- Email: [email protected]
Octreotide in Bronchobiliary Fistula Management
1512
CORRESPONDENCE
20 Rue Leblanc 75015 Paris, France e-mail: [email protected]
References 1. Nakagawa K, Yasumitu T, Fukuhara K, Shiono H, Kikui M. Poor prognosis after lung resection for patients with adenosquamous carcinoma of the lung. Ann Thorac Surg 2003;75: 1740 –4. 2. Riquet M, Perrotin C, Lang-Lazdunski L, et al. Do patients with adenosquamous carcinoma of the lung need a more aggressive approach? J Thorac Cardiovasc Surg 2001;122: 618 –9. 3. Manac’h D, Riquet M, Medioni J, Le Pimpec-Barthes F, Dujon A, Danel C. Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor. Ann Thorac Surg 2001;71:1088 –93.
Ann Thorac Surg 2004;78:1511– 8
Katsuhiro Nakagawa, MD, PhD Department of Thoracic Surgery Osaka Prefectural Medical Center for Respiratory and Allergy Diseases 3-7-1, Habikino Habikino City, Osaka, Japan, 583-8588 e-mail: [email protected]
References 1. Nakagawa K, Yasumitu T, Fukuhara K, Shiono H, Kikui M. Poor prognosis after lung resection for patients with adenosquamous carcinoma of the lung. Ann Thorac Surg 2003;75: 1740 –4. 2. Riquet M, Perrotin C, Lang-Lazdunski L, et al. Do patients with adenosquamous carcinoma of the lung need a more aggressive approach? J Thorac Cardiovasc Surg 2001;122: 618 –9.
Reply
To the Editor:
MISCELLANEOUS
Thank you for reading our report [1]. I agree that the prognosis for patients with adenosquamous carcinoma is poorer than that for patients with other histological types of lung cancer. I originally had assumed that pleural invasion was an independent prognostic factor, but this was not substantiated by the multivariate analysis. However, I think your opinion about pleural invasion is very useful and informative. I have encountered several patients with histopathological evidence of lymphatic invasion directly beneath the visceral pleura. The reason for the high frequency of pleural invasion associated with adenosquamous carcinoma compared with other histological types of lung cancer is unclear. Such subpleural lymphatic invasion may be an index of the aggressive behavior of adenosquamous carcinoma of the lung. For patients with stage IIIA disease, which was treated by complete resection in our hospital between September 1976 and August 1998, the 5-year survival rate was 7.4% for patients who had involvement of only one mediastinal lymph node station (N2) with visceral pleural invasion (n ⫽ 71) and 27.2% for those who had involvement of one mediastinal lymph node station (N2) without visceral pleural invasion (n ⫽ 47). The 5-year survival rate was 16.1% for patients with involvement of two or more mediastinal lymph node stations (N2) irrespective of the status of visceral pleural invasion (n ⫽ 128). The outcome of patients who had involvement of only one lymph node station without visceral pleural invasion was significantly better than that of patients with other types of N2 disease. As in the study of Riquet and coauthors [2], outcome did not differ significantly between patients who had involvement of one mediastinal lymph node station with pleural invasion and those who had involvement of two or more mediastinal lymph node stations irrespective of the status of visceral pleural invasion. In the patients with visceral pleural invasion, it can be imagined that tumor cells invading the parietal pleural lymph nodes were reabsorbed and transferred to the mediastinal lymph nodes; however, no direct evidence is available to corroborate this. It is an open question whether reabsorption of tumor cells in the parietal pleural can be verified clinically or experimentally. The reasons for the poor prognosis for patients with adenosquamous carcinoma of the lung remain unclear. Perhaps techniques such as gene analysis will help to identify the most critical factors. © 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Octreotide in Bronchobiliary Fistula Management To the Editor: Singh and colleagues [1] described the management of bronchobiliary fistula (BBF) by endoscopic retrograde cholangiography and medical therapy. Their use of octreotide for BBF was not previously documented according to our MEDLINE search. We report 2 cases of patients demonstrating the therapeutic utility of octreotide in BBF management. A 56-year-old woman was seen with chest pain, fever, and bilioptysis. History included percutaneous liver abscess drainage and thoracotomy for iatrogenic hemothorax 4 years earlier. There was no jaundice or pallor. Crackles were heard at the base of the right lung. The level of alkaline phosphatase was slightly elevated (154 IU/L). A biliary scan showed activity above the diaphragm, and endoscopic cholangiography revealed a filling defect in the intrahepatic ductal system with contrast material extravasating into the right lung. Multiple bile duct stones were extracted, and a stent was inserted into the common bile duct for biliary decompression, but bilioptysis persisted 4 days later. A repeat cholangiogram confirmed a persistent BBF. A 28-day trial of octreotide, 100 g subcutaneously three times a day, was initiated, during which progressive reduction in bilioptysis was seen until resolution on day 17, and repeat biliary scanning confirmed closure of the fistula. The patient remained asymptomatic after discontinuance of octreotide and removal of the endobiliary stent. A 71-year-old woman was seen with painless bilioptysis 4 months after undergoing a right hepatectomy for colon metastases. Decreased air entry and dullness to percussion were noted at the base of the right lung. The alkaline phosphatase level was elevated (431 IU/L). The presence of a BBF was suggested by a right subphrenic accumulation of fluid on a computed tomographic scan and by isotope concentration above the right hemidiaphragm on a biliary scan. An endoscopic cholangiogram confirmed the diagnosis of BBF, and a common bile duct stent was inserted, but bilioptysis continued for 4 days. Octreotide was then initiated at 100 g subcutaneously three times a day, with marked reduction in frequency and production of bilioptysis; however, follow-up biliary scanning showed a persistent BBF. Octreotide was continued until the patient underwent operation to repair the BBF 6 weeks later. A laceration of the inferior vena cava resulted in uncontrollable hemorrhage and cardiac arrest. Postmortem examination revealed a patent malignant BBF. Reports of BBF secondary to choledocholithiasis or right 0003-4975/04/$30.00
Ann Thorac Surg 2004;78:1511– 8
Michael Ong, BSc (Hons) Kouros Moozar, MD Lawrence B. Cohen, MD, FRCP(C) Division of Gastroenterology Sunnybrook and Women’s College Health Sciences Centre Room HG 63 2075 Bayview Ave Toronto, ON, Canada M4N 3M5 e-mail: [email protected]
References 1. Singh B, Moodley J, Sheik-Gafoor MH, Dhooma N, Reddi A. Conservative management of thoracobiliary fistula. Ann Thorac Surg 2002;73:1088 –91. 2. Rose DM, Rose AT, Chapman WC, Wright JK, Lopez RR, Pinson CW. Management of bronchobiliary fistula as a late complication of hepatic resection. Am Surg 1998;64:873–6. 3. Kocak S, Bumin C, Karayalcin K, Alacayir I, Aribal D. Treatment of external biliary, pancreatic and intestinal fistulas with a somatostatin analog. Dig Dis 1994;12:62–8. 4. Hesse U, Ysebaert D, de Hemptinne B. Role of somatostatin-14 and its analogues in the management of gastrointestinal fistulae: clinical data. Gut 2001;49(Suppl 4):11–21.
Reply
To the Editor: The persistence of a thoracobiliary fistula (TBF) is widely attributed to the differential pressure gradient between the common bile duct and the sphincter of Oddi [1, 2]. When this pressure gradient is effectively eliminated (as after an endoscopic sphincterotomy), the output of the biliary fistula is dramatically reduced, thus facilitating rapid closure of the fistula. The consistent and enduring success of endoscopic sphincterotomy in the management of TBF lends credence to the role of differential biliary pressures in the persistence of this type of fistula. Although there is little doubt that other factors can be implicated in the continuance of a TBF, the most notable of which appears to be sepsis, the importance of these factors cannot be conclusively established. A role for octreotide in the management of TBF has been adopted from studies that have demonstrated its beneficial effect in the management of enterocutaneous and pancreatic fistulas [3]. Octreotide as an adjunct to standard treatment (support and drainage of sepsis) has been associated with diminution of fistulous output, but its effectiveness remains to be proven by well-designed comparative studies [4]. Indeed, persistent use of octreotide has been associated with a higher incidence of thrombotic and septic complications [5]. Like others [3, 4], we recommend the use of octreotide as adjunctive therapy rather than as definitive treatment of TBF. Biliary decompression by sphincterotomy should be the mainstay of therapy when there is persistence of the fistula despite standard medical therapy. © 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
1513
Bhugwan Singh, FCS (SA) Jaynathan Moodley, FCS(SA) Department of Surgery Faculty of Health Sciences Nelson K. Mandela School of Medicine University of Natal Private Bag 7 Congella 4013, South Africa. e-mail: [email protected]
References 1. Hoffman BJ, Cunningham JT, Marsh WH. Endoscopic management of biliary fistulas with small caliber stents. Am J Gastroenterol 1990;85:705–7. 2. Geenen JE, Toouli L, Hogan WJ, et al. Endoscopic sphincterotomy: follow-up evaluation of effects on the sphincter of Oddi. Gastroenterology 1984;87:54 –8. 3. Kocak S, Bumin C, Karayalcin K, Alacayir I, Aribal D. Treatment of external biliary, pancreatic and intestinal fistulas with a somatostatin analog. Dig Dis 1994;12:62–8. 4. Martineau P, Shwed JA, Denis R. Is octreotide a new hope for enterocutaneous and external pancreatic fistulas closure? Am J Surg 1996;172:386 –95. 5. Avarez C, McFadden DW, Reber HA. Complicated enterocutaneous fistulas: failure of octreotide to improve healing. World J Surg 2000;24:533–7.
Apparent Reduction of Cerebral Microemboli During Off-Pump Operations To the Editor: I was interested to read the randomized study by Lund and colleagues [1] in which they reported decreased intraoperative cerebral microemboli in patients having off-pump coronary artery bypass grafting compared with those having an on-pump operation. The findings are important and confirm the results of other nonrandomized, studies. However, arterial line filters are known to reduce microemboli during cardiopulmonary bypass [2]. Some arterial line filters are better than others at limiting microemboli [3]. Therefore, it would be very helpful to know whether arterial line filters were used in the on-pump group and, if so, what type. On the basis of the number of microemboli reported, I expect that filters were used, but this should have been noted. The method of pH control during hypothermia is also important in determining neuropsychological outcome and, possibly, microemboli delivery to the brain [4]. When comparing two methods such as on-pump and off-pump operations and measuring postoperative neuropsychological change, albeit as a secondary outcome, one should demonstrate that each method is being made as safe in neuroprotective terms as possible. It cannot be assumed that alpha-stat strategy and arterial lines are universally used. When relating the number of microemboli to neuropsychological outcome, Lund and colleagues were rightly circumspect. The Doppler consensus criterion for detecting microemboli is based on an arbitrary size of gaseous or particulate emboli, and the pathological effect of both types remains speculative. The use of methods for distinguishing between gaseous and solid microemboli has not yet been reported in clinical practice. As Lund and associates pointed out, both inflammation and altered cerebral blood flow may also potentially affect neuropsychological outcome. In regard to cerebral blood flow, transcranial Doppler is a useful method to simultaneously record both middle cerebral 0003-4975/04/$30.00
MISCELLANEOUS
hepatectomy are rare, but morbidity and mortality are high as a result of pulmonary sequelae and therapeutic complications [2]. We think our experience with the use of octreotide to lower morbidity in BBF is encouraging. Patients benefit from amelioration of bilioptysis [3], and accelerated fistula closure may occur in response to octreotide [4]. However, octreotide can precipitate rebound biliary output when discontinued and is ineffective if infection, obstruction, or malignancy maintain fistula patency [4].
CORRESPONDENCE
CORRESPONDENCE
20 Rue Leblanc 75015 Paris, France e-mail: [email protected]
References 1. Nakagawa K, Yasumitu T, Fukuhara K, Shiono H, Kikui M. Poor prognosis after lung resection for patients with adenosquamous carcinoma of the lung. Ann Thorac Surg 2003;75: 1740 –4. 2. Riquet M, Perrotin C, Lang-Lazdunski L, et al. Do patients with adenosquamous carcinoma of the lung need a more aggressive approach? J Thorac Cardiovasc Surg 2001;122: 618 –9. 3. Manac’h D, Riquet M, Medioni J, Le Pimpec-Barthes F, Dujon A, Danel C. Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor. Ann Thorac Surg 2001;71:1088 –93.
Ann Thorac Surg 2004;78:1511– 8
Katsuhiro Nakagawa, MD, PhD Department of Thoracic Surgery Osaka Prefectural Medical Center for Respiratory and Allergy Diseases 3-7-1, Habikino Habikino City, Osaka, Japan, 583-8588 e-mail: [email protected]
References 1. Nakagawa K, Yasumitu T, Fukuhara K, Shiono H, Kikui M. Poor prognosis after lung resection for patients with adenosquamous carcinoma of the lung. Ann Thorac Surg 2003;75: 1740 –4. 2. Riquet M, Perrotin C, Lang-Lazdunski L, et al. Do patients with adenosquamous carcinoma of the lung need a more aggressive approach? J Thorac Cardiovasc Surg 2001;122: 618 –9.
Reply
To the Editor:
MISCELLANEOUS
Thank you for reading our report [1]. I agree that the prognosis for patients with adenosquamous carcinoma is poorer than that for patients with other histological types of lung cancer. I originally had assumed that pleural invasion was an independent prognostic factor, but this was not substantiated by the multivariate analysis. However, I think your opinion about pleural invasion is very useful and informative. I have encountered several patients with histopathological evidence of lymphatic invasion directly beneath the visceral pleura. The reason for the high frequency of pleural invasion associated with adenosquamous carcinoma compared with other histological types of lung cancer is unclear. Such subpleural lymphatic invasion may be an index of the aggressive behavior of adenosquamous carcinoma of the lung. For patients with stage IIIA disease, which was treated by complete resection in our hospital between September 1976 and August 1998, the 5-year survival rate was 7.4% for patients who had involvement of only one mediastinal lymph node station (N2) with visceral pleural invasion (n ⫽ 71) and 27.2% for those who had involvement of one mediastinal lymph node station (N2) without visceral pleural invasion (n ⫽ 47). The 5-year survival rate was 16.1% for patients with involvement of two or more mediastinal lymph node stations (N2) irrespective of the status of visceral pleural invasion (n ⫽ 128). The outcome of patients who had involvement of only one lymph node station without visceral pleural invasion was significantly better than that of patients with other types of N2 disease. As in the study of Riquet and coauthors [2], outcome did not differ significantly between patients who had involvement of one mediastinal lymph node station with pleural invasion and those who had involvement of two or more mediastinal lymph node stations irrespective of the status of visceral pleural invasion. In the patients with visceral pleural invasion, it can be imagined that tumor cells invading the parietal pleural lymph nodes were reabsorbed and transferred to the mediastinal lymph nodes; however, no direct evidence is available to corroborate this. It is an open question whether reabsorption of tumor cells in the parietal pleural can be verified clinically or experimentally. The reasons for the poor prognosis for patients with adenosquamous carcinoma of the lung remain unclear. Perhaps techniques such as gene analysis will help to identify the most critical factors. © 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Octreotide in Bronchobiliary Fistula Management To the Editor: Singh and colleagues [1] described the management of bronchobiliary fistula (BBF) by endoscopic retrograde cholangiography and medical therapy. Their use of octreotide for BBF was not previously documented according to our MEDLINE search. We report 2 cases of patients demonstrating the therapeutic utility of octreotide in BBF management. A 56-year-old woman was seen with chest pain, fever, and bilioptysis. History included percutaneous liver abscess drainage and thoracotomy for iatrogenic hemothorax 4 years earlier. There was no jaundice or pallor. Crackles were heard at the base of the right lung. The level of alkaline phosphatase was slightly elevated (154 IU/L). A biliary scan showed activity above the diaphragm, and endoscopic cholangiography revealed a filling defect in the intrahepatic ductal system with contrast material extravasating into the right lung. Multiple bile duct stones were extracted, and a stent was inserted into the common bile duct for biliary decompression, but bilioptysis persisted 4 days later. A repeat cholangiogram confirmed a persistent BBF. A 28-day trial of octreotide, 100 g subcutaneously three times a day, was initiated, during which progressive reduction in bilioptysis was seen until resolution on day 17, and repeat biliary scanning confirmed closure of the fistula. The patient remained asymptomatic after discontinuance of octreotide and removal of the endobiliary stent. A 71-year-old woman was seen with painless bilioptysis 4 months after undergoing a right hepatectomy for colon metastases. Decreased air entry and dullness to percussion were noted at the base of the right lung. The alkaline phosphatase level was elevated (431 IU/L). The presence of a BBF was suggested by a right subphrenic accumulation of fluid on a computed tomographic scan and by isotope concentration above the right hemidiaphragm on a biliary scan. An endoscopic cholangiogram confirmed the diagnosis of BBF, and a common bile duct stent was inserted, but bilioptysis continued for 4 days. Octreotide was then initiated at 100 g subcutaneously three times a day, with marked reduction in frequency and production of bilioptysis; however, follow-up biliary scanning showed a persistent BBF. Octreotide was continued until the patient underwent operation to repair the BBF 6 weeks later. A laceration of the inferior vena cava resulted in uncontrollable hemorrhage and cardiac arrest. Postmortem examination revealed a patent malignant BBF. Reports of BBF secondary to choledocholithiasis or right 0003-4975/04/$30.00
Ann Thorac Surg 2004;78:1511– 8
Michael Ong, BSc (Hons) Kouros Moozar, MD Lawrence B. Cohen, MD, FRCP(C) Division of Gastroenterology Sunnybrook and Women’s College Health Sciences Centre Room HG 63 2075 Bayview Ave Toronto, ON, Canada M4N 3M5 e-mail: [email protected]
References 1. Singh B, Moodley J, Sheik-Gafoor MH, Dhooma N, Reddi A. Conservative management of thoracobiliary fistula. Ann Thorac Surg 2002;73:1088 –91. 2. Rose DM, Rose AT, Chapman WC, Wright JK, Lopez RR, Pinson CW. Management of bronchobiliary fistula as a late complication of hepatic resection. Am Surg 1998;64:873–6. 3. Kocak S, Bumin C, Karayalcin K, Alacayir I, Aribal D. Treatment of external biliary, pancreatic and intestinal fistulas with a somatostatin analog. Dig Dis 1994;12:62–8. 4. Hesse U, Ysebaert D, de Hemptinne B. Role of somatostatin-14 and its analogues in the management of gastrointestinal fistulae: clinical data. Gut 2001;49(Suppl 4):11–21.
Reply
To the Editor: The persistence of a thoracobiliary fistula (TBF) is widely attributed to the differential pressure gradient between the common bile duct and the sphincter of Oddi [1, 2]. When this pressure gradient is effectively eliminated (as after an endoscopic sphincterotomy), the output of the biliary fistula is dramatically reduced, thus facilitating rapid closure of the fistula. The consistent and enduring success of endoscopic sphincterotomy in the management of TBF lends credence to the role of differential biliary pressures in the persistence of this type of fistula. Although there is little doubt that other factors can be implicated in the continuance of a TBF, the most notable of which appears to be sepsis, the importance of these factors cannot be conclusively established. A role for octreotide in the management of TBF has been adopted from studies that have demonstrated its beneficial effect in the management of enterocutaneous and pancreatic fistulas [3]. Octreotide as an adjunct to standard treatment (support and drainage of sepsis) has been associated with diminution of fistulous output, but its effectiveness remains to be proven by well-designed comparative studies [4]. Indeed, persistent use of octreotide has been associated with a higher incidence of thrombotic and septic complications [5]. Like others [3, 4], we recommend the use of octreotide as adjunctive therapy rather than as definitive treatment of TBF. Biliary decompression by sphincterotomy should be the mainstay of therapy when there is persistence of the fistula despite standard medical therapy. © 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
1513
Bhugwan Singh, FCS (SA) Jaynathan Moodley, FCS(SA) Department of Surgery Faculty of Health Sciences Nelson K. Mandela School of Medicine University of Natal Private Bag 7 Congella 4013, South Africa. e-mail: [email protected]
References 1. Hoffman BJ, Cunningham JT, Marsh WH. Endoscopic management of biliary fistulas with small caliber stents. Am J Gastroenterol 1990;85:705–7. 2. Geenen JE, Toouli L, Hogan WJ, et al. Endoscopic sphincterotomy: follow-up evaluation of effects on the sphincter of Oddi. Gastroenterology 1984;87:54 –8. 3. Kocak S, Bumin C, Karayalcin K, Alacayir I, Aribal D. Treatment of external biliary, pancreatic and intestinal fistulas with a somatostatin analog. Dig Dis 1994;12:62–8. 4. Martineau P, Shwed JA, Denis R. Is octreotide a new hope for enterocutaneous and external pancreatic fistulas closure? Am J Surg 1996;172:386 –95. 5. Avarez C, McFadden DW, Reber HA. Complicated enterocutaneous fistulas: failure of octreotide to improve healing. World J Surg 2000;24:533–7.
Apparent Reduction of Cerebral Microemboli During Off-Pump Operations To the Editor: I was interested to read the randomized study by Lund and colleagues [1] in which they reported decreased intraoperative cerebral microemboli in patients having off-pump coronary artery bypass grafting compared with those having an on-pump operation. The findings are important and confirm the results of other nonrandomized, studies. However, arterial line filters are known to reduce microemboli during cardiopulmonary bypass [2]. Some arterial line filters are better than others at limiting microemboli [3]. Therefore, it would be very helpful to know whether arterial line filters were used in the on-pump group and, if so, what type. On the basis of the number of microemboli reported, I expect that filters were used, but this should have been noted. The method of pH control during hypothermia is also important in determining neuropsychological outcome and, possibly, microemboli delivery to the brain [4]. When comparing two methods such as on-pump and off-pump operations and measuring postoperative neuropsychological change, albeit as a secondary outcome, one should demonstrate that each method is being made as safe in neuroprotective terms as possible. It cannot be assumed that alpha-stat strategy and arterial lines are universally used. When relating the number of microemboli to neuropsychological outcome, Lund and colleagues were rightly circumspect. The Doppler consensus criterion for detecting microemboli is based on an arbitrary size of gaseous or particulate emboli, and the pathological effect of both types remains speculative. The use of methods for distinguishing between gaseous and solid microemboli has not yet been reported in clinical practice. As Lund and associates pointed out, both inflammation and altered cerebral blood flow may also potentially affect neuropsychological outcome. In regard to cerebral blood flow, transcranial Doppler is a useful method to simultaneously record both middle cerebral 0003-4975/04/$30.00
MISCELLANEOUS
hepatectomy are rare, but morbidity and mortality are high as a result of pulmonary sequelae and therapeutic complications [2]. We think our experience with the use of octreotide to lower morbidity in BBF is encouraging. Patients benefit from amelioration of bilioptysis [3], and accelerated fistula closure may occur in response to octreotide [4]. However, octreotide can precipitate rebound biliary output when discontinued and is ineffective if infection, obstruction, or malignancy maintain fistula patency [4].
CORRESPONDENCE