146. ACCESSO TRANSMEDIASTINICO AL CAVO PLEURICO CONTROLATERALE NEL TRATTAMENTO SIMULTANEO DI LESIONI POLMONARI BILATERALI. UN'OPZIONE CHIRURGICA PER CASI SELEZIONATI

Scopo del lavoro è di descrivere 6 casi di pazienti portatori di patologie polmonari bilaterali, trattate simultaneamente mediante toracotomia ed accesso transmediastinico al cavo controlaterale. Sono stati trattati con questo approccio transmediastinico pazienti con: Ca broncogeno del lobo inferiore dx e bolla del lobo superiore sinistro (1 caso, bilobectomia (inferiore e medio) dx + bullectomia sin); pneumotorace spontaneo recidivante bilaterale da blebs degli apici polmonari (4 casi: pleurectomia e bullectomia + pleurectomia e/o bullectomia controlaterale transmediastinica); pneumotorace dx da enfisema bolloso bilaterale (bullectomia e pleurectomia dx + capitonnage bolla apicale sin). Il decorso postoperatorio è stato regolare in tutti i pazienti ad eccezione del paziente trattato per pnx recidivante da enfisema bolloso bilaterale. In questo paziente è stato necessario reintervenire in 2? giornata per riparare le brecce parenchimali in corrispondenza delle superfici suturate poiché l?entità delle perdite aeree non consentiva la completa riespansione del polmone destro. In 3? giornata dal secondo intervento è stato necessario eseguire una laparotomia d?urgenza per una peritonite da perforazione duodenale. Dopo questo terzo intervento il paziente non è stato in grado di riprendere la ventilazione spontanea ed è deceduto in 30 gg dal terzo intervento con insufficienza respiratoria. Gli ovvi vantaggi funzionali derivanti dal risparmio di una seconda toracotomia giustificano, a nostro avviso, ulteriori ricerche su questo approccio alternativo al trattamento di lesioni polmonari bilaterali.

192. Bilateral Open Treatment Of Spontaneous Pneumothorax. A New Access

S Nazari P Buniva, A Aluffi, S Salvi, Z Mourad, G Rescigno,

Eur J Cardiothorac Surg 2000; 18:608-610.

A new technique for bilateral apical bullectomy and pleurectomy via axillary minithoracotomy and transmediastinal access to the contralateral side, was used in 13 patients with bilateral apical blebs and/or pneumothorax. The contralateral space is reached at the posterior superior mediastinum, passing between the first thoracic vertebral bodies (T1-T4) and the oesophagus. The contralateral lung apex is then pulled into the thoracotomy side and apical bullectomy carried out by linear stapler. The obvious advantages of avoiding a second thoracotomy while providing complete solution to the clinical problem are particularly important in young patients with spontaneous pneumothorax caused by bilateral apical blebs.

199. Simultaneous bilateral apical bullectomy through access on only one side

Claudio ROSSELLA, Paolo BUNIVA, Alessandro ALUFFI, Stefano NAZARI

Ann Thorac Surg: 2005, 79:1098

Foundation Alexis Carrel, Pavia, Italy

Dept of Surgery, IRCCS San Matteo, Pavia

To the editor,

We read with great interest the paper by Yi-Cheng Wu and coworkers (1) reporting their successful experience with bilateral simultaneous transmediastinal treatment of spontaneous pneumothorax from apical blebs, which they performed entirely as a videoassisted mini-invasive procedure. We consider it extremely important to provide a complete solution to the clinical problem in young patients with spontaneous pneumothorax caused by bilateral apical blebs (2).

We have also developed an open procedure for the same purpose, i.e, bilateral simultaneous apical pleurectomy and bullectomy using access from only one side (3). However, in our experience we have found that it is easier and simpler to access the contralateral lung apex via the space between the esophagus and the first 3-4 thoracic vertebral bodies (Fig 1); in fact, apical bullectomy through this transmediastinal access is very simple and easy, and it is even possible to attract the contralateral apex into the side of the hemithorax access.

In our first few cases we also used the anterior substernal approach described by Yi-Cheng Wu and coworkers, with the aim of extending the parietal pleurectomy; however, in our experience, the contralateral lung apex cannot be fully attracted into the thoracotomy side through this opening as it can be through the prevertebral access. In our more recent cases we have therefore limited the contralateral access to through the prevertebral-retroesophageal space only.

We congratulate the authors on their successful clinical achievements.

1) Wu YC, Chu Y, Liu YH, Yeh CH, Chen TP, Liu HP: Thoracoscopic ipsilateral approach to

contralateral bullous lesion in patients with bilateral spontaneous pneumothorax.

Ann Thorac Surg 2003;76:1665-7

2) Nazari S: Psychological implications in the surgical treatment of pneumothorax.

Ann Thorac Surg. 1997 Jun;63; 1830-1

3) Nazari S, Buniva P, Aluffi A, Salvi S: Bilateral open treatment of spontaneous pneumothorax:

a new access.

Eur J Cardiothorac Surg 2000; 18:608-610