Reply

Abstract

Kirschner's comment focuses on two points: the use of a chest tube after pneumonectomy and the similarity of our case to one recently reported in another journal.1Buniva P Aluffi A Rescigno G Rademacher J Nazari S Cardiac herniation and torsion after partial pericardiectomy during right pneumonectomy.Tex Heart Inst J. 2001; 28: 73PubMed Google Scholar Regarding the use of a chest tube after pneumonectomy, it is worthwhile to repeat the commentaries of Nazari and Cooley cited in Kischner's letter.2Nazari S Letter.Tex Heart Inst J. 2002; 29: 72PubMed Google Scholar, 3Cooley DA Editorial commentary (letter).Tex Heart Inst J. 2002; 29: 73Google Scholar It is a personal choice of the surgeon, and no evidence exists supporting one option or the other. However, we would like to remind Kischner that after pneumonectomy, the chest tube is not attached to continued suction and does not “court disaster produced by excessive mediastinal shift,” as he says, but is connected to an appropriately balanced pneumonectomy drain set.4Waters PF Pneumonectomy.in: Thoracic surgery. Churchill Livingstone, New York1995: 844-848Google Scholar This is completely different from the one-way valve used after partial lung tissue resection. It is designed to achieve both positive and negative pressure control avoiding any abnormal mediastinal shift. We reply to the second point of Kischner's comment stressing the role played by induction chemotherapy in our case, as emphasized both in the title and in the discussion of our article. In the past 5 years we performed 208 pneumonectomies, 47 with intrapericardial vessel ligation. The pericardial defect was closed directly by stitches in 35 cases and by a pericardial patch in 12 cases in which the defect was too large and a direct suture would have been under tension. The reported case of cardiac herniation was the first in our experience. We are sure that the closure we performed in the first operation was not under any abnormal tension, that the pericardium was fibrotic because of the previous chemotherapy, and that this played a major role in its disruption. The message we would like to give is not that cardiac herniation may happen after intrapericardial pneumonectomy—this is widely known—but that it is more likely if the patient has undergone previous induction chemotherapy. In these cases, the use of pericardium to close small defects can also be recommended.