- Email: [email protected]
Are There Enough General Thoracic Surgeons?
1062
CORRESPONDENCE
bronchopleural fistula. We congratulate them on an original idea and an innovative technique. However, we have three questions from the description and would like to add to the discussion. First, what is the material of the skeleton of the “siliconecovered bronchial occlusion stent”? It appears to be a selfexpandable metallic stent. If so, we are concerned about the durability of the stent. Chae and colleagues did not refer to this point. Disruption of the bronchial wall by metallic stents has been reported [2, 3]. Given the point about the durability of the stent, we would rather have performed a thoracotomy than use a stent device because the middle-aged patient seemed able to tolerate the operation. We consider that the standard treatment for bronchopleural fistulas is a thoracotomy with primary closure and coverage with a vascularized muscle flap of the bronchial leak site. We think that almost all of the reports in their reference list [1] say as much. Stents should be used only in patients for whom a conventional operation is ineffective or where surgical treatment is medically contraindicated. In addition, once a metallic stent is placed, it cannot be removed. Second, Chae and colleagues [1] stated that the transsternal ligation of the left main bronchus is difficult because of the short bronchial stump length and concomitant possible aspiration in the right lung. However, we estimate that a 15-mm length is enough to suture the stump or perform a tracheobronchial plasty [4]. Third, another concern is the length of the left main bronchial stump after pneumonectomy. According to the authors’ Figure 2 [1] of the bronchial occlusion stent, we estimate that the length of the left main bronchial stump was too long. In context, it was described as 15 mm, but the stent body, which was supposed to be placed in the remaining “bronchus pocket,” is more than 2 cm long. Too long a bronchial stump is one cause of fistulas due to poor blood supply. Mitsuhiro Kamiyoshihara, MD, PhD Toshiteru Nagashima, MD Department of General Thoracic Surgery Maebashi Red Cross Hospital 3-21-36 Asahi-Cho Maebashi Gunma 371-0014 Japan e-mail: [email protected]
Ann Thorac Surg 2010;90:1059 – 63
bronchopleural fistula after a left pneumonectomy due to a destroyed lung. They closed the fistula by a silicone-covered, wine-glass, configured occluder stent produced by a local manufacturer (S & G Biotech, Seongnam, Gyunggi-do, Korea). The authors reported the technique as a novel method for managing a postpneumonectomy fistula. We wish to state that the technique has been previously described and published [2]. The team used a covered, distal-release, tracheobronchial stent (Tracheobronxane Silmet [Novetech, La Ciotat Cedex, France]) in a hand-made “hourglass” design in 3 patients. As described in the published report [2], the figures of the technical details and chest roentgenogram after stenting can be seen. We recently developed a further step in which a piece of polyglactin 910 (Vicryl) mesh (Ethicon Inc, Somerville, NJ) was wrapped around the hourglass stent, providing greater granulation tissue. One year after stent placement, control bronchoscopy revealed closed fistulas with fibrous tissue completely covering the stent with polyglactin 910 (Vicryl) mesh (Ethicon Inc). We agree with Chae and colleagues [1] that patients who are poor surgical candidates might be best treated with a stent placement that functions as a double barrier (described as an hourglass or wine-glass configuration) as a promising option to treat postoperative bronchopleural fistula. Cagatay Tezel, MD Department of Thoracic Surgery Sureyyapasa Chest Diseases and Thoracic Surgery Teaching Hospital Caferaga mah. Gül sok Budak Apt 1/6 Moda, Kadiköy Istanbul, 34710 TR34710 Turkey e-mail: [email protected]
References 1. Chae EY, Shin JH, Song HY, Kim JH, Shim TS, Kim DK. Bronchopleural fistula treated with a silicone-covered bronchial occlusion stent. Ann Thorac Surg 2010;89:293– 6. 2. Kutlu CA, Patlakoglu S, Tasci AE, Kapicibasi O. A novel technique for bronchopleural fistula closure: an hourglassshaped stent. J Thorac Cardivasc Surg 2009;137:e46 –7.
References
MISCELLANEOUS
1. Chae EY, Shin JH, Song HY, Kim JH, Shim TS, Kim DK. Bronchopleural fistula treated with a silicone-covered bronchial occlusion stent. Ann Thorac Surg 2010;89:293– 6. 2. Hind CRK, Donnelly RJ. Expandable metal stents for tracheal obstruction: permanent or temporary? A cautionary tale. Thorax 1992;47:757– 8. 3. Hiramiec JE, Haasler GB. Tracheal wire stent complications in malacia: implication of position and design. Ann Thorac Surg 1997;63:209 –12. 4. Suzuki T, Suzuki S, Kamio Y, Hori G. Closure with bronchial wall flap and omental pedicle of defect caused by dehiscence of tracheal suture line after extended right upper sleeve lobectomy. J Thorac Cardiovasc Surg 1996;112:1116 –7.
1-Year Follow-Up With an Hourglass-Shaped Stent To the Editor: We read with great interest the case reported by Chae and colleagues [1]. The authors presented a successfully managed © 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Are There Enough General Thoracic Surgeons? To the Editor: I enjoyed the article by Schipper and colleagues [1]. I was surprised by the high percentage of general thoracic cases performed by general surgeons. In a recent presentation at the Western Thoracic Surgical Association [2], we noted our general thoracic surgical population included a high percentage of patients who were turned down for surgical intervention with resectable lung cancer. Could this situation be partially explained by the fact that increasing numbers of patients are being seen by general surgeons rather than thoracic surgeons? Second, will this trend become increasingly problematic with fewer thoracic surgery residencies and fewer thoracic surgeons being trained each year? With the current projections it appears that even more general thoracic cases will be performed by general surgeons in the future. 0003-4975/$36.00
Ann Thorac Surg 2010;90:1059 – 63
Cardiothoracic Surgery Wayne State University/DMC 3990 John R, Suite 8805 Detroit, MI 48201 e-mail: [email protected]
References 1. Schipper PH, Diggs BS, Ungerleider RM, Welke KF. The influence of surgeon specialty on outcomes in general thoracic surgery: a national sample 1996 to 2005. Ann Thorac Surg 2009;88:1566 –73. 2. Edelman D, Baciewicz FA. Outcomes in lung cancer patients initially refused operation. Presentation 35th Annual Meeting Western Thoracic Surgical Association, Banff, Alberta, Canada, June 24 –27, 2009.
Reply To the Editor: We thank Dr Baciewicz for his comments [1]. To answer his first question, “Are increasing numbers of thoracic surgery patients being seen by general surgeons?,” we queried the National Inpatient Sample [2]. Using the same definitions as outlined in our article [3] and over the same time span (1996 to 2005), we compared the percentage of surgeons each year meeting each definition (cardiac surgeon, general thoracic surgeon, or general surgeon). In general, 70% of surgeons doing general thoracic cases were general surgeons, 27% were cardiac surgeons, and 3% were general thoracic surgeons. These three percentages had slight variability from year to year but were largely similar across this time period, with no increasing or decreasing trends. We then examined the percentage of cases performed by each of these surgeons. We found that for cardiac surgeons and general surgeons, the yearly total number of lobectomies and decortications was increasing and the yearly total number of pneumonectomies and wedge resections was decreasing. For general thoracic surgeons, there was year-to-year variability in total number of each index case, but no trend increasing or decreasing. The percentage of the yearly total number of each index case performed by each surgeon group varies slightly from year to year but is largely similar, with no increasing or decreasing trend. Our data do not support the statement that increasing numbers of thoracic surgery patients are being seen by general surgeons— or by cardiac surgeons or general thoracic surgeons.
1063
Rather, the division of labor seems to be fairly constant over this time span. Our data do show that general surgeons perform most of all three procedures, although the best outcomes are achieved by cardiac surgeons and general thoracic surgeons. Using out data, we are not able to answer Dr Baciewicz’s second question, “Will this trend become increasingly problematic with fewer thoracic surgery residencies and fewer thoracic surgeons being trained each year?” However, we agree that a projected deficit of cardiothoracic surgeons is an important consideration for our profession, our government, and our society. It is especially important if the surgeons lacking could be doing better work cheaper. Drs Doug Wood and Farhood Farjah wrote an editorial that accompanied our article [4]. A summary of their editorial, with which we agree, is that the data exist. The data have been presented in several different articles from several different data sources, with similar conclusions as outlined in the editorial by Wood and Farjah and in our article. Cardiac and, in particular, general thoracic surgeons perform general thoracic surgery with less morbidity, less mortality, fewer hospital days, and with better outcomes (longer survival). The next step is to act on these findings through health care policy and education of patients, surgeons, referring physicians, insurers, and politicians to improve the health of our patients. Paul H. Schipper, MD Brian S. Diggs, MD Cardiothoracic Surgery Oregon Health and Science University 3181 SW Sam Jackson Park Rd Mail Code L353 Portland, OR 97239 e-mail: [email protected]
References 1. Baciewicz FA, Edelman D. Are there enough general thoracic surgeons? (letter). Ann Thorac Surg 2010;90:1062–3. 2. HCUP Databases. Healthcare Cost and Utilization Project (HCUP). 1996 –2005. Rockville, MD: Agency for Healthcare Research and Quality; 1998. Available at: http://www.hcup-us. ahrq.gov/nisoverview.jsp. Accessed November 2008. 3. Schipper PH, Diggs BS, Ungerleider RM, Welke KF. The influence of surgeon specialty on outcomes in general thoracic surgery: a national sample 1996 to 2005. Ann Thorac Surg 2009;88:1566 –73. 4. Wood DE, Farjah F. Surgeon specialty is associated with better outcomes: the facts speak for themselves. Ann Thorac Surg 2009;88:1393–5. MISCELLANEOUS
Frank A. Baciewicz, Jr, MD David Edelman, MD
CORRESPONDENCE
CORRESPONDENCE
bronchopleural fistula. We congratulate them on an original idea and an innovative technique. However, we have three questions from the description and would like to add to the discussion. First, what is the material of the skeleton of the “siliconecovered bronchial occlusion stent”? It appears to be a selfexpandable metallic stent. If so, we are concerned about the durability of the stent. Chae and colleagues did not refer to this point. Disruption of the bronchial wall by metallic stents has been reported [2, 3]. Given the point about the durability of the stent, we would rather have performed a thoracotomy than use a stent device because the middle-aged patient seemed able to tolerate the operation. We consider that the standard treatment for bronchopleural fistulas is a thoracotomy with primary closure and coverage with a vascularized muscle flap of the bronchial leak site. We think that almost all of the reports in their reference list [1] say as much. Stents should be used only in patients for whom a conventional operation is ineffective or where surgical treatment is medically contraindicated. In addition, once a metallic stent is placed, it cannot be removed. Second, Chae and colleagues [1] stated that the transsternal ligation of the left main bronchus is difficult because of the short bronchial stump length and concomitant possible aspiration in the right lung. However, we estimate that a 15-mm length is enough to suture the stump or perform a tracheobronchial plasty [4]. Third, another concern is the length of the left main bronchial stump after pneumonectomy. According to the authors’ Figure 2 [1] of the bronchial occlusion stent, we estimate that the length of the left main bronchial stump was too long. In context, it was described as 15 mm, but the stent body, which was supposed to be placed in the remaining “bronchus pocket,” is more than 2 cm long. Too long a bronchial stump is one cause of fistulas due to poor blood supply. Mitsuhiro Kamiyoshihara, MD, PhD Toshiteru Nagashima, MD Department of General Thoracic Surgery Maebashi Red Cross Hospital 3-21-36 Asahi-Cho Maebashi Gunma 371-0014 Japan e-mail: [email protected]
Ann Thorac Surg 2010;90:1059 – 63
bronchopleural fistula after a left pneumonectomy due to a destroyed lung. They closed the fistula by a silicone-covered, wine-glass, configured occluder stent produced by a local manufacturer (S & G Biotech, Seongnam, Gyunggi-do, Korea). The authors reported the technique as a novel method for managing a postpneumonectomy fistula. We wish to state that the technique has been previously described and published [2]. The team used a covered, distal-release, tracheobronchial stent (Tracheobronxane Silmet [Novetech, La Ciotat Cedex, France]) in a hand-made “hourglass” design in 3 patients. As described in the published report [2], the figures of the technical details and chest roentgenogram after stenting can be seen. We recently developed a further step in which a piece of polyglactin 910 (Vicryl) mesh (Ethicon Inc, Somerville, NJ) was wrapped around the hourglass stent, providing greater granulation tissue. One year after stent placement, control bronchoscopy revealed closed fistulas with fibrous tissue completely covering the stent with polyglactin 910 (Vicryl) mesh (Ethicon Inc). We agree with Chae and colleagues [1] that patients who are poor surgical candidates might be best treated with a stent placement that functions as a double barrier (described as an hourglass or wine-glass configuration) as a promising option to treat postoperative bronchopleural fistula. Cagatay Tezel, MD Department of Thoracic Surgery Sureyyapasa Chest Diseases and Thoracic Surgery Teaching Hospital Caferaga mah. Gül sok Budak Apt 1/6 Moda, Kadiköy Istanbul, 34710 TR34710 Turkey e-mail: [email protected]
References 1. Chae EY, Shin JH, Song HY, Kim JH, Shim TS, Kim DK. Bronchopleural fistula treated with a silicone-covered bronchial occlusion stent. Ann Thorac Surg 2010;89:293– 6. 2. Kutlu CA, Patlakoglu S, Tasci AE, Kapicibasi O. A novel technique for bronchopleural fistula closure: an hourglassshaped stent. J Thorac Cardivasc Surg 2009;137:e46 –7.
References
MISCELLANEOUS
1. Chae EY, Shin JH, Song HY, Kim JH, Shim TS, Kim DK. Bronchopleural fistula treated with a silicone-covered bronchial occlusion stent. Ann Thorac Surg 2010;89:293– 6. 2. Hind CRK, Donnelly RJ. Expandable metal stents for tracheal obstruction: permanent or temporary? A cautionary tale. Thorax 1992;47:757– 8. 3. Hiramiec JE, Haasler GB. Tracheal wire stent complications in malacia: implication of position and design. Ann Thorac Surg 1997;63:209 –12. 4. Suzuki T, Suzuki S, Kamio Y, Hori G. Closure with bronchial wall flap and omental pedicle of defect caused by dehiscence of tracheal suture line after extended right upper sleeve lobectomy. J Thorac Cardiovasc Surg 1996;112:1116 –7.
1-Year Follow-Up With an Hourglass-Shaped Stent To the Editor: We read with great interest the case reported by Chae and colleagues [1]. The authors presented a successfully managed © 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Are There Enough General Thoracic Surgeons? To the Editor: I enjoyed the article by Schipper and colleagues [1]. I was surprised by the high percentage of general thoracic cases performed by general surgeons. In a recent presentation at the Western Thoracic Surgical Association [2], we noted our general thoracic surgical population included a high percentage of patients who were turned down for surgical intervention with resectable lung cancer. Could this situation be partially explained by the fact that increasing numbers of patients are being seen by general surgeons rather than thoracic surgeons? Second, will this trend become increasingly problematic with fewer thoracic surgery residencies and fewer thoracic surgeons being trained each year? With the current projections it appears that even more general thoracic cases will be performed by general surgeons in the future. 0003-4975/$36.00
Ann Thorac Surg 2010;90:1059 – 63
Cardiothoracic Surgery Wayne State University/DMC 3990 John R, Suite 8805 Detroit, MI 48201 e-mail: [email protected]
References 1. Schipper PH, Diggs BS, Ungerleider RM, Welke KF. The influence of surgeon specialty on outcomes in general thoracic surgery: a national sample 1996 to 2005. Ann Thorac Surg 2009;88:1566 –73. 2. Edelman D, Baciewicz FA. Outcomes in lung cancer patients initially refused operation. Presentation 35th Annual Meeting Western Thoracic Surgical Association, Banff, Alberta, Canada, June 24 –27, 2009.
Reply To the Editor: We thank Dr Baciewicz for his comments [1]. To answer his first question, “Are increasing numbers of thoracic surgery patients being seen by general surgeons?,” we queried the National Inpatient Sample [2]. Using the same definitions as outlined in our article [3] and over the same time span (1996 to 2005), we compared the percentage of surgeons each year meeting each definition (cardiac surgeon, general thoracic surgeon, or general surgeon). In general, 70% of surgeons doing general thoracic cases were general surgeons, 27% were cardiac surgeons, and 3% were general thoracic surgeons. These three percentages had slight variability from year to year but were largely similar across this time period, with no increasing or decreasing trends. We then examined the percentage of cases performed by each of these surgeons. We found that for cardiac surgeons and general surgeons, the yearly total number of lobectomies and decortications was increasing and the yearly total number of pneumonectomies and wedge resections was decreasing. For general thoracic surgeons, there was year-to-year variability in total number of each index case, but no trend increasing or decreasing. The percentage of the yearly total number of each index case performed by each surgeon group varies slightly from year to year but is largely similar, with no increasing or decreasing trend. Our data do not support the statement that increasing numbers of thoracic surgery patients are being seen by general surgeons— or by cardiac surgeons or general thoracic surgeons.
1063
Rather, the division of labor seems to be fairly constant over this time span. Our data do show that general surgeons perform most of all three procedures, although the best outcomes are achieved by cardiac surgeons and general thoracic surgeons. Using out data, we are not able to answer Dr Baciewicz’s second question, “Will this trend become increasingly problematic with fewer thoracic surgery residencies and fewer thoracic surgeons being trained each year?” However, we agree that a projected deficit of cardiothoracic surgeons is an important consideration for our profession, our government, and our society. It is especially important if the surgeons lacking could be doing better work cheaper. Drs Doug Wood and Farhood Farjah wrote an editorial that accompanied our article [4]. A summary of their editorial, with which we agree, is that the data exist. The data have been presented in several different articles from several different data sources, with similar conclusions as outlined in the editorial by Wood and Farjah and in our article. Cardiac and, in particular, general thoracic surgeons perform general thoracic surgery with less morbidity, less mortality, fewer hospital days, and with better outcomes (longer survival). The next step is to act on these findings through health care policy and education of patients, surgeons, referring physicians, insurers, and politicians to improve the health of our patients. Paul H. Schipper, MD Brian S. Diggs, MD Cardiothoracic Surgery Oregon Health and Science University 3181 SW Sam Jackson Park Rd Mail Code L353 Portland, OR 97239 e-mail: [email protected]
References 1. Baciewicz FA, Edelman D. Are there enough general thoracic surgeons? (letter). Ann Thorac Surg 2010;90:1062–3. 2. HCUP Databases. Healthcare Cost and Utilization Project (HCUP). 1996 –2005. Rockville, MD: Agency for Healthcare Research and Quality; 1998. Available at: http://www.hcup-us. ahrq.gov/nisoverview.jsp. Accessed November 2008. 3. Schipper PH, Diggs BS, Ungerleider RM, Welke KF. The influence of surgeon specialty on outcomes in general thoracic surgery: a national sample 1996 to 2005. Ann Thorac Surg 2009;88:1566 –73. 4. Wood DE, Farjah F. Surgeon specialty is associated with better outcomes: the facts speak for themselves. Ann Thorac Surg 2009;88:1393–5. MISCELLANEOUS
Frank A. Baciewicz, Jr, MD David Edelman, MD
CORRESPONDENCE