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VATS is not thoracoscopy
Ann Thorac Surg 1996;62:623-32
long enough to reach any site within the pleural cavity and wide enough to easily encircle and seal any kind of tracheobronchial anastomosis. Its efficacy in protecting and sealing the suture line has been proved in 59 patients undergoing various types of tracheobronchial reconstructive procedures. In particular, it is noteworthy how effective the intercostal pedicle flap was in preventing the occurrence of a bronchopleural fistula in 3 patients previously treated by radiotherapy who had a complete (1) or partial (2) dehiscence of the anastomosis. Bronchoscopically, the pleural surface of the flap was visible bulging into the bronchial lumen, but no bronchopleural or bronchovascular fistula developed, and the patients fully recovered after 6 to 12 months of airway stenting by a silicone prosthesis. In our article [2] we also addressed the issue of revascularization of the airway stumps, and we demonstrated arteriographically that a properly prepared intercostal pedicle flap may indeed generate a fine vascular network around the anastomosis early in the postoperative period. To the best of our knowledge this has not yet been proved for any other intrathoracic flap (eg, pleura alone, pericardium, mediastinal fat). Our experience has now increased to 96 patients undergoing bronchial sleeve resection, 24 of whom had had preoperative neoadjuvant chemotherapy for stages IlIA and IIIB lung cancer. The intercostal pedicle flap was used in all of them to encircle the anastomosis. Patients undergoing neoadjuvant chemotherapy, as Anderson and Miller [1] point out most correctly, are particularly at risk for bronchial complications after lobectomy and pneumonectomy, and even more so after sleeve resection. Interestingly, in our group of 24 such patients we did not experience any bronchial complication. We are strongly persuaded that much of the credit for this good result goes to the excellent protection and early revascularization yielded by the intercostal flap technique. To obtain an ideal flap, the latter has to be taken down before the pleural cavity is opened; this has been regarded as a disadvantage, because one could not be sure whether a sleeve should be performed or not. However, w h e n neoadjuvant therapy patients are concerned, some kind of bronchial protection is recommendable anyhow as pointed out by Anderson and Miller [1], and the intercostal pedicle flap may well be prepared in advance. Anderson and Miller [1] should be c o m m e n d e d for bringing up the issue of flap protection of tracheobronchial sutures, but their fine overview on such an intriguing subject is not complete unless the effectiveness and ease of the intercostal pedicle flap is pointed out. In our experience this proved to be by far the best technique to seal and revascularize bronchial anastomoses.
Erino A. Rendina, MD Federico Venuta, MD Tiziano De Giacomo, MD Costante Ricci, MD Department of Thoracic Surgery, II Clinica Chirurgica University "La Sapienza" of Rome Policlinico Umberto 1, 00161, Roma, Italy References 1. Anderson TM, Miller JI Jr. Use of pleura, azygos vein, pericardium, and muscle flaps in tracheobronchial surgery. Ann Thorac Surg 1995;60:729-33. 2. Rendina EA, Venuta F, Ricci P, et al. Protection and revascularization of bronchial anastomoses by the intercostal pedicle flap. J Thorac Cardiovasc Surg 1994;107:1251-4. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
CORRESPONDENCE
631
Reply To the Editor: I agree that the intercostal muscle flap is an excellent means of coverage of the bronchial stump. It was not mentioned in our article because articles on its advantages have been published numerous times in The Annals in the last 10 years. Our article covered other means available for coverage of the bronchial stump.
Joseph I. Miller, Jr, MD Department of Cardiothoracic Surgery Emory University School of Medicine 25 Prescott St, NE Atlanta, GA 30308
V A T S Is Not Thoracoscopy
To the Editor: After reading the April edition of The Annals of Thoracic Surgery, I became confused because there were several articles that discussed video-assisted thoracic surgery (VATS) or thoracoscopy; however, it was never made clear which procedure was being performed. Currently, the terms VATS and thoracoscopy are being intermingled and interchanged as if they were the same identical procedure. There are absolute, genuine differences between these two techniques. From 1965 until the late 1980s, I had experience with approximately 300 traditional thoracoscopies. Since 1990, I have had experience with more than 1,000 VATS procedures. In my opinion, VATS is not thoracoscopy and thoracoscopy is not VATS. The Joint Committee, in late 1991, devoted a large part of their first meeting searching for an appropriate n a m e for this new technique. Nobody suggested that it be called thoracoscopy. In fact, the name of that Committee eventually became the Joint Committee of the AATS/STS for Thoracoscopy and Video-Assisted Thoracic Surgery. Early on, the members of the Joint Committee recognized that these were two separate and distinct procedures. W h e n guidelines were published, the Joint Committee decided to omit thoracoscopy from that publication because it was already a well-known procedure with its own established guidelines. The new guidelines concerned only VATS [1]. Recently, Dr John Benfield favored the name video-assisted thoracic surgery for this new technique and called for a eulogy for thoracoscopy [2]. Thoraeoscopy can be mistaken for pleuroscopy, which some interventional pulmonologists have been using to perform very simple procedures. In fact, courses in medical thoracoscopy for pulmonologists are being advertised [3]. Video-assisted thoracic surgery, however, is really a thoracic surgical procedure that is used by thoracic surgeons to perform complex surgical operations. Unfortunately, the intermingling of these two terms is becoming commonplace throughout the thoracic surgical literature. Presently, the term thoracoscopy often signifies VATS and, of course, the term VATS always refers to VATS. How will we know when thoracoscopy really indicates a traditional, oldfashioned thoracoscopy? There are major differences between the two procedures (Table 1). It would be more meaningful and less confusing to refer to these two separate and distinct procedures using the terminology r e c o m m e n d e d by the Joint Committee of the AATS/STS for Thoracoscopy and Video-Assisted Thoracic Sur0003-4975/96/$15.00
632
CORRESPONDENCE
Ann Thorac Surg 1996;62:623-32
Table 1. Differences Between Thoracoscopy and VATS
References
Thoracoscopy
1. AATS/STS Joint Committee on Video-Assisted Thoracic Surgery. Guidelines for granting hospital privileges in videoassisted thoracic surgery. Ann Thorac Surg 1995;60:1456. 2. Benfield JR. In favor of video-assisted thoracic surgery and a eulogy for thoracoscopy. A n n Surg Oncol 1994;1:91-2. 3. Beamis Jr. JF, Boutin C, D u m o n JF. Therapeutic bronchoscopy a n d medical thoracoscopy. Chest 1996;109:20. 4. Jacobaeus HC. Ueber die M6glichkeit die Zystoskopie bei untersuchung ser~se, h/Shlungen Ansuwenden. M u n c h Med Wochenschr 1910;57:2090-2.
Old No video Direct visualization Tunnel-like visualization Limited access One incision Three-dimensional visualization One h a n d operates Only the surgeon participates Palpation without visualization Simple procedures
VATS New Video Indirect visualization Panoramic visualization Ample access Two to four incisions Two-dimensional visualization Two hands operate Entire team participates Palpation with visualization Complex procedures
VATS - video-assisted thoracic surgery.
gery, ie, VATS for VATS and thoracoscopy for the traditional procedure described by Jacobaeus [4l.
Ralph ]. Lewis, MD 185 Livingston Ave New Brunswick, NJ 08901
© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CORRECTION
Di Simone MP, Felice V, D'Errico A, et al. Onset timing of delayed complications and criteria of follow-up after operation for esophageal achalasia. Ann Thorac Surg 1996; 61:1106-11. There is an error in Dr Ellis' Invited Commentary to this article. The sentence that reads "there are now reports of 22 patients with achalasia and Barrett's esophagus in w h o m an adenocarcinoma developed up to 30 years after the diagnosis of achalasia" should read "there are now reports of 7 patients with achalasia a n d Barrett's esophagus in whom an adenocarcinoma developed up to 30 years after the diagnosis of achalasia."
0003-4975/96/$15.00
long enough to reach any site within the pleural cavity and wide enough to easily encircle and seal any kind of tracheobronchial anastomosis. Its efficacy in protecting and sealing the suture line has been proved in 59 patients undergoing various types of tracheobronchial reconstructive procedures. In particular, it is noteworthy how effective the intercostal pedicle flap was in preventing the occurrence of a bronchopleural fistula in 3 patients previously treated by radiotherapy who had a complete (1) or partial (2) dehiscence of the anastomosis. Bronchoscopically, the pleural surface of the flap was visible bulging into the bronchial lumen, but no bronchopleural or bronchovascular fistula developed, and the patients fully recovered after 6 to 12 months of airway stenting by a silicone prosthesis. In our article [2] we also addressed the issue of revascularization of the airway stumps, and we demonstrated arteriographically that a properly prepared intercostal pedicle flap may indeed generate a fine vascular network around the anastomosis early in the postoperative period. To the best of our knowledge this has not yet been proved for any other intrathoracic flap (eg, pleura alone, pericardium, mediastinal fat). Our experience has now increased to 96 patients undergoing bronchial sleeve resection, 24 of whom had had preoperative neoadjuvant chemotherapy for stages IlIA and IIIB lung cancer. The intercostal pedicle flap was used in all of them to encircle the anastomosis. Patients undergoing neoadjuvant chemotherapy, as Anderson and Miller [1] point out most correctly, are particularly at risk for bronchial complications after lobectomy and pneumonectomy, and even more so after sleeve resection. Interestingly, in our group of 24 such patients we did not experience any bronchial complication. We are strongly persuaded that much of the credit for this good result goes to the excellent protection and early revascularization yielded by the intercostal flap technique. To obtain an ideal flap, the latter has to be taken down before the pleural cavity is opened; this has been regarded as a disadvantage, because one could not be sure whether a sleeve should be performed or not. However, w h e n neoadjuvant therapy patients are concerned, some kind of bronchial protection is recommendable anyhow as pointed out by Anderson and Miller [1], and the intercostal pedicle flap may well be prepared in advance. Anderson and Miller [1] should be c o m m e n d e d for bringing up the issue of flap protection of tracheobronchial sutures, but their fine overview on such an intriguing subject is not complete unless the effectiveness and ease of the intercostal pedicle flap is pointed out. In our experience this proved to be by far the best technique to seal and revascularize bronchial anastomoses.
Erino A. Rendina, MD Federico Venuta, MD Tiziano De Giacomo, MD Costante Ricci, MD Department of Thoracic Surgery, II Clinica Chirurgica University "La Sapienza" of Rome Policlinico Umberto 1, 00161, Roma, Italy References 1. Anderson TM, Miller JI Jr. Use of pleura, azygos vein, pericardium, and muscle flaps in tracheobronchial surgery. Ann Thorac Surg 1995;60:729-33. 2. Rendina EA, Venuta F, Ricci P, et al. Protection and revascularization of bronchial anastomoses by the intercostal pedicle flap. J Thorac Cardiovasc Surg 1994;107:1251-4. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
CORRESPONDENCE
631
Reply To the Editor: I agree that the intercostal muscle flap is an excellent means of coverage of the bronchial stump. It was not mentioned in our article because articles on its advantages have been published numerous times in The Annals in the last 10 years. Our article covered other means available for coverage of the bronchial stump.
Joseph I. Miller, Jr, MD Department of Cardiothoracic Surgery Emory University School of Medicine 25 Prescott St, NE Atlanta, GA 30308
V A T S Is Not Thoracoscopy
To the Editor: After reading the April edition of The Annals of Thoracic Surgery, I became confused because there were several articles that discussed video-assisted thoracic surgery (VATS) or thoracoscopy; however, it was never made clear which procedure was being performed. Currently, the terms VATS and thoracoscopy are being intermingled and interchanged as if they were the same identical procedure. There are absolute, genuine differences between these two techniques. From 1965 until the late 1980s, I had experience with approximately 300 traditional thoracoscopies. Since 1990, I have had experience with more than 1,000 VATS procedures. In my opinion, VATS is not thoracoscopy and thoracoscopy is not VATS. The Joint Committee, in late 1991, devoted a large part of their first meeting searching for an appropriate n a m e for this new technique. Nobody suggested that it be called thoracoscopy. In fact, the name of that Committee eventually became the Joint Committee of the AATS/STS for Thoracoscopy and Video-Assisted Thoracic Surgery. Early on, the members of the Joint Committee recognized that these were two separate and distinct procedures. W h e n guidelines were published, the Joint Committee decided to omit thoracoscopy from that publication because it was already a well-known procedure with its own established guidelines. The new guidelines concerned only VATS [1]. Recently, Dr John Benfield favored the name video-assisted thoracic surgery for this new technique and called for a eulogy for thoracoscopy [2]. Thoraeoscopy can be mistaken for pleuroscopy, which some interventional pulmonologists have been using to perform very simple procedures. In fact, courses in medical thoracoscopy for pulmonologists are being advertised [3]. Video-assisted thoracic surgery, however, is really a thoracic surgical procedure that is used by thoracic surgeons to perform complex surgical operations. Unfortunately, the intermingling of these two terms is becoming commonplace throughout the thoracic surgical literature. Presently, the term thoracoscopy often signifies VATS and, of course, the term VATS always refers to VATS. How will we know when thoracoscopy really indicates a traditional, oldfashioned thoracoscopy? There are major differences between the two procedures (Table 1). It would be more meaningful and less confusing to refer to these two separate and distinct procedures using the terminology r e c o m m e n d e d by the Joint Committee of the AATS/STS for Thoracoscopy and Video-Assisted Thoracic Sur0003-4975/96/$15.00
632
CORRESPONDENCE
Ann Thorac Surg 1996;62:623-32
Table 1. Differences Between Thoracoscopy and VATS
References
Thoracoscopy
1. AATS/STS Joint Committee on Video-Assisted Thoracic Surgery. Guidelines for granting hospital privileges in videoassisted thoracic surgery. Ann Thorac Surg 1995;60:1456. 2. Benfield JR. In favor of video-assisted thoracic surgery and a eulogy for thoracoscopy. A n n Surg Oncol 1994;1:91-2. 3. Beamis Jr. JF, Boutin C, D u m o n JF. Therapeutic bronchoscopy a n d medical thoracoscopy. Chest 1996;109:20. 4. Jacobaeus HC. Ueber die M6glichkeit die Zystoskopie bei untersuchung ser~se, h/Shlungen Ansuwenden. M u n c h Med Wochenschr 1910;57:2090-2.
Old No video Direct visualization Tunnel-like visualization Limited access One incision Three-dimensional visualization One h a n d operates Only the surgeon participates Palpation without visualization Simple procedures
VATS New Video Indirect visualization Panoramic visualization Ample access Two to four incisions Two-dimensional visualization Two hands operate Entire team participates Palpation with visualization Complex procedures
VATS - video-assisted thoracic surgery.
gery, ie, VATS for VATS and thoracoscopy for the traditional procedure described by Jacobaeus [4l.
Ralph ]. Lewis, MD 185 Livingston Ave New Brunswick, NJ 08901
© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CORRECTION
Di Simone MP, Felice V, D'Errico A, et al. Onset timing of delayed complications and criteria of follow-up after operation for esophageal achalasia. Ann Thorac Surg 1996; 61:1106-11. There is an error in Dr Ellis' Invited Commentary to this article. The sentence that reads "there are now reports of 22 patients with achalasia and Barrett's esophagus in w h o m an adenocarcinoma developed up to 30 years after the diagnosis of achalasia" should read "there are now reports of 7 patients with achalasia a n d Barrett's esophagus in whom an adenocarcinoma developed up to 30 years after the diagnosis of achalasia."
0003-4975/96/$15.00