years based on a study that we did in the 1980s [2]. We thought this was a message that was valid but one that surgeons were not quite ready to hear as most were caught up in a proselytic wave of enthusiasm for autotransfusion of unprocessed blood. As Dr Goodnough points
CORRESPONDENCE
dium and epicardium involved by tumor, attempts to repair the defect were unsuccessful and the patient exsanguinated in the operating room. The “effusions” referred to by Ohri and associates may not be truly so, although the blood associated with angiosarcomas may be clinically and grossly confused with effusions. Rosai [2] describes angiosarcomas in numerous body sites as “grossly . . . highly hemorrhagic.” The large amounts of blood (and it is frank blood, and not just a transudate or exudate with blood staining) associated with many of these lesions in other organs and tissues would not be described as “effusions,” nor should they properly be so when the pericardium is involved by such neoplasms. The association of large amounts of blood with these angiosarcomas may make them clinically confused with effusions (which are much more common), but after pathologic examination the correct assignation should be made. A gross photograph from the autopsy of our patient (Fig 1) emphasizes this point. The 4 or 5 cm of what appears to be simply loculated blood filling the pericardial cavity, and which might be described as ”effusion” by echocardiography, is, in fact, all hemorrhagic tumor. Perhaps the same comments could apply to the case of Ohri and associates, whose patient is described as having normal intracardiac anatomy with tumor obliterating the pericardial cavity, compressing the right heart, and apparently growing from outside into ventricle and atrium. No rupture of large vascular structures would be necessary to explain the presence of the large amounts of blood, a feature integral to the diagnosis of many angiosarcomas. The hemorrhage associated with pericardial angiosarcomas may be diffuse or localized over only parts of the pericardial space, and is often sufficient to allow successful pericardiocentesis of it. Demonstration of this phenomenon can be found in other references, for instance the article by Herrmann and colleagues [3], which illustrates that even intracavitary angiosarcomas may eventually grow into pericardium and be complicated by hemopericardium mixed with tumor, the pericardial hemorrhage without rupture as its basis.
Ann Thorac Surg 1994;5725&64
For these reasons, in cases like those of Ohri and associates, there may be no need to invoke preoperative ”cardiac rupture” to explain the blood in the patient’s pericardial cavity. Instead, it may be that the defect in right atrium of their patient arose at the time of operation. Opening the pericardium and trying to take down these tumoral adhesions, particularly when the tumor invades thin-walled structures such as the right atrium and superior vena cava, may be fraught with great technical difficulties, and ultimately with patient death as illustrated in our case. Many of these same comments might apply to 2 of the cases from the literature compiled by Ohri and associates [4, 51. In them no preautopsy or preoperative substantiation for “rupture” is given. Parenthetically, it should be said that the autopsy separation of the heart may be complicated by right atrial tears in just the same way, and for just the same reasons, as it occurs at operation. Resultant defects, whether at operation or autopsy, should not be overdiagnosed and need not necessarily be invoked to explain cases of tumor-associated hemopericardium. Two other cases discussed by Ohri and associates [6, 71 are distinct, with flow of blood from right atrium to the pericardial cavity clearly demonstrated by echocardiography, color Doppler echocardiography, or contrast echocardiography.
Virginia M . Walley, M D Roy G. Masters, M D Anatomical Pathology, Department of Laboratory Medicine and Cardiac Surgery, Department of Surgery University of Ottawa Heart Institute Ottawa Civic Hospital 1053 Carling Ave Ottawa, Ont, KlY 4E9 Canada References 1. Ohri SK, Nihoyannopoulos P, Taylor KM, Keogh BE. Angiosarcoma of the heart causing cardiac rupture: a rare cause of hemopericardium. Ann Thorac Surg 1993;55:5258. 2. Rosai J. Soft tissue. In: Ackerman‘s surgical pathology. Toronto: Mosby, 1989:1586. 3. Herrmann MA, Shankerman RA, Edwards WD, Shub C, Schaff HV. Primary cardiac angiosarcoma: a clinicopathologic study of six cases. J Thorac Cardiovasc Surg 1992;103:65W. 4. Lob0 AJ, Butland RJ, Stewart S, Shneerson JM. Primary cardiac angiosarcoma causing rupture of the heart and spontaneous bilateral pneumothorax. Thorax 1989;44:78-9. 5. Lantz DA, Dougherty TH, Lucca MJ. Primary angiosarcoma of the heart causing cardiac rupture. Am Heart J 1989;118:186-8. 6. Lutas EM, Stelzer P. Echocardiographic demonstration of right atrial rupture in a patient with right-sided cardiac tumor. Chest 1983;83:921-2. 7. Satou Y, Nakagawa Y, Miki H, Suzuki H, Takahashi M. Cardiac angiosarcoma with ruptured right atrium diagnosed by echocardiography. Chest 1991;100:274-5.
About the Surgical Treatment of Pulmonary Mycetoma To the Editor:
Fig 1. This gross photograph is of the left and right ventricles with the apex of the heart removed at autopsy, and is an equivalent of an echocardiogram short-axis view of the heart. Marked expansion of the pericardial space is seen. Although the material in the pericardial space bears a resemblance to loculated sanguineous effusion or hematoma, it is, in fact, all angiosarcoma with large amounts of associated blood.
We read with much interest the article by Massard and associates [l] concerning the results of surgical treatment of pleuropulmonary aspergllloma. Between January 1979 and December 1991,77 patients with parenchymal mycetomas have been resected in our division, located in a former sanatorium in northern Italy. Clinical features, type of operation, and results are summarized in Tables 1 and 2. We agree with Massard and co-workers that asymptomatic patients should be subjected to operation to avoid catastrophic
CORRESPONDENCE
Ann Thorac Surg 1994:5725W
Table 1. Clinical Features of Patients Undergoing Operation for Pulmonary Mycetoma (January 1979-December 1991) Variable Observed Resected Major symptoms Hemoptysis Massive hemoptysis Chronic cough Dyspnea Asymptomatic Underlying diseases Tuberculosis Bronchiectasis Bullous emphysema Abscess Silicosis Lung cancer (excavated) None (primary)
No. of Patients 104 77
Percentage 74
91 9 89 48 12
87.5 8.6 85.6 46.1 11.5
55 18 11 7 6 2 4
52.9 17.3 10.6 6.7
5.8 1.9 3.8
complications. In addition, whenever possible, resections wider than lobectomies should be avoided because the postoperative course can be difficult for these often very debilitated patients. We would like to emphasize three points of major concern in scheduling operation for mycetoma:
Table 2. Type of Operation and Results of Surgical Treatment of Pulmonary Mycetoma in 77 Patients (January 1979-December 1991) Variable Treatment Conservative Surgical Segmental resection” Lobectomy” Bilobectomy” Pneumonectomy” Other Results of operation Healing Complications Postoperative morbidity Air space problems Recurrent tuberculosis Bronchopleural fistula Late morbidity Air space problems Deaths Postoperative mortality Massive hemoptysis Respiratory failure Late mortality Empyema a
Often via an extrapleural approach.
(1) Preoperative diagnosis should be aimed at evaluating the anatornosurgical features of pulmonary involvement of Aspergillus. Essential to correct surgical treatment is the fundamental distinction between simple (ie, cavitation with thin walls and minimal associated pleuroparenchymal sequelae) and complex mycetomas (ie, connected to the thoracic wall through thick and extremely vascularized pleural adhesions). If correctly interpreted, these features may guide the surgeon to predict the potential for postoperative complications, such as bleeding and pleural space problems with subsequent evolution to empyema and bronchopleural fistula. Diagnosis is made by conventional radiologic and endoscopic procedures: chest computed tomography and selective bronchography may at times be added to determine the actual extension of the pathologic involvement. Even in asymptomatic patients, a thorough evaluation of the anatornosurgical situation is mandatory in the event of a possible emergency treatment and to provide a reference stage in the evolution of the disease. (2) A careful evaluation of the costhenefit ratio must be made when a surgical option is contemplated. This is especially true for those patients presenting with mycetoma and recurrent episodes of hemoptysis. Functional and nutritional status must be weighed against the anticipated extension of the resection, keeping in mind that hemoptysis can turn into a fatal hemorrhage in up to 30% of patients with pulmonary mycetoma [2]. Based on these considerations, we share the aggressive approach toward patients with pulmonary mycetomas independent of their symptoms. (3) A conservative surgical approach is preferable based on the observation that mycetomas often develop in heavily compromised lungs. Major intraoperative and early postoperative bleeding (up to a total of 2,000 mL) is the rule when the lungs are manipulated for the removal of complex mycetomas. Furthermore, the chance of development of disseminated intravascular coagulation in the early postoperative period should not be underestimated. In addition, care should be taken in not causing disruption of the cavitation while attempting pneumolysis. In fact, Aspergillus empyema represented the only cause of late mortality in our series. Accordingly, a liberal use of additional procedures for the obliteration of the pleural cavity is recommended. Further investigations are needed to define the possible role of “adjuvant” medical treatments (itraconazole)in reducing the risk of postoperative Aspergillus empyema. In conclusion, Dr Massard and his colleagues should be commended for their effort in recalling the attention of thoracic surgeons to this increasingly challenging surgical disease.
No. of Patients
Percentage
27 77 30 35 2 8 2
26 74 39 45.4 2.6 10.4 2.6
57 15 7 2 2 3 8 8 5 3 1
74 19.5 9.0
Gaetano Rocco, M D Adriano Rizzi, M D Mario Robustellini, M D Gerolamo Rossi, M D Claudio Della Pona, M D Fabio Massera, M D
10.5
Division of Thoracic Surgery ” E . Morelli“ Regional Hospital Via Zubiani, 33 23039 Sondalo, Italy
6.5
261
2
References
2 2
1. Massard G , Roeslin N, Wihlm JM, Dumont P, Witz JP, Morand G . Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment. Ann Thorac Surg 1992;54: 1159-64.
262
CORRESPONDENCE
2. Garvey J, Crastnopol P, Weisz D, Khan F. The surgical treatment of pulmonary aspergillomas. J Thorac Cardiovasc Surg 1977;74:542-7.
Reply
To the Editor:
We wish to congratulate Dr Rocco and colleagues on their extensive surgical experience with pulmonary aspergilloma, as well as on their excellent postoperative results. Although we totally agree with their comments, we would like to take the opportunity to stress some points of interest, and to focus especially on the contribution of thoracoplasty to the treatment of mycetomas. The prognostic significance of the clinical and radiologic presentation cannot be overemphasized. The “simple mycetoma” (cavitation of limited volume with thin walls in a normal lung) [ l ] occurs in otherwise healthy patients, with a normal respiratory function, and may be addressed to with a conventional lobectomy or segmentectomy without major surgical risk. Nevertheless, even in these favorable cases, the dissection of the pedicle may be hazardous, and we recommend routine taping of the main pulmonary artery to control quickly any arterial injury. We speculate that the majority of Dr Rocco’s patients presented with this type of lesion, as 65 of 77 patients (84%) treated with surgical means were amenable to segmentectomy or lobectomy. This would explain the lower overall mortality (6.5% versus 9.5% in our experience). Comparatively, if we refer to the patients we treated with lobectomy or segmentectomy, the mortality was 5.8% [2]. The lower incidence of pleural space problems (7.4% versus 47%) may be interpreted to suggest that the underlying lungs were less diseased and less fibrosed, and were thus able to reexpand more easily. In contrast, the “complex mycetoma” (cavitation with thick walls in a sequellary lung) [ l ] occurs in symptomatic patients, who usually have a long history of pulmonary disease and have impaired functional values. It is specifically this group of patients who represent the real problem. One cannot afford to decide for a no-treatment option, because the symptoms seriously disable the patient, and because there is a major risk for catastrophic spontaneous complications. Whenever both the extent of the disease and the respiratory function studies allow the surgeon to plan for lobectomy, the surgeon will have to face a challenging procedure. Major bleeding is to be expected from adhesions to the chest wall vascularized by the intercostal vessels as well as during dissection of the pedicle. Furthermore, with large lesions, the major risk is being constrained to decide on a pneumonectomy intraoperatively-either because of the extent of the disease, or because of an injury to the pulmonary artery. However, pneumonectomy is the type of operation that should be avoided as far as possible. First, many patients will have an obvious functional contraindication. Second, in our experience with aspergillomas, pneumonectomy has regularly led to major complications. Among 6 attempts at pleuropneumonectomy, 1 patient died intraoperatively with a laceration of the pulmonary artery. All 5 survivors bled extensively, and empyema thoracis developed postoperatively in 4 of 5 [2]. Although an attempt at resection should be avoided in these difficult cases, we believe that conservative management with intracavitary injections or even speleotomy and removal of the fungus ball is not satisfactory, and is acceptable only for very debilitated patients. All these conservative treatments do not remove the cavitation, and relapse of the Aspergillus infection is likely as long as the cavitation persists. It is in this setting that we
Ann Thorac Surg 1994;5725664
recommend thoracoplasty. This procedure achieves (1)removal of the fungus ball and (2) obliteration of the cavitation without removing functional lung tissue. The number of ribs to be resected is planned on a standard posteroanterior chest view, the lowest rib to be resected being tangential to the inferior border of the cavity. We routinely resect the first rib to assure a total collapse of the apex, with a complete release of the superior sulcus. The anterior part of the lowermost rib may be left in situ. Next the cavity is entered through a pneumonotomy and the fungus ball is removed; a 16F catheter is inserted into the cavity for postoperative irrigations with amphotericin. The extrapleural space is drained with two 24F chest tubes connected to strong suction. However, we have to admit that thoracoplasty carries a considerable mortality and morbidity, which is the price to pay for a definite cure [2]. This same treatment has been effective for management of aspergillus empyema. Fifteen patients were operated on with thoracoplasty between 1976 and 1991 (14 first choice, 1 after a failed decortication). There was one postoperative death. One patient has been lost to follow-up. The remaining 13 were all considered to be cured on clinical, radiologic, and serologic examinations, with follow-up ranging from 1 to 15 years. Muscle plombage might be an alternative to thoracoplasty. We have no extensive experience with intrathoracic muscle transfers. Muscle plombage in any case requires uninjured chest wall muscles and was not feasable in our cases before 1990, when we started to use muscle-sparing incisions routinely. However, as the muscles of the chest wall are actively implicated in the motility of the shoulder girdle, the question arises whether the functional sequelae of a muscle transfer procedure are less than those of a thoracoplasty. The answer to this question requires further expertise. Again, we wish to compliment Dr Rocco and colleagues on their impressive experience.
Gilbert Massard, M D Norbert Roeslin, M D Jean-Marie Wihlm, M D Pascal Dumont, M D Georges Morand, M D Department of Thoracic Surgery H6pitaux Uniuersitaires de Strasbourg F-67091 Strasbourg, France
References 1. Daly RC, Pairolero PC, Piehler JM, Trastek VF, Payne WS, Bernatz PE. Pulmonary aspergilloma. Results of surgical treatment. J Thorac Cardiovasc Surg 1986;92:981-8. 2. Massard G, Roeslin N, Wihlm JM, Dumont P, Witz JP, Morand G. Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment. Ann Thorac Surg 1992;54: 1159-64.
Autotransfusion in Routine Cardiac Operations To the Editor: We were delighted to see the article by Ward and associates [l]in the July issue of The Annals of Thoracic Surgery. Their study notes, as have others, that autotransfusion of unprocessed mediastinal shed blood after cardiac operations does not benefit the patient. We have been convinced of this for several years based on a study that we did in the 1980s [2]. We thought this was a message that was valid but one that surgeons were not quite ready to hear as most were caught up in a proselytic wave of enthusiasm for autotransfusion of unprocessed blood. As Dr Goodnough points