- Email: [email protected]
Who Should Treat Sleep Apnea and How?
because these procedures were usually performed in patients who were UPPP failures or were performed multiple simultaneously with UPPP. In addition, have been developed for the correction procedures of retroglossal collapse. This factor added an extra to the evaluation of retroglossal layer of complexity exist for the assessment of that did not surgery UPPP. One has the sense from examining the anal¬ ysis of Sher et al1 that surgical procedures that increased retroglossal airway caliber in those patients with retroglossal narrowing improved the outcome, osteotomy and especially if the maxillomandibular advancement procedure was included in the opera¬ tion.
Drawbacks to this analysis are addressed by the authors. Randomized, controlled studies of the treat¬ ment of OSA do not exist. Follow-up data reported in most studies are incomplete and short-term in nature. Reporting of pre- and postoperative poly¬ somnographic data is nonuniform, concentrates on the quantity of abnormal respiratory events, and does not routinely include sleep quality data. No variables have been examined in this quality-of-life In setting. addition, inclusion and exclusion criteria vary widely across studies and the details of the vary in different centers. surgical procedures In spite of these drawbacks, valuable conclusions can be drawn from this meta-analysis: (1) Results of UPPP improve if the site of upper airway collapse is identified preoperatively and the UPPP is restricted to those patients with isolated retropalatal obstruc¬ tion; (2) Both short-term and long-term follow-up should be conducted postopera¬ polysomnograms OSA and (3) patients with retroglossal ob¬ tively; struction benefit best from surgical procedures that increase the caliber of the retroglossal airway. Recommendations for further research are a valu¬ able outcome of the practice guideline development process. From this review it is clear that we do not have a final evaluation of the role of pharyngeal surgery in the treatment of OSA. Specific recom¬ mendations that one might draw from this discussion are: (1) The method of preoperative determination of the pharyngeal site of obstruction is not standard¬ ized. Should this evaluation be done in sleep or is an office procedure such as upper airway endoscopy with the Muller maneuver adequate? (2) The surgi¬ cal approach to retroglossal obstruction needs fur¬ ther study. Do these patients need UPPP or is an isolated approach to the retroglossal airway suffi¬ cient? If so, what operative procedure is best? (3) The long-term course of OSA patients who undergo pharyngeal surgery needs further documentation. If of the OSA occurs, is further surgery bene¬ relapseand at what site? (4) Variables other than ficial, respiratory abnormality indices, such as quality-of266
life variables, need to be studied as outcome vari¬ ables to better assess whether pharyngeal surgery is truly helping these individuals in an overall sense. In all, the meta-analysis evaluation of the surgical treatment of OSA conducted by Sher et al1 is outstanding and is an extremely valuable contribu¬ tion to the literature and to our understanding of the treatment of OSA. The authors and the American Sleep Disorders Association are to be congratulated on their high standards of scientific approach to This review should improve our sleep medicine. to the apnea patient interested in a approachcorrectionsleep of his or her OSA. It should also surgical in the field plan research that will help investigators advance our knowledge beyond the status quo. This paper is strongly recommended as a valuable reference to the readership of CHEST. David W. Hudgel, MD, FCCP Cleveland, Ohio Professor of Medicine, Case Western Reserve
University,
and
MetroHealth Medical Center. Pulmonary Division, Dr. Hudgel, Pulmonary Division, MetroHealth Reprint requests: Medical Center, 2500 MetroHealth Drive, Cleveland, OH 441091998
References 1 Sher A, Schechtman K, Piccirillo J. An American
Sleep
Disorders Association review: the efficacy of surgical modifi¬ cations of the upper ainvay in adults with obstructive sleep apnea syndrome. Sleep 1996; 19:156-77
Who Should Treat Sleep Apnea and How? HP he article by Loube and Strauss in this issue of ¦*¦ CHEST (see page 382) raises three important issues: (1) Who should diagnose and treat obstructive (2) How should it be treated? and (3) sleep should apnea? the effectiveness of that treatment be How assessed?
Because sleep apnea is a serious and highly prev¬ alent disorder, those who display either loud snoring or excessive sleepiness are members of an attractive at a time when many pool of potential patientsIn the last 20 years whole are practices shrinking. new industries have sprung up, manufacturing equipment to identify and treat these patients with¬ out any face-to-face examination by a sleep specialist. Portable home monitoring equipment with auto¬ mated scoring of respiratory events is being heavily marketed to ear, nose, and throat (ENT) and pulmo¬ nary physicians as income-producing aids. These, along with the development of "self-titrating" nasal continuous positive airway pressure (CPAP) devices, Editorials
foster a belief that these patients can be diagnosed and treated by any physician without special training in sleep disorders medicine. with the movement to despecialize this Along has practice come another, to demedicalize it. Den¬ tists have begun inquiring of their patients with observed small airways, "Do you snore?" They are rapidly becoming primary care practitioners for sleep Oral apnea. appliances designed to prevent snoring and apneic events have proliferated since the first of these, the tongue retaining device, (TRD), was tested for its effectiveness in a sleep laboratory in 1982.1 Only a few other devices have undergone such testing and even fewer have involved large enough samples to establish the patient characteris¬ tics predictive of their success.2 Loube and Strauss drew their sample of dentists from what is probably the most responsible group of those engaged in fitting these devices for snoring and/or sleep apnea: those who are members of the Dental Society. Yet by question¬ Sleep Disorders naire, only 18% of their patients had formal sleep laboratory testing to check if their respiratory events were being adequately controlled by the appliance. Still more troublesome is that even in the practice of this most knowledgeable group, 5% of the patients had not had an initial diagnostic sleep test. The first question, who should diagnose and treat sleep apnea, must be broken down into two parts: a diagnosis must precede treatment, and this should be made by a sleep specialist familiar with the range of sleep disorders that may present with similar symptoms. Once these are ruled out and sleep apnea is confirmed by all night clinical polysomnography (PSG), the next step is to choose, among the many options, the treatment that is most likely to succeed for this patient and is acceptable to him or her. The second question, how should sleep apnea be treated, must be answered "judiciously," as there are four routes open. An oral appliance is one option for the snorer with mild to moderate apnea.3 Behavior change is a second choice. This includes weight loss plus exercise, restriction of alcohol, and sleep posi¬ tion training for those whose PSG shows respiratory events to be confined to supine sleep. All have been proven effective in selected cases. A third option is surgery to create a more patent nasal airway and/or to reduce the redundant oropharyngal tissue. The fourth option is the one most likely to succeed: a
nasal CPAP for those with a respiratory disturbance index over 20, or even less if the patient is unable to tolerate minor fluctuations in oxygen saturation with¬
out
waking.
Which of these, or which combination of treat¬ ments, is selected depends on a careful interpreta¬ tion of the PSG, as well as of the patient's structural
to comply with long-term regi¬ ability mens. No one treatment fits all patients. Some cannot tolerate sleeping with equipment and will both an intraoral device and an
features and
external mask. reject The number of those continuing to use either TRDs or CPAPs for more than a year is discouraging.45 Oral appliances that reposition the lower jaw may be for the retrognathic patient, providing the helpful nasal airway is patent and bruxism does not occur in sleep. Surgery will continue to be a gamble or a treatment of last resort. Behavioral treatments are rarely applied as a single modality but are clearly safer, less expensive, and less intrusive for patients who are motivated to take charge of their health. Ideally, sleep apnea requires a combination of treatments
provided by a multidisciplinary
team
coordinated by a sleep specialist. The airway should be assessed by an ENT physician; the pulmonary status by a pulmonologist; the contribution of the body mass index, neck circumference, length and position of the lower jaw, as well as the patient's ability to understand and comply with the various treatment programs, by his or her sleep specialist. The third question, how to assess the treatment effectiveness, is easy to ask but hard to pay for. Whatever plan is developed, it is important that the patient be reassessed after 6 months and then annu¬ ally by PSGs. These can be done in the home at reduced cost, provided the data are interpreted by the sleep specialist. The potential population of snorer/apneic patients is so wide and the cost of the proper care so high that the field is ripe for abuses. Cut-rate care that cuts corners is often more expensive in the long run. Oral appliances have a place in the roster of treatments. Their appropriateness for any one patient should be determined not by subjective opinions, but by objec¬ tive data. The choice to use them should be made by the sleep specialist and the patient with full knowl¬ edge of inall options, along with the commitment to restudy order to validate its effectiveness. Rosalind Cartivright, ABSM
Chicago
Sleep Disorder Service, Rush-Presbyterian-St. Luke's Reprint requests: Dr. Rosalind Cartivright, Rush-PresbijterianSt. Luke's Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612 From the
Hospital.
1
Cartwright
treatment
705-09
References
R, Samelson C. The effects of a nonsurgical for obstructive sleep apnea. JAMA 1982; 248:
appliances for the treatment of snoring and obstructive sleep apnea. In: Kryger M, Roth T, Dement W, eds. Principles and practice of sleep medicine. 2nd ed.
2 Lowe A. Dental
CHEST / 111 / 2 / FEBRUARY, 1997
267
Philadelphia: WB Saunders, 1994; 722-35 3 Schmidt-Nowara W, Lowe A, Weigand L, et al. Oral appli¬ ances for the treatment of snoring and obstructive sleep apnea: a review. Sleep 1995; 18:501-10 4 Clark G, Cartwright R. A survey of treatment efficacy of patients treated with the tongue retaining device [abstract].
Sleep Res 1995; 24:213 5 Kribbs N, Pack A, Kline L, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 1993; 147:887-95
Cost-Effective and Surgically Effective Lung Volume Reduction Surgery Liu et al in this issue of CHEST (see Thepagepaper489)byofresurrects an intriguing technique for management bullae during thoracoscopic surgery. Before the introduction of the endoscopic stapler in 1991, thoracoscopic management of blebs and bullae consisted of ligation by suture endoloops. Because of some early failures, which in retrospect may have been due to usage of loops during an early stage in the surgical learning curve, this technique was the more technically simple quickly abandoned when became available. endoscopic staplerreduction surgery as described by Lung volume an al1 et technique and by using open Cooper Keenan et al~ using a thoracoscopic approach in¬ volved bulla ligation with either an open or endo¬ scopic stapling technique. Because of the air leaks caused by the metallic staples placed across emphysematous lung tissue, bovine pericardial strips were used to "buttress" the staple line.3 A recent random¬ ized study by Hazelrigg et al4 showed pericardial in decreasing air leaks, buttressing to be effective which are the most common complication of lung volume reduction surgery. An alternative is the "plication" technique of David Sugarbaker, MD, FCCP (personal communication, 1996), which uses the patient's own lung to buttress the staple line. The technique of Liu et al is interesting because it a "cost-effective" to be not technique, only effective technique. Their "surgically" rate of 8.9% over 10 days is prolongedto airthatleak of any published surgical series to superior date. The technique, which appears to be technically and able to be mastered straightforward who simple andthoracic have had moderate most surgeons by in involves collapse of the experience thoracoscopy, bulla by stabbing and twisting. Two or three suture endoloops are then placed across the base of the twisted bulla. Another interesting aspect of the described by Liu et al is the talc pleurode¬ technique sis performed at the conclusion of the procedure. appears but also
268
a
additional component of the tech¬ nique leading to the low air leak rate. One point about which many surgeons performing lung volume reduction surgery may differ, however, is in the use of postoperative chest tube suction. It is our own as well as that of many others, that no suction feeling, be it is should placedtheon the chest tubesWe unless have found to necessary keep lung expanded. that leaks appear to be fewer and seal quicker when no suction is used. The technique of bulla ligation by loops described be added to each surgeon's by Liu et al should armamentarium. It not only has the potential to decrease the $1,500 to $2,000 spent on staplers and bovine pericardium for each procedure, but it may be a useful adjunct when stapler application is technically difficult. Michael J. Mack, MD Dallas
This may be
an
Cardiothoracic Surgery Associates of North Texas, Columbia Hospital Medical City Dallas.
References 1 Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995; 109: 106-19
2 Keenan
RJ, Landreneau RJ,
Ciurbe FCS,
et
al. Unilateral
thoracoscopic surgical approach for diffuse emphysema. J Thorac Cardiovasc Surg 1996; 111:308-16 3 Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994; 57:1038-39 4 Hazelrigg SR, Boley TM, Naunheim KS, et al. The effect of bovine pericardial strips on air leak after stapled pulmonary resection. Ann Thorac Surg (in press) 1997
Video-Assisted
Anniversary
Thoracoscopy's
T"1 his year marks the fifth anniversary of the begin¦*¦ ning of the new era of video-assisted thoracic surgery. During that time, nearly every type of thoracic surgical operation has been performed the scope." A simple literature search yields "through 185 publications on thoracoscopy in the 5-year pe¬ riod before video-assisted thoracic surgery. In the most recent 5 years up to September 1996, there have been 591 publications on thoracoscopy and video-assisted thoracic surgery. Of course, some of these manuscripts simply introduce a new proce¬ dure, present a small series of a menu of various or extend already-published series. Even procedures,for accounting these factors, the number of publica¬ tions represents a huge volume of patients operated Editorials
Drawbacks to this analysis are addressed by the authors. Randomized, controlled studies of the treat¬ ment of OSA do not exist. Follow-up data reported in most studies are incomplete and short-term in nature. Reporting of pre- and postoperative poly¬ somnographic data is nonuniform, concentrates on the quantity of abnormal respiratory events, and does not routinely include sleep quality data. No variables have been examined in this quality-of-life In setting. addition, inclusion and exclusion criteria vary widely across studies and the details of the vary in different centers. surgical procedures In spite of these drawbacks, valuable conclusions can be drawn from this meta-analysis: (1) Results of UPPP improve if the site of upper airway collapse is identified preoperatively and the UPPP is restricted to those patients with isolated retropalatal obstruc¬ tion; (2) Both short-term and long-term follow-up should be conducted postopera¬ polysomnograms OSA and (3) patients with retroglossal ob¬ tively; struction benefit best from surgical procedures that increase the caliber of the retroglossal airway. Recommendations for further research are a valu¬ able outcome of the practice guideline development process. From this review it is clear that we do not have a final evaluation of the role of pharyngeal surgery in the treatment of OSA. Specific recom¬ mendations that one might draw from this discussion are: (1) The method of preoperative determination of the pharyngeal site of obstruction is not standard¬ ized. Should this evaluation be done in sleep or is an office procedure such as upper airway endoscopy with the Muller maneuver adequate? (2) The surgi¬ cal approach to retroglossal obstruction needs fur¬ ther study. Do these patients need UPPP or is an isolated approach to the retroglossal airway suffi¬ cient? If so, what operative procedure is best? (3) The long-term course of OSA patients who undergo pharyngeal surgery needs further documentation. If of the OSA occurs, is further surgery bene¬ relapseand at what site? (4) Variables other than ficial, respiratory abnormality indices, such as quality-of266
life variables, need to be studied as outcome vari¬ ables to better assess whether pharyngeal surgery is truly helping these individuals in an overall sense. In all, the meta-analysis evaluation of the surgical treatment of OSA conducted by Sher et al1 is outstanding and is an extremely valuable contribu¬ tion to the literature and to our understanding of the treatment of OSA. The authors and the American Sleep Disorders Association are to be congratulated on their high standards of scientific approach to This review should improve our sleep medicine. to the apnea patient interested in a approachcorrectionsleep of his or her OSA. It should also surgical in the field plan research that will help investigators advance our knowledge beyond the status quo. This paper is strongly recommended as a valuable reference to the readership of CHEST. David W. Hudgel, MD, FCCP Cleveland, Ohio Professor of Medicine, Case Western Reserve
University,
and
MetroHealth Medical Center. Pulmonary Division, Dr. Hudgel, Pulmonary Division, MetroHealth Reprint requests: Medical Center, 2500 MetroHealth Drive, Cleveland, OH 441091998
References 1 Sher A, Schechtman K, Piccirillo J. An American
Sleep
Disorders Association review: the efficacy of surgical modifi¬ cations of the upper ainvay in adults with obstructive sleep apnea syndrome. Sleep 1996; 19:156-77
Who Should Treat Sleep Apnea and How? HP he article by Loube and Strauss in this issue of ¦*¦ CHEST (see page 382) raises three important issues: (1) Who should diagnose and treat obstructive (2) How should it be treated? and (3) sleep should apnea? the effectiveness of that treatment be How assessed?
Because sleep apnea is a serious and highly prev¬ alent disorder, those who display either loud snoring or excessive sleepiness are members of an attractive at a time when many pool of potential patientsIn the last 20 years whole are practices shrinking. new industries have sprung up, manufacturing equipment to identify and treat these patients with¬ out any face-to-face examination by a sleep specialist. Portable home monitoring equipment with auto¬ mated scoring of respiratory events is being heavily marketed to ear, nose, and throat (ENT) and pulmo¬ nary physicians as income-producing aids. These, along with the development of "self-titrating" nasal continuous positive airway pressure (CPAP) devices, Editorials
foster a belief that these patients can be diagnosed and treated by any physician without special training in sleep disorders medicine. with the movement to despecialize this Along has practice come another, to demedicalize it. Den¬ tists have begun inquiring of their patients with observed small airways, "Do you snore?" They are rapidly becoming primary care practitioners for sleep Oral apnea. appliances designed to prevent snoring and apneic events have proliferated since the first of these, the tongue retaining device, (TRD), was tested for its effectiveness in a sleep laboratory in 1982.1 Only a few other devices have undergone such testing and even fewer have involved large enough samples to establish the patient characteris¬ tics predictive of their success.2 Loube and Strauss drew their sample of dentists from what is probably the most responsible group of those engaged in fitting these devices for snoring and/or sleep apnea: those who are members of the Dental Society. Yet by question¬ Sleep Disorders naire, only 18% of their patients had formal sleep laboratory testing to check if their respiratory events were being adequately controlled by the appliance. Still more troublesome is that even in the practice of this most knowledgeable group, 5% of the patients had not had an initial diagnostic sleep test. The first question, who should diagnose and treat sleep apnea, must be broken down into two parts: a diagnosis must precede treatment, and this should be made by a sleep specialist familiar with the range of sleep disorders that may present with similar symptoms. Once these are ruled out and sleep apnea is confirmed by all night clinical polysomnography (PSG), the next step is to choose, among the many options, the treatment that is most likely to succeed for this patient and is acceptable to him or her. The second question, how should sleep apnea be treated, must be answered "judiciously," as there are four routes open. An oral appliance is one option for the snorer with mild to moderate apnea.3 Behavior change is a second choice. This includes weight loss plus exercise, restriction of alcohol, and sleep posi¬ tion training for those whose PSG shows respiratory events to be confined to supine sleep. All have been proven effective in selected cases. A third option is surgery to create a more patent nasal airway and/or to reduce the redundant oropharyngal tissue. The fourth option is the one most likely to succeed: a
nasal CPAP for those with a respiratory disturbance index over 20, or even less if the patient is unable to tolerate minor fluctuations in oxygen saturation with¬
out
waking.
Which of these, or which combination of treat¬ ments, is selected depends on a careful interpreta¬ tion of the PSG, as well as of the patient's structural
to comply with long-term regi¬ ability mens. No one treatment fits all patients. Some cannot tolerate sleeping with equipment and will both an intraoral device and an
features and
external mask. reject The number of those continuing to use either TRDs or CPAPs for more than a year is discouraging.45 Oral appliances that reposition the lower jaw may be for the retrognathic patient, providing the helpful nasal airway is patent and bruxism does not occur in sleep. Surgery will continue to be a gamble or a treatment of last resort. Behavioral treatments are rarely applied as a single modality but are clearly safer, less expensive, and less intrusive for patients who are motivated to take charge of their health. Ideally, sleep apnea requires a combination of treatments
provided by a multidisciplinary
team
coordinated by a sleep specialist. The airway should be assessed by an ENT physician; the pulmonary status by a pulmonologist; the contribution of the body mass index, neck circumference, length and position of the lower jaw, as well as the patient's ability to understand and comply with the various treatment programs, by his or her sleep specialist. The third question, how to assess the treatment effectiveness, is easy to ask but hard to pay for. Whatever plan is developed, it is important that the patient be reassessed after 6 months and then annu¬ ally by PSGs. These can be done in the home at reduced cost, provided the data are interpreted by the sleep specialist. The potential population of snorer/apneic patients is so wide and the cost of the proper care so high that the field is ripe for abuses. Cut-rate care that cuts corners is often more expensive in the long run. Oral appliances have a place in the roster of treatments. Their appropriateness for any one patient should be determined not by subjective opinions, but by objec¬ tive data. The choice to use them should be made by the sleep specialist and the patient with full knowl¬ edge of inall options, along with the commitment to restudy order to validate its effectiveness. Rosalind Cartivright, ABSM
Chicago
Sleep Disorder Service, Rush-Presbyterian-St. Luke's Reprint requests: Dr. Rosalind Cartivright, Rush-PresbijterianSt. Luke's Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612 From the
Hospital.
1
Cartwright
treatment
705-09
References
R, Samelson C. The effects of a nonsurgical for obstructive sleep apnea. JAMA 1982; 248:
appliances for the treatment of snoring and obstructive sleep apnea. In: Kryger M, Roth T, Dement W, eds. Principles and practice of sleep medicine. 2nd ed.
2 Lowe A. Dental
CHEST / 111 / 2 / FEBRUARY, 1997
267
Philadelphia: WB Saunders, 1994; 722-35 3 Schmidt-Nowara W, Lowe A, Weigand L, et al. Oral appli¬ ances for the treatment of snoring and obstructive sleep apnea: a review. Sleep 1995; 18:501-10 4 Clark G, Cartwright R. A survey of treatment efficacy of patients treated with the tongue retaining device [abstract].
Sleep Res 1995; 24:213 5 Kribbs N, Pack A, Kline L, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 1993; 147:887-95
Cost-Effective and Surgically Effective Lung Volume Reduction Surgery Liu et al in this issue of CHEST (see Thepagepaper489)byofresurrects an intriguing technique for management bullae during thoracoscopic surgery. Before the introduction of the endoscopic stapler in 1991, thoracoscopic management of blebs and bullae consisted of ligation by suture endoloops. Because of some early failures, which in retrospect may have been due to usage of loops during an early stage in the surgical learning curve, this technique was the more technically simple quickly abandoned when became available. endoscopic staplerreduction surgery as described by Lung volume an al1 et technique and by using open Cooper Keenan et al~ using a thoracoscopic approach in¬ volved bulla ligation with either an open or endo¬ scopic stapling technique. Because of the air leaks caused by the metallic staples placed across emphysematous lung tissue, bovine pericardial strips were used to "buttress" the staple line.3 A recent random¬ ized study by Hazelrigg et al4 showed pericardial in decreasing air leaks, buttressing to be effective which are the most common complication of lung volume reduction surgery. An alternative is the "plication" technique of David Sugarbaker, MD, FCCP (personal communication, 1996), which uses the patient's own lung to buttress the staple line. The technique of Liu et al is interesting because it a "cost-effective" to be not technique, only effective technique. Their "surgically" rate of 8.9% over 10 days is prolongedto airthatleak of any published surgical series to superior date. The technique, which appears to be technically and able to be mastered straightforward who simple andthoracic have had moderate most surgeons by in involves collapse of the experience thoracoscopy, bulla by stabbing and twisting. Two or three suture endoloops are then placed across the base of the twisted bulla. Another interesting aspect of the described by Liu et al is the talc pleurode¬ technique sis performed at the conclusion of the procedure. appears but also
268
a
additional component of the tech¬ nique leading to the low air leak rate. One point about which many surgeons performing lung volume reduction surgery may differ, however, is in the use of postoperative chest tube suction. It is our own as well as that of many others, that no suction feeling, be it is should placedtheon the chest tubesWe unless have found to necessary keep lung expanded. that leaks appear to be fewer and seal quicker when no suction is used. The technique of bulla ligation by loops described be added to each surgeon's by Liu et al should armamentarium. It not only has the potential to decrease the $1,500 to $2,000 spent on staplers and bovine pericardium for each procedure, but it may be a useful adjunct when stapler application is technically difficult. Michael J. Mack, MD Dallas
This may be
an
Cardiothoracic Surgery Associates of North Texas, Columbia Hospital Medical City Dallas.
References 1 Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995; 109: 106-19
2 Keenan
RJ, Landreneau RJ,
Ciurbe FCS,
et
al. Unilateral
thoracoscopic surgical approach for diffuse emphysema. J Thorac Cardiovasc Surg 1996; 111:308-16 3 Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994; 57:1038-39 4 Hazelrigg SR, Boley TM, Naunheim KS, et al. The effect of bovine pericardial strips on air leak after stapled pulmonary resection. Ann Thorac Surg (in press) 1997
Video-Assisted
Anniversary
Thoracoscopy's
T"1 his year marks the fifth anniversary of the begin¦*¦ ning of the new era of video-assisted thoracic surgery. During that time, nearly every type of thoracic surgical operation has been performed the scope." A simple literature search yields "through 185 publications on thoracoscopy in the 5-year pe¬ riod before video-assisted thoracic surgery. In the most recent 5 years up to September 1996, there have been 591 publications on thoracoscopy and video-assisted thoracic surgery. Of course, some of these manuscripts simply introduce a new proce¬ dure, present a small series of a menu of various or extend already-published series. Even procedures,for accounting these factors, the number of publica¬ tions represents a huge volume of patients operated Editorials