Reply to Halezeroglu

Abstract

We would like to thank Dr Halezeroglu for his comment [1]. To elucidate his doubts first we have to explain that only four of our patients were assessed pN2 after pneumonectomy (not seven as he writes). The remaining three patients were assessed pN2 after additional resection but they were all pN0 after pneumonectomy. All our pN2 patients had just micrometastases without significant enlargement of N2 nodes. We completely agree that preoperative evaluation should be as meticulous and precise as possible but our series started in 1981 when EBUS, EUS or VATS were not available. As to the range of additional resection after pneumonectomy, we have no experience with resections larger than wedge or single segmentectomy (with or without small part of the rib) and we relied on the recommendations delivered by Donnington et al., who reported favorable long-term survival after wedge versus lobectomy performed after pneumonectomy. Nevertheless, we consider lobectomy after pneumonectomy acceptable for the patients with excellent cardiopulmonary reserve and we would like to congratulate Dr Halezeroglu on his two cases. It would be nice to know their postoperative PFT results. We propose to exclude middle lobe from further considerations because from the functional point of view it can be treated as a large segment and focus rather on ‘regular’ lobes (upper or lower). Our observations of the PFT after segmentectomy performed on the patients with both lungs clearly show lack of PFT deterioration or even improvement after proper rehabilitation. Single segmentectomy has no significant impact on pulmonary function. The first author delivered the invited lecture covering this topic in details during the ESTS Annual Conference in Cluj, Romania. The situation is different for the patients with one lung. We can agree that some of them can withstand upper or lower lobectomy but we are pretty sure that the deterioration of PFT will be definitely quite severe. Even after wedge resection or single segmentectomywe observed significant decrease of the PFT values and deterioration of theWHO status in this group of patients. It clearly indicates how fragile the pulmonary reserve is after pneumonectomy. Fortunately, due to careful preoperative selection regarding their functional reserve, they have all survived the perioperative period. We are afraid it might be difficult, at least for some of the patients treated by lobectomy, particularly in caseof perioperative complications. In conclusion, we would still recommend wedge resection as a method of choice for the patients treated previously by pneumonectomy (particularly on the right side) due to good functional results and acceptable safety and long-term survival. We would suggest lobectomy after pneumonectomy as an ultimate and tolerable solution only for the extremely carefully selected group of patients.