- Email: [email protected]
Incision for Uniportal VATS: Above the Rib or Intercostal Space?
CORRESPONDENCE
About the Effect of Cell-Saving Devices and Filters To the Editor: Congratulations to Vermeijden and coworkers for this valuable study [1]. The authors investigated the contribution of cell-saving devices and filtration of the salvaged blood to transfusion requirements. They conducted this study in 6 different centers and concluded that the “use of cell-saving devices, with or without a filter, does not reduce the total number of allogeneic blood products, but reduces the percentage of patients who need blood products during cardiac surgery.” We have some concerns about the study design that we think may directly affect the results of the study. The authors conducted this study by using a cellsaving device in 1 group and a leukocyte-depleting filter in the other. Because this study was carried on at different medical institutions, we should know the exact brand name and the technical information about the cell-saving device that each institution used. There are several cell-saving devices in use with different characteristics. If all of the institutions used the same type of the device that is fine. However, the devices on the market have different pore sizes, variable wash speeds, different pump and centrifuge speeds, and so on. Therefore the use of different machines may produce different results. We think that the authors should inform the reader about this issue. Ismail Yurekli, MD Mert Kestelli, MD Habib Cakir, MD Sahin Iscan, MD Department of Cardiovascular Surgery Izmir Katip Celebi University Ataturk Education and Research Hospital Yali Mah 6436 sok No 82 D 3 Karsiyaka-Izmir, Turkey email: [email protected]
Reference 1. Vermeijden WJ, van Klarenbosch J, Gu YJ, et al. Effects of cellsaving devices and filters on transfusion in cardiac surgery: a multicenter randomized study. Ann Thorac Surg 2015;99: 26–32.
MISCELLANEOUS
Reply To the Editor: We thank Yurekli and colleagues [1] for their interesting comment. As mentioned in the Methods section of our article [2] 3 kinds of cellsaving devices were used. Three centers used the CATS continuous system (Fresenius, Bad Homburg, Germany), 2 centers used the Dideco-electa (Sorin, Milan, Italy) bowl system, and 1 center used the BRAT5 (Haemonetics, Baintree, MA) bowl system. In our opinion the question centers on possible differences between cell salvage with a continuous system versus cell salvage with a bowl device. This is indeed a question that warrants further investigation. In our study a continuous device was used in 276 patients and a bowl device in 88 patients. Each center used only 1 type of device and all centers used the standard manufacturer’s washing program. Blood collected with the CATS system was 2140 1071 mL and with the bowl devices 2445 2135 mL (p ¼ 0.20). This resulted in a mean processed blood amount of 654 360 mL for the CATS system and mean of 721 668 mL (p ¼ 0.38) for the bowl devices. The red blood Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
cell (RBC) extraction ratio of the devices thus amounts to 31% and 29%, respectively. A recent study also used 2 different cell saving devices without apparent differences in RBC extraction ratio between the 2 devices [3]. Another recent in vitro study also showed that there were no significant differences between the continuous versus the bowl device regarding the RBC extraction ratio [4]. An older study neither showed a difference between different cell saving devices in concentrating red blood cells [5]. The positive effects of cell saving devices on reduction of transfusion requirements in cardiac surgery might not be limited to the return of lost RBCs. There is evidence that the use of cell salvage reduces the inflammatory response and perhaps a cell savers major contribution is its “hemo-concentrating effect” [6]. The effects of the different cell saving devices (continuous versus bowl system) on these latter aspects as well as on transfusion requirements and patient outcome have not yet been investigated in a major clinical trial. In conclusion, although we cannot completely exclude that difference in processing methods between the devices played a role, our data suggest that this did not influence the results of our study. Wytze J. Vermeijden, MD, PhD Department of Intensive Care and Thorax Centre Twente Medisch Spectrum Twente Enschede, the Netherlands email: [email protected] Adrianus J. de Vries, MD, PhD Department of Anesthesiology University Medical Centre Groningen Groningen, the Netherlands
References 1. Yurekli I, Kestelli M, Cakir H, Iscan S. About the effect of cellsaving devices and filters (letter). Ann Thorac Surg 2016;101: 2020. 2. Vermeijden WJ, van Klarenbosch J, Gu YJ, et al. Effects of cellsaving devices and filters on transfusion in cardiac surgery: a multicenter randomized study. Ann Thorac Surg 2015;99: 26–32. 3. Weltert L, Nardella S, Rondinelli MB, Pierelli L, De Paulis R. Reduction of allogeneic red blood cell usage during cardiac surgery by an integrated intra- and postoperative blood salvage strategy: results of a randomized comparison. Transfusion 2013;53:790–7. 4. Seyfried TF, Haas L, Gruber M, Breu A, Loibl M, Hansen E. Fat removal during cell salvage: a comparison of four different cell salvage devices. Transfusion 2015;55:1637–43. 5. Burman JF, Westlake AS, Davidson SJ, et al. Study of five cell salvage machines in coronary artery surgery. Transfus Med 2002;12:173–9. 6. Gabel J, Westerberg M, Bengtsson A, Jeppsson A. Cell salvage of cardiotomy suction blood improves the balance between pro- and anti-inflammatory cytokines after cardiac surgery. Eur J Cardiothorac Surg 2013;44:506–11.
Incision for Uniportal VATS: Above the Rib or Intercostal Space? To the Editor: We read the article by Son and colleagues [1] with great interest. They demonstrated a modified incision and closure Ann Thorac Surg 2016;101:2020–9 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.10.085
Ann Thorac Surg 2016;101:2020–9
CORRESPONDENCE
2021
Fig 1. (A) A skin incision is created above the intercostal space. (B) The chest wall muscle is closed with a chest tube inserted through the upper intercostal space. (C) A subcutaneous running suture is performed with 3-0 Prolene suture and (D) pulled up for wound sealing after chest tube removal.
Shun-Mao Yang, MD Shuenn-Wen Kuo, MD Department of Thoracic Surgery National Taiwan University Hospital 7, Chung-Shan South Rd Taipei 10002, Taiwan email: [email protected]
References 1. Son BS, Park JM, Seok JP, Kim DH. Modified incision and closure techniques for single-incision thoracoscopic lobectomy. Ann Thorac Surg 2015;99:349–51. 2. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013;95:426–32.
Reply To the Editor: We thank Dr Yang and his colleagues [1] for their interest in our article [2], and we appreciate the editor for giving us the opportunity to reply. We performed a single-incision thoracoscopic surgical procedure (SITS) to decrease the risk of intercostal nerve injury, which can cause postoperative neuralgia. Although we applied the SITS lobectomy to achieve a better cosmetic effect,
MISCELLANEOUS
technique for uniportal video-assisted thoracic surgery (VATS) lobectomy. The uniportal approach for thoracoscopic surgery was introduced in our institute at almost the same time as in the authors’ hospital, and we also encounter peritubular leakage in some cases. This article has inspired us to modify our closure technique. In our method, the incision is made in the middle of the intercostal space (Fig 1A), and the chest tube is inserted through the upper adjacent intercostal space under direct visualization or video guidance (Fig 1B). Similar to most thoracic surgeons who perform uniportal VATS, we considered making the incision in the middle of the intercostal space to achieve better instrument and scope handling, especially in cases where the target is lower (such as release of the inferior pulmonary ligament). Some experts, such as Gonzalez-Rivas and colleagues [2], prefer not to use the wound protector to obtain a wider instrument movement range; however, if the incision is made above the rib, a wound protector will be necessary. We also apply our modified skin closure with a subcutaneous running suture to achieve better cosmetic results (Fig 1C). The chest tube can be removed while the subcutaneous running suture is pulled tightly, to ensure wound sealing (Fig 1D). In conclusion, we believe that separate placement of the chest tube from the single incision opening may help avoid peritubular leakage. Through this modified method, the incision can still be made in the middle of the intercostal space.
About the Effect of Cell-Saving Devices and Filters To the Editor: Congratulations to Vermeijden and coworkers for this valuable study [1]. The authors investigated the contribution of cell-saving devices and filtration of the salvaged blood to transfusion requirements. They conducted this study in 6 different centers and concluded that the “use of cell-saving devices, with or without a filter, does not reduce the total number of allogeneic blood products, but reduces the percentage of patients who need blood products during cardiac surgery.” We have some concerns about the study design that we think may directly affect the results of the study. The authors conducted this study by using a cellsaving device in 1 group and a leukocyte-depleting filter in the other. Because this study was carried on at different medical institutions, we should know the exact brand name and the technical information about the cell-saving device that each institution used. There are several cell-saving devices in use with different characteristics. If all of the institutions used the same type of the device that is fine. However, the devices on the market have different pore sizes, variable wash speeds, different pump and centrifuge speeds, and so on. Therefore the use of different machines may produce different results. We think that the authors should inform the reader about this issue. Ismail Yurekli, MD Mert Kestelli, MD Habib Cakir, MD Sahin Iscan, MD Department of Cardiovascular Surgery Izmir Katip Celebi University Ataturk Education and Research Hospital Yali Mah 6436 sok No 82 D 3 Karsiyaka-Izmir, Turkey email: [email protected]
Reference 1. Vermeijden WJ, van Klarenbosch J, Gu YJ, et al. Effects of cellsaving devices and filters on transfusion in cardiac surgery: a multicenter randomized study. Ann Thorac Surg 2015;99: 26–32.
MISCELLANEOUS
Reply To the Editor: We thank Yurekli and colleagues [1] for their interesting comment. As mentioned in the Methods section of our article [2] 3 kinds of cellsaving devices were used. Three centers used the CATS continuous system (Fresenius, Bad Homburg, Germany), 2 centers used the Dideco-electa (Sorin, Milan, Italy) bowl system, and 1 center used the BRAT5 (Haemonetics, Baintree, MA) bowl system. In our opinion the question centers on possible differences between cell salvage with a continuous system versus cell salvage with a bowl device. This is indeed a question that warrants further investigation. In our study a continuous device was used in 276 patients and a bowl device in 88 patients. Each center used only 1 type of device and all centers used the standard manufacturer’s washing program. Blood collected with the CATS system was 2140 1071 mL and with the bowl devices 2445 2135 mL (p ¼ 0.20). This resulted in a mean processed blood amount of 654 360 mL for the CATS system and mean of 721 668 mL (p ¼ 0.38) for the bowl devices. The red blood Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
cell (RBC) extraction ratio of the devices thus amounts to 31% and 29%, respectively. A recent study also used 2 different cell saving devices without apparent differences in RBC extraction ratio between the 2 devices [3]. Another recent in vitro study also showed that there were no significant differences between the continuous versus the bowl device regarding the RBC extraction ratio [4]. An older study neither showed a difference between different cell saving devices in concentrating red blood cells [5]. The positive effects of cell saving devices on reduction of transfusion requirements in cardiac surgery might not be limited to the return of lost RBCs. There is evidence that the use of cell salvage reduces the inflammatory response and perhaps a cell savers major contribution is its “hemo-concentrating effect” [6]. The effects of the different cell saving devices (continuous versus bowl system) on these latter aspects as well as on transfusion requirements and patient outcome have not yet been investigated in a major clinical trial. In conclusion, although we cannot completely exclude that difference in processing methods between the devices played a role, our data suggest that this did not influence the results of our study. Wytze J. Vermeijden, MD, PhD Department of Intensive Care and Thorax Centre Twente Medisch Spectrum Twente Enschede, the Netherlands email: [email protected] Adrianus J. de Vries, MD, PhD Department of Anesthesiology University Medical Centre Groningen Groningen, the Netherlands
References 1. Yurekli I, Kestelli M, Cakir H, Iscan S. About the effect of cellsaving devices and filters (letter). Ann Thorac Surg 2016;101: 2020. 2. Vermeijden WJ, van Klarenbosch J, Gu YJ, et al. Effects of cellsaving devices and filters on transfusion in cardiac surgery: a multicenter randomized study. Ann Thorac Surg 2015;99: 26–32. 3. Weltert L, Nardella S, Rondinelli MB, Pierelli L, De Paulis R. Reduction of allogeneic red blood cell usage during cardiac surgery by an integrated intra- and postoperative blood salvage strategy: results of a randomized comparison. Transfusion 2013;53:790–7. 4. Seyfried TF, Haas L, Gruber M, Breu A, Loibl M, Hansen E. Fat removal during cell salvage: a comparison of four different cell salvage devices. Transfusion 2015;55:1637–43. 5. Burman JF, Westlake AS, Davidson SJ, et al. Study of five cell salvage machines in coronary artery surgery. Transfus Med 2002;12:173–9. 6. Gabel J, Westerberg M, Bengtsson A, Jeppsson A. Cell salvage of cardiotomy suction blood improves the balance between pro- and anti-inflammatory cytokines after cardiac surgery. Eur J Cardiothorac Surg 2013;44:506–11.
Incision for Uniportal VATS: Above the Rib or Intercostal Space? To the Editor: We read the article by Son and colleagues [1] with great interest. They demonstrated a modified incision and closure Ann Thorac Surg 2016;101:2020–9 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.10.085
Ann Thorac Surg 2016;101:2020–9
CORRESPONDENCE
2021
Fig 1. (A) A skin incision is created above the intercostal space. (B) The chest wall muscle is closed with a chest tube inserted through the upper intercostal space. (C) A subcutaneous running suture is performed with 3-0 Prolene suture and (D) pulled up for wound sealing after chest tube removal.
Shun-Mao Yang, MD Shuenn-Wen Kuo, MD Department of Thoracic Surgery National Taiwan University Hospital 7, Chung-Shan South Rd Taipei 10002, Taiwan email: [email protected]
References 1. Son BS, Park JM, Seok JP, Kim DH. Modified incision and closure techniques for single-incision thoracoscopic lobectomy. Ann Thorac Surg 2015;99:349–51. 2. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013;95:426–32.
Reply To the Editor: We thank Dr Yang and his colleagues [1] for their interest in our article [2], and we appreciate the editor for giving us the opportunity to reply. We performed a single-incision thoracoscopic surgical procedure (SITS) to decrease the risk of intercostal nerve injury, which can cause postoperative neuralgia. Although we applied the SITS lobectomy to achieve a better cosmetic effect,
MISCELLANEOUS
technique for uniportal video-assisted thoracic surgery (VATS) lobectomy. The uniportal approach for thoracoscopic surgery was introduced in our institute at almost the same time as in the authors’ hospital, and we also encounter peritubular leakage in some cases. This article has inspired us to modify our closure technique. In our method, the incision is made in the middle of the intercostal space (Fig 1A), and the chest tube is inserted through the upper adjacent intercostal space under direct visualization or video guidance (Fig 1B). Similar to most thoracic surgeons who perform uniportal VATS, we considered making the incision in the middle of the intercostal space to achieve better instrument and scope handling, especially in cases where the target is lower (such as release of the inferior pulmonary ligament). Some experts, such as Gonzalez-Rivas and colleagues [2], prefer not to use the wound protector to obtain a wider instrument movement range; however, if the incision is made above the rib, a wound protector will be necessary. We also apply our modified skin closure with a subcutaneous running suture to achieve better cosmetic results (Fig 1C). The chest tube can be removed while the subcutaneous running suture is pulled tightly, to ensure wound sealing (Fig 1D). In conclusion, we believe that separate placement of the chest tube from the single incision opening may help avoid peritubular leakage. Through this modified method, the incision can still be made in the middle of the intercostal space.