- Email: [email protected]
Ultrasonic dissectors for neurogenic tumors of the superior sulcus
Ann Thorac Surg 2004;77:2259 – 64
References 1. Martinod E, Seguin A, Pfeuty K, et al. Long-term evaluation of the replacement of the trachea with an autologous aortic graft. Ann Thorac Surg 2003;75:1572–8. 2. Dodge-Khatami A, Nijdam NC, Broekhuis E, Von Rosenstiel IA, Dahlem PG, Hazekamp MG. Carotid artery patch plasty as a last resort repair for long-segment congenital tracheal stenosis. J Thorac Cardiovasc Surg 2002;123:826 –8.
Reply
CORRESPONDENCE
2263
tissue into tracheal tissue. Surgical perspectives [in French]. C R Acad Sci III 2000;323:455–60. 3. Martinod E, Zegdi R, Zakine G, et al. A novel approach to tracheal replacement: the use of an aortic graft. J Thorac Cardiovasc Surg 2001;122:197–8. 4. Martinod E, Seguin A, Pfeuty K, et al. Long-term evaluation of the replacement of the trachea with an autologous aortic graft. Ann Thorac Surg 2003;75:1572–8. 5. Dodge-Khatami A, Nijdam NC, Broekhuis E, Von Rosenstiel IA, Dahlem PG, Hazekamp MG. Carotid artery patch plasty as a last resort repair for long-segment congenital tracheal stenosis. J Thorac Cardiovasc Surg 2002;123:826 –8.
To the Editor:
Emmanuel Martinod, MD Jacques F. Azorin, MD Service de Chirurgie Thoracique et Vasculaire Hoˆ pital Avicenne 125 Route de Stalingrad 93000 Bobigny, France e-mail: [email protected] Alain F. Carpentier, MD, PhD Laboratoire d’Etude des Greffes et Prothe`ses Cardiaques Hoˆ pital Broussais UPRES 264, Universite´ Paris 6 96 Rue Didot 75014 Paris, France
References 1. Martinod E, Aupecle B, Zegdi R, et al. Remplacement segmentaire de la trache´ e par une autogreffe aortique: la “trache´ e-arte`re.” Presse Med 1999;28:1638. 2. Martinod E, Zakine G, Fornes P, et al. Metaplasia of aortic © 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ultrasonic Dissectors for Neurogenic Tumors of the Superior Sulcus To the Editor: I read with interest the article of Pons and colleagues reporting the benefit of using a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) for removal of neurogenic tumors of the superior sulcus [1]. Thoracoscopic dissection with ultrasonically activated devices is our routine approach for most mediastinal tumors, particularly when they are located in its posterior segment. We agree with the authors that ultrasonic dissectors (UD) make these operations safer, because there is no risk of electrical transmission to nerves or to the spine. UDs, however, have limitations and drawbacks [2] that are not mentioned by the authors: 1. Although the working temperature of a UD is usually under 100°C, the temperature increases to 200°C if the UD is activated for more than 10 seconds. This may result in thermal injuries, as reported in laparoscopic surgery [3, 4]. Few surgeons are aware of this potential risk, and they have a tendency to increase the activation time as the diameter of vessels to be coagulated increases. 2. Most surgeons know that the working principle of a UD is a high-frequency vibration that produces a cavitation effect, but few realize that this effect is maximal at the tip of the instrument. This effect may lead to severe mechanical injury if the application of the scissors blades is incorrect. In our experience, these features make the use of a UD during the dissection of tumors of the superior sulcus sometimes difficult. Indeed, these tumors are often bulky and partly stuck within the thoracic outlet. This means there is little room to maneuver the UD. When the blades of the device are on the lateral or posterior aspect of the tumor, the tip of the instrument is out of visual control. Eventually, one may say that a UD facilitates the videoassisted thoracoscopic surgical dissection of neurogenic tumors and makes resection safer. However the working principle must be clearly understood in order to avoid misuse and potential complications. In some instances, a UD cannot be safely used and other tools such as clips are necessary, even though these may seem somewhat quaint. Dominique Gossot, MD Thoracic Department Institut Mutualiste Montsouris 42 Bd Jourdan F-75014 Paris, France e-mail: [email protected]
References 1. Pons F, Lang-Lazdunski L, Bonnet PM, Meyrat L, Jancovici R. Videothoracoscopic resection of neurogenic tumors of the 0003-4975/04/$30.00
MISCELLANEOUS
We thank Drs Hazekamp and Nijdam for their very interesting comments. Facing the unsolved problem of tracheal replacement, we proposed an original solution: the use of an arterial autograft. In successive experiments, we [1– 4] demonstrated that the carotid artery could be used as an autologous patch for the repair of limited tracheal defects, that an autologous aortic graft could be a valuable substitute for the trachea after extensive resection, and that a temporary silicone stent is needed for extensive tracheal replacement to avoid collapse of the new airway. We observed a progressive transformation of the arterial graft into tracheal tissue with regeneration of epithelium and cartilage. These histologic changes could explain why the grafts remained functional with a 3-year follow-up. Dodge-Khatami and colleagues [5] confirmed these results with carotid patch plasty to repair a long-segment congenital tracheal stenosis in a 4-month-old girl. Since then, they have successfully placed a patch from the ascending aorta in 2 additional patients. These experimental and clinical results seem to indicate that the choice of an autologous arterial substitute could be appropriate in children. However, use of a complete circular autologous aortic segment in selected instances must still be evaluated. For tracheal replacement in adults, the choice of an aortic allograft appears to be more attractive to avoid harvest of an arterial segment. Extensive tracheal replacement with an aortic allograft has be evaluated experimentally before clinical application. This could be a very promising alternative for patients with lesions extending over more than half the length of the trachea.
2264
CORRESPONDENCE
superior sulcus using the harmonic scalpel. Ann Thorac Surg 2003;75:602–4. 2. Gossot D, Buess G, Cuschieri A, et al. Ultrasonic dissection for endoscopic surgery. Surg Endosc 1999;13:412–7. 3. Kanehira E, Kinoshita T, Omura K. Ultrasonically activated devices for endoscopic surgery. Min Invas Ther Allied Technol 1999;8:69 –94. 4. Kadesky KM, Schlopf B, Magee JF, Blair GK. Proximity injury by the ultrasonically activated scalpel during dissection. J Pediatr Surg 1997;32:878 –9.
Reply
To the Editor: I totally agree with Dr Gossot’s remarks that the working temperature of the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) increases if activated for more than 5 seconds. Of course, the Harmonic Scalpel is, as is every cutting or coagulating surgical device, dangerous if applied in the wrong place or used beyond visual control (eg, for tumors of the superior sulcus using the videothoracoscopic approach). The operation should always be converted into a thoracotomy should visual control be suboptimal. These rules are not quaint but common sense. If the rules are respected, ultrasonic dissection is safe and the device is convenient for the removal of neurogenic tumors. Franc¸ ois Pons, MD Service de Chirurgie Thoracique et Generale Hoˆ pital d’Instruction des Armees Percy 101 Avenue Henri Barbusse BP 406 Clamart Cedex 92141, France e-mail: [email protected]
Ann Thorac Surg 2004;77:2259 – 64
the interval between perforation and presentation is not a valid contraindication to surgical repair even though one must expect far more major complications in those patients whose diseases are diagnosed late. However, their Table 5 contains an error and, more importantly, seems to compare series but fails to indicate the major differences between those series. Prognosis— of death and major complications—is related to varying causes and underlying pathology; these are not differentiated in Table 5. One should compare instrumental perforations (19 in this report) only with instrumental perforations and Boerhaave’s (2 in this report) with only Boerhaave’s perforation. This mixing of groups of diffuse causes and pathophysiologies is a common practice in most reports of esophageal perforations. Prognoses and surgical risks of all patients are not the same. The error is in reporting: our report [2] actually contained 8 patients who had repair more than 24 hours after presentation, not NS as shown in Table 5. Our series of 34 patients, all with Boerhaave’s perforations, should not be compared with patients with instrumental perforations—particularly those after extractions of foreign bodies or achalasia. The authors should be congratulated on their superb results in this series, which adds support to the concept that all esophageal perforations should be repaired when technically feasible. James W. Pate, MD Division of Cardiothoracic Surgery University of Tennessee Health Science Center 956 Court Ave Memphis, TN 38163 e-mail: [email protected]
References Esophageal Perforations To the Editor: MISCELLANEOUS
The excellent report on esophageal perforations by Port and colleagues [1] again demonstrates the important principle that
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki NK. Thoracic esophageal perforations: a decade of experience. Ann Thorac Surg 2003;74:1071–4. 2. Pate JW, Walker WA, Cole FH Jr, Owen EW, Johnson WH. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989;47:689 –92.
0003-4975/04/$30.00
References 1. Martinod E, Seguin A, Pfeuty K, et al. Long-term evaluation of the replacement of the trachea with an autologous aortic graft. Ann Thorac Surg 2003;75:1572–8. 2. Dodge-Khatami A, Nijdam NC, Broekhuis E, Von Rosenstiel IA, Dahlem PG, Hazekamp MG. Carotid artery patch plasty as a last resort repair for long-segment congenital tracheal stenosis. J Thorac Cardiovasc Surg 2002;123:826 –8.
Reply
CORRESPONDENCE
2263
tissue into tracheal tissue. Surgical perspectives [in French]. C R Acad Sci III 2000;323:455–60. 3. Martinod E, Zegdi R, Zakine G, et al. A novel approach to tracheal replacement: the use of an aortic graft. J Thorac Cardiovasc Surg 2001;122:197–8. 4. Martinod E, Seguin A, Pfeuty K, et al. Long-term evaluation of the replacement of the trachea with an autologous aortic graft. Ann Thorac Surg 2003;75:1572–8. 5. Dodge-Khatami A, Nijdam NC, Broekhuis E, Von Rosenstiel IA, Dahlem PG, Hazekamp MG. Carotid artery patch plasty as a last resort repair for long-segment congenital tracheal stenosis. J Thorac Cardiovasc Surg 2002;123:826 –8.
To the Editor:
Emmanuel Martinod, MD Jacques F. Azorin, MD Service de Chirurgie Thoracique et Vasculaire Hoˆ pital Avicenne 125 Route de Stalingrad 93000 Bobigny, France e-mail: [email protected] Alain F. Carpentier, MD, PhD Laboratoire d’Etude des Greffes et Prothe`ses Cardiaques Hoˆ pital Broussais UPRES 264, Universite´ Paris 6 96 Rue Didot 75014 Paris, France
References 1. Martinod E, Aupecle B, Zegdi R, et al. Remplacement segmentaire de la trache´ e par une autogreffe aortique: la “trache´ e-arte`re.” Presse Med 1999;28:1638. 2. Martinod E, Zakine G, Fornes P, et al. Metaplasia of aortic © 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ultrasonic Dissectors for Neurogenic Tumors of the Superior Sulcus To the Editor: I read with interest the article of Pons and colleagues reporting the benefit of using a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) for removal of neurogenic tumors of the superior sulcus [1]. Thoracoscopic dissection with ultrasonically activated devices is our routine approach for most mediastinal tumors, particularly when they are located in its posterior segment. We agree with the authors that ultrasonic dissectors (UD) make these operations safer, because there is no risk of electrical transmission to nerves or to the spine. UDs, however, have limitations and drawbacks [2] that are not mentioned by the authors: 1. Although the working temperature of a UD is usually under 100°C, the temperature increases to 200°C if the UD is activated for more than 10 seconds. This may result in thermal injuries, as reported in laparoscopic surgery [3, 4]. Few surgeons are aware of this potential risk, and they have a tendency to increase the activation time as the diameter of vessels to be coagulated increases. 2. Most surgeons know that the working principle of a UD is a high-frequency vibration that produces a cavitation effect, but few realize that this effect is maximal at the tip of the instrument. This effect may lead to severe mechanical injury if the application of the scissors blades is incorrect. In our experience, these features make the use of a UD during the dissection of tumors of the superior sulcus sometimes difficult. Indeed, these tumors are often bulky and partly stuck within the thoracic outlet. This means there is little room to maneuver the UD. When the blades of the device are on the lateral or posterior aspect of the tumor, the tip of the instrument is out of visual control. Eventually, one may say that a UD facilitates the videoassisted thoracoscopic surgical dissection of neurogenic tumors and makes resection safer. However the working principle must be clearly understood in order to avoid misuse and potential complications. In some instances, a UD cannot be safely used and other tools such as clips are necessary, even though these may seem somewhat quaint. Dominique Gossot, MD Thoracic Department Institut Mutualiste Montsouris 42 Bd Jourdan F-75014 Paris, France e-mail: [email protected]
References 1. Pons F, Lang-Lazdunski L, Bonnet PM, Meyrat L, Jancovici R. Videothoracoscopic resection of neurogenic tumors of the 0003-4975/04/$30.00
MISCELLANEOUS
We thank Drs Hazekamp and Nijdam for their very interesting comments. Facing the unsolved problem of tracheal replacement, we proposed an original solution: the use of an arterial autograft. In successive experiments, we [1– 4] demonstrated that the carotid artery could be used as an autologous patch for the repair of limited tracheal defects, that an autologous aortic graft could be a valuable substitute for the trachea after extensive resection, and that a temporary silicone stent is needed for extensive tracheal replacement to avoid collapse of the new airway. We observed a progressive transformation of the arterial graft into tracheal tissue with regeneration of epithelium and cartilage. These histologic changes could explain why the grafts remained functional with a 3-year follow-up. Dodge-Khatami and colleagues [5] confirmed these results with carotid patch plasty to repair a long-segment congenital tracheal stenosis in a 4-month-old girl. Since then, they have successfully placed a patch from the ascending aorta in 2 additional patients. These experimental and clinical results seem to indicate that the choice of an autologous arterial substitute could be appropriate in children. However, use of a complete circular autologous aortic segment in selected instances must still be evaluated. For tracheal replacement in adults, the choice of an aortic allograft appears to be more attractive to avoid harvest of an arterial segment. Extensive tracheal replacement with an aortic allograft has be evaluated experimentally before clinical application. This could be a very promising alternative for patients with lesions extending over more than half the length of the trachea.
2264
CORRESPONDENCE
superior sulcus using the harmonic scalpel. Ann Thorac Surg 2003;75:602–4. 2. Gossot D, Buess G, Cuschieri A, et al. Ultrasonic dissection for endoscopic surgery. Surg Endosc 1999;13:412–7. 3. Kanehira E, Kinoshita T, Omura K. Ultrasonically activated devices for endoscopic surgery. Min Invas Ther Allied Technol 1999;8:69 –94. 4. Kadesky KM, Schlopf B, Magee JF, Blair GK. Proximity injury by the ultrasonically activated scalpel during dissection. J Pediatr Surg 1997;32:878 –9.
Reply
To the Editor: I totally agree with Dr Gossot’s remarks that the working temperature of the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) increases if activated for more than 5 seconds. Of course, the Harmonic Scalpel is, as is every cutting or coagulating surgical device, dangerous if applied in the wrong place or used beyond visual control (eg, for tumors of the superior sulcus using the videothoracoscopic approach). The operation should always be converted into a thoracotomy should visual control be suboptimal. These rules are not quaint but common sense. If the rules are respected, ultrasonic dissection is safe and the device is convenient for the removal of neurogenic tumors. Franc¸ ois Pons, MD Service de Chirurgie Thoracique et Generale Hoˆ pital d’Instruction des Armees Percy 101 Avenue Henri Barbusse BP 406 Clamart Cedex 92141, France e-mail: [email protected]
Ann Thorac Surg 2004;77:2259 – 64
the interval between perforation and presentation is not a valid contraindication to surgical repair even though one must expect far more major complications in those patients whose diseases are diagnosed late. However, their Table 5 contains an error and, more importantly, seems to compare series but fails to indicate the major differences between those series. Prognosis— of death and major complications—is related to varying causes and underlying pathology; these are not differentiated in Table 5. One should compare instrumental perforations (19 in this report) only with instrumental perforations and Boerhaave’s (2 in this report) with only Boerhaave’s perforation. This mixing of groups of diffuse causes and pathophysiologies is a common practice in most reports of esophageal perforations. Prognoses and surgical risks of all patients are not the same. The error is in reporting: our report [2] actually contained 8 patients who had repair more than 24 hours after presentation, not NS as shown in Table 5. Our series of 34 patients, all with Boerhaave’s perforations, should not be compared with patients with instrumental perforations—particularly those after extractions of foreign bodies or achalasia. The authors should be congratulated on their superb results in this series, which adds support to the concept that all esophageal perforations should be repaired when technically feasible. James W. Pate, MD Division of Cardiothoracic Surgery University of Tennessee Health Science Center 956 Court Ave Memphis, TN 38163 e-mail: [email protected]
References Esophageal Perforations To the Editor: MISCELLANEOUS
The excellent report on esophageal perforations by Port and colleagues [1] again demonstrates the important principle that
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki NK. Thoracic esophageal perforations: a decade of experience. Ann Thorac Surg 2003;74:1071–4. 2. Pate JW, Walker WA, Cole FH Jr, Owen EW, Johnson WH. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989;47:689 –92.
0003-4975/04/$30.00