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Tracheal Reconstruction
300 The Annals of Thoracic Surgery Vol 38 No 3 September 1984
report on use of one-lung anesthesia in cases of neonatal lung abscess. We are certain that the method they described is very effective and of considerable value in the relatively rare event of a thoracic surgical procedure in ii neonate requiring one-lung anesthesia. However, it should be cautiously considered in the seriously ill infant and may be ha.zardousin neonates with hypoxemia and respiratory failure. Computed tomography seems to have contributed substantially to the differentiation of a pulmonary abscess from a pleural process. The radiological as well as the pathological findings in the authors' first case report would otherwise be more compatible with a lobar pneumonia complicated by a loculated empyema. In the second case report, the patient's lesion was histologically determined to be an infected bronchogenic cyst. This, as the authors are well aware, is not an abscess. The lesion has clear boundaries, and the risk of bronchial spillage is minimal. Weber and co-workers indirectly advocate early surgical treatment of neonatal lung abscess. Certainly the removal of a large amount of purulent material facilitates recovery, as is true of any abscess. The authors state that a neonatal abscess is unlikely to respond to conservative treatment. They base their opinion partly on the report by Moore and colleagues [2] from 1960. In this study, more than half of the patients (10 out of 18) received no antibiotic treatment at all and the others, only 2 of whom were younger than 12 months of age, were given penicillin, which is not always suffiaent. Siegel and McCracken (31, also cited by Weber and co-workers, recommend early surgical intervention based on their experience with 6 neonates. Two of their patients had congenital lesions (bronchogenic cyst and adenomatous malformation), not abscesses. One was operated on to rule out a cyst, and 1 required operative intervention for a ruptured abscess with bronchopleural fistula and tension pneumothorax. One abscess resolved with medical treatment. Only in a single instance was operation indicated as a treatment for an unresponsive lung abscess. Therefore, there are insufficient grounds for recommending early operative intervention in the treatment of primary lung abscess in neonates. On the other hand, the series reported by Mark and Turner [4] implies that conservative treatment may be effective in most cases. Among 25 children with primary lung abscess, 23 recovered with medical treatment and only 2 required operative intervention. Unfortunately, this report included only 6 infants younger than 1 year of age. True primary lung abscess in a neonate appears to be a very rare entity. In my opinion, it should be treated mainly with antibiotics and bronchoscopy; data are insufficient to determine the rule for or the timing of surgical intervention. Alon Yellin, M . D . Division of Surgery City of Hope National Medical Center 1500 E Duarte Rd Duarte, C A 91010
References 1. Weber TR, Vane DW, Krishna G, et al: Neonatal lung ab-
scess: resection using one-lung anesthesia. Ann Thorac Surg 36:464, 1983 2. Moore TC, Battersby JS, Stanley J: Pulmonary abscess in infancy and childhood. Ann Surg 151:496, 1960 3. Siegel JD, McCracken GH: Neonatal lung abscess. Am J Dis Child 133:947, 1982 4. Mark PH, Turner JAP: Lung abscess in childhood. Thorax 23:216, 1968
Reply To the Editor: My co-workers and I appreciate Dr. Yellin's interest in our technique of one-lung anesthesia for neonatal lung abscess, but we feel compelled to comment on several of his criticisms. Neonatal lung abscess, although quite rare, nevertheless is seen in most pediatric hospitals and must be dealt with in a manner that is both safe and efficacious. While we agree that seriously ill infants are poor operative candidates, these are precisely the infants for whom we are frequently called on to provide surgical management. The technique of one-lung anesthesia has been shown to be a safe method for the management of lung abscess in infants with both hypoxemia and severe respiratory distress. Since infected bronchogenic cysts and lung abscess look identical when evaluated by most radiological methods, it is usually not possible to distinguish between these two entities preoperatively in the newborn. Both lesions represent collections of purulent material that can cause increasing sepsis, and the principles of total removal of the lesion remain valid. It is true that there is very little risk of bronchial spillage of pus from infected congenital lung cysts, but again preoperative differentiation is usually not possible. Dr. Yellin's opinion that neonatal lung abscess should be treated mainly with antibiotics and bronchoscopy is not supported by any data cited. All 3 of our patients were treated with antibiotics until no improvement ensued or clinical deterioration was evident. At that point, resection of the infected lesion resulted in prompt resolution of the septic course. We agree completely with Dr. Yellin that primary lung abscess in neonates is quite rare. However, surgeons who are contemplating resection of these lesions should consider onelung anesthesia as a safe method to accomplish that goal. Thomas R . Weber, M . D . Department of Pediatric Surgery St. Louis University Medical Center St. Louis University School of Medicine 1325 S Grand St. Louis, M O 63104
Tracheal Reconstruction To the Editor: I congratulate Dr.Akl and his co-workers on their successful use of a new method of tracheal reconstruction that permitted replacement of the entire trachea in a 3-month-old infant (Ann Thorac Surg 36265, 1983). We performed identical experiments in mongrel dogs and dissections in human cadavers in Valparaiso in 1973. The results of our experiments and dissections were discussed in a personal communication to Dr. Hermes Grillo in 1975. I am glad to see that the experimental hypothesis regarding the usefulness of the left main bronchus in selected patients has finally been demonstrated to be a valid surgical therapeutic alternative in a clinical setting. To date, we have not found this situation in our clinical practice with adult patients. Alfred0 Rioseco, M .D . , F.C.C.P. Health Service of V i i u del Mar Casilla 816 Viria del Mar, Chile
301 Correspondence
Editor's Note (H.S.)
Dr. Hermes Grillo has confirmed Dr. Rioseco's statement about the communication he sent to Dr. Grillo in 1975. In all respects, Dr. Rioseco's and Dr. Akl's concepts appear to be identical. However, the Editor of The Annals of Thoracic Surgery will continue to invoke the Ingelfinger position on claims of priority (i.e., not to recognize them), because any claim of priority is likely to invoke angry protests from many comers of the world denying the claimant's right to the title (N Engl J Med 290:740, 1974).
Bilateral Sequential IMA Grafting To the Editor: In their report entitled "Multivessel Coronary Revascularization without Saphenous Vein: Long-term Results of Bilateral Internal Mammary Artery Grafting" (Ann Thorac Surg 36540, 1983), Lytle and colleagues state that the major disadvantage of using the internal mammary artery (IMA) is that there are only two such vessels per patient and other conduits may be needed when more than two grafts are indicated. Recently we were able to successfully accomplish multivessel coronary revascularization utilizing bilateral sequential IMA grafts in 2 patients. In a 63-year-old man who was found during operation to have inadequate veins, the right IMA was grafted to the proximal and distal left anterior descending coronary artery and the left IMA was grafted to the first circumflex marginal branch and the distal circumflex coronary artery. In a 72-year-old woman who had had bilateral vein stripping, the right IMA was grafted to the left anterior descending coronary artery and the left IMA, to the circumflex marginal and diagonal branches. This approach was a logical step following use of a unilateral sequential IMA coronary artery bypass in 7 patients and bilateral IMA-simple coronary artery bypass in several others. Follow-up angiograms obtained in 2 of the patients with sequential grafts have demonstrated the patency of all anastomoses. Although technically more complicatedand demanding, multiple-vessel revascularization using bilateral sequential IMA grafting is both feasible and useful in patients with inadequate veins.
References 1. McNicholas KW, Niguidula FN: A technique for placement of left atrial monitoring line. Ann Thorac Surg 35:568, 1983 2. Iglesias A, Gil Aguado M, NuAez L: Safer insertion of left atrial pressure monitoring catheter. J Cardiovasc Surg (Torho) 21:513, 1980
Reply To the Editor: Dr. Niguidula and I are grateful to Dr. Iglesias for calling to our attention his article on left atrial catheter placement, and we acknowledge his contribution. Because of our practice of venting the left ventricle through a patent foramen ovale or a stab wound in the fossa ovalis, we have not used the "puncture technique" he described, but we recognize its potential usefulness. We share his enthusiasm for transseptal placement of left atrial pressure monitoring catheters. Kathleen W . McNicholas, M . D . Deborah Heart and Lung Center Browns Mills, NJ 08015
Modification of Eder-Puestow Dilators To the Editor: Each time a larger olive is to be placed on the Eder-Puestow dilating system, the handle has to be taken off the entire length of the guidewire; then, the olive and handle must be threaded back on. By placing a slit on each olive just larger than the guidewire (Figure, A), one can exchange the olives without having to thread them off the wire or remove the handle (Figure, B). Initially, there was fear that this slit might in some way cause perforation or slicing of the esophagus, but this fear has been allayed after four years of use of the technique without the occurrence of such complications.
Nadiv Shapira, M . D . Gerald M . Lemole, M . D . Department of Thoracic and Cardiovascular Surgery Deborah Heart and Lung Center Browns Mills, NJ 08015
Placement of LAP Monitoring Line To the Editor: I wish to commend Drs. McNicholas and Niguidula on their interesting article in The Annals [l]. However, in 1980 my associates and I [2] reported an almost identical surgicaltechnique for insertion of a left atrial pressure monitoring line. At that time, we had used this technique in 20 patients: 15 with tricuspid valve lesions and 5 with congenital defects. To date, we have employed it in more than 100 patients in whom the right atrium should be opened as a part of the surgical procedure. We have not observed any complications related to its use. I regret that our paper was overlooked. Alfonso Iglesias, M . D . Department of Cardiac Surgery Ciudad Sanitaria "La Paz" Universidad Autbnoma a'e Madrid M d r i d , Spain
A
'I, 'I,,,,
.
.
...
a m . ./
B Modification of Eder-Puestow dilating system to facilitate exchange of dilating olives. ( A ) Exchange of dilator portion. ( B ) Dilator in position for use. F . L. Korompai, M . D . R. H. Hayward, M.B., Ch.B. Division of Thoracic and Cardiovascular Surgery Texas A&M University School of Medicine Scott and White Clinic 2401 s 31st St Temple, T X 76508
report on use of one-lung anesthesia in cases of neonatal lung abscess. We are certain that the method they described is very effective and of considerable value in the relatively rare event of a thoracic surgical procedure in ii neonate requiring one-lung anesthesia. However, it should be cautiously considered in the seriously ill infant and may be ha.zardousin neonates with hypoxemia and respiratory failure. Computed tomography seems to have contributed substantially to the differentiation of a pulmonary abscess from a pleural process. The radiological as well as the pathological findings in the authors' first case report would otherwise be more compatible with a lobar pneumonia complicated by a loculated empyema. In the second case report, the patient's lesion was histologically determined to be an infected bronchogenic cyst. This, as the authors are well aware, is not an abscess. The lesion has clear boundaries, and the risk of bronchial spillage is minimal. Weber and co-workers indirectly advocate early surgical treatment of neonatal lung abscess. Certainly the removal of a large amount of purulent material facilitates recovery, as is true of any abscess. The authors state that a neonatal abscess is unlikely to respond to conservative treatment. They base their opinion partly on the report by Moore and colleagues [2] from 1960. In this study, more than half of the patients (10 out of 18) received no antibiotic treatment at all and the others, only 2 of whom were younger than 12 months of age, were given penicillin, which is not always suffiaent. Siegel and McCracken (31, also cited by Weber and co-workers, recommend early surgical intervention based on their experience with 6 neonates. Two of their patients had congenital lesions (bronchogenic cyst and adenomatous malformation), not abscesses. One was operated on to rule out a cyst, and 1 required operative intervention for a ruptured abscess with bronchopleural fistula and tension pneumothorax. One abscess resolved with medical treatment. Only in a single instance was operation indicated as a treatment for an unresponsive lung abscess. Therefore, there are insufficient grounds for recommending early operative intervention in the treatment of primary lung abscess in neonates. On the other hand, the series reported by Mark and Turner [4] implies that conservative treatment may be effective in most cases. Among 25 children with primary lung abscess, 23 recovered with medical treatment and only 2 required operative intervention. Unfortunately, this report included only 6 infants younger than 1 year of age. True primary lung abscess in a neonate appears to be a very rare entity. In my opinion, it should be treated mainly with antibiotics and bronchoscopy; data are insufficient to determine the rule for or the timing of surgical intervention. Alon Yellin, M . D . Division of Surgery City of Hope National Medical Center 1500 E Duarte Rd Duarte, C A 91010
References 1. Weber TR, Vane DW, Krishna G, et al: Neonatal lung ab-
scess: resection using one-lung anesthesia. Ann Thorac Surg 36:464, 1983 2. Moore TC, Battersby JS, Stanley J: Pulmonary abscess in infancy and childhood. Ann Surg 151:496, 1960 3. Siegel JD, McCracken GH: Neonatal lung abscess. Am J Dis Child 133:947, 1982 4. Mark PH, Turner JAP: Lung abscess in childhood. Thorax 23:216, 1968
Reply To the Editor: My co-workers and I appreciate Dr. Yellin's interest in our technique of one-lung anesthesia for neonatal lung abscess, but we feel compelled to comment on several of his criticisms. Neonatal lung abscess, although quite rare, nevertheless is seen in most pediatric hospitals and must be dealt with in a manner that is both safe and efficacious. While we agree that seriously ill infants are poor operative candidates, these are precisely the infants for whom we are frequently called on to provide surgical management. The technique of one-lung anesthesia has been shown to be a safe method for the management of lung abscess in infants with both hypoxemia and severe respiratory distress. Since infected bronchogenic cysts and lung abscess look identical when evaluated by most radiological methods, it is usually not possible to distinguish between these two entities preoperatively in the newborn. Both lesions represent collections of purulent material that can cause increasing sepsis, and the principles of total removal of the lesion remain valid. It is true that there is very little risk of bronchial spillage of pus from infected congenital lung cysts, but again preoperative differentiation is usually not possible. Dr. Yellin's opinion that neonatal lung abscess should be treated mainly with antibiotics and bronchoscopy is not supported by any data cited. All 3 of our patients were treated with antibiotics until no improvement ensued or clinical deterioration was evident. At that point, resection of the infected lesion resulted in prompt resolution of the septic course. We agree completely with Dr. Yellin that primary lung abscess in neonates is quite rare. However, surgeons who are contemplating resection of these lesions should consider onelung anesthesia as a safe method to accomplish that goal. Thomas R . Weber, M . D . Department of Pediatric Surgery St. Louis University Medical Center St. Louis University School of Medicine 1325 S Grand St. Louis, M O 63104
Tracheal Reconstruction To the Editor: I congratulate Dr.Akl and his co-workers on their successful use of a new method of tracheal reconstruction that permitted replacement of the entire trachea in a 3-month-old infant (Ann Thorac Surg 36265, 1983). We performed identical experiments in mongrel dogs and dissections in human cadavers in Valparaiso in 1973. The results of our experiments and dissections were discussed in a personal communication to Dr. Hermes Grillo in 1975. I am glad to see that the experimental hypothesis regarding the usefulness of the left main bronchus in selected patients has finally been demonstrated to be a valid surgical therapeutic alternative in a clinical setting. To date, we have not found this situation in our clinical practice with adult patients. Alfred0 Rioseco, M .D . , F.C.C.P. Health Service of V i i u del Mar Casilla 816 Viria del Mar, Chile
301 Correspondence
Editor's Note (H.S.)
Dr. Hermes Grillo has confirmed Dr. Rioseco's statement about the communication he sent to Dr. Grillo in 1975. In all respects, Dr. Rioseco's and Dr. Akl's concepts appear to be identical. However, the Editor of The Annals of Thoracic Surgery will continue to invoke the Ingelfinger position on claims of priority (i.e., not to recognize them), because any claim of priority is likely to invoke angry protests from many comers of the world denying the claimant's right to the title (N Engl J Med 290:740, 1974).
Bilateral Sequential IMA Grafting To the Editor: In their report entitled "Multivessel Coronary Revascularization without Saphenous Vein: Long-term Results of Bilateral Internal Mammary Artery Grafting" (Ann Thorac Surg 36540, 1983), Lytle and colleagues state that the major disadvantage of using the internal mammary artery (IMA) is that there are only two such vessels per patient and other conduits may be needed when more than two grafts are indicated. Recently we were able to successfully accomplish multivessel coronary revascularization utilizing bilateral sequential IMA grafts in 2 patients. In a 63-year-old man who was found during operation to have inadequate veins, the right IMA was grafted to the proximal and distal left anterior descending coronary artery and the left IMA was grafted to the first circumflex marginal branch and the distal circumflex coronary artery. In a 72-year-old woman who had had bilateral vein stripping, the right IMA was grafted to the left anterior descending coronary artery and the left IMA, to the circumflex marginal and diagonal branches. This approach was a logical step following use of a unilateral sequential IMA coronary artery bypass in 7 patients and bilateral IMA-simple coronary artery bypass in several others. Follow-up angiograms obtained in 2 of the patients with sequential grafts have demonstrated the patency of all anastomoses. Although technically more complicatedand demanding, multiple-vessel revascularization using bilateral sequential IMA grafting is both feasible and useful in patients with inadequate veins.
References 1. McNicholas KW, Niguidula FN: A technique for placement of left atrial monitoring line. Ann Thorac Surg 35:568, 1983 2. Iglesias A, Gil Aguado M, NuAez L: Safer insertion of left atrial pressure monitoring catheter. J Cardiovasc Surg (Torho) 21:513, 1980
Reply To the Editor: Dr. Niguidula and I are grateful to Dr. Iglesias for calling to our attention his article on left atrial catheter placement, and we acknowledge his contribution. Because of our practice of venting the left ventricle through a patent foramen ovale or a stab wound in the fossa ovalis, we have not used the "puncture technique" he described, but we recognize its potential usefulness. We share his enthusiasm for transseptal placement of left atrial pressure monitoring catheters. Kathleen W . McNicholas, M . D . Deborah Heart and Lung Center Browns Mills, NJ 08015
Modification of Eder-Puestow Dilators To the Editor: Each time a larger olive is to be placed on the Eder-Puestow dilating system, the handle has to be taken off the entire length of the guidewire; then, the olive and handle must be threaded back on. By placing a slit on each olive just larger than the guidewire (Figure, A), one can exchange the olives without having to thread them off the wire or remove the handle (Figure, B). Initially, there was fear that this slit might in some way cause perforation or slicing of the esophagus, but this fear has been allayed after four years of use of the technique without the occurrence of such complications.
Nadiv Shapira, M . D . Gerald M . Lemole, M . D . Department of Thoracic and Cardiovascular Surgery Deborah Heart and Lung Center Browns Mills, NJ 08015
Placement of LAP Monitoring Line To the Editor: I wish to commend Drs. McNicholas and Niguidula on their interesting article in The Annals [l]. However, in 1980 my associates and I [2] reported an almost identical surgicaltechnique for insertion of a left atrial pressure monitoring line. At that time, we had used this technique in 20 patients: 15 with tricuspid valve lesions and 5 with congenital defects. To date, we have employed it in more than 100 patients in whom the right atrium should be opened as a part of the surgical procedure. We have not observed any complications related to its use. I regret that our paper was overlooked. Alfonso Iglesias, M . D . Department of Cardiac Surgery Ciudad Sanitaria "La Paz" Universidad Autbnoma a'e Madrid M d r i d , Spain
A
'I, 'I,,,,
.
.
...
a m . ./
B Modification of Eder-Puestow dilating system to facilitate exchange of dilating olives. ( A ) Exchange of dilator portion. ( B ) Dilator in position for use. F . L. Korompai, M . D . R. H. Hayward, M.B., Ch.B. Division of Thoracic and Cardiovascular Surgery Texas A&M University School of Medicine Scott and White Clinic 2401 s 31st St Temple, T X 76508