5-1-1, Toneyama, Toyonaka Osaka 560-8552, Japan e-mail: [email protected]
References 1. Lee W, Daly BDT, DiPetrillo TA, et al. Limited resection for non–small cell lung cancer: observed local control with implantation of I-125 brachytherapy seeds. Ann Thorac Surg 2003;75:237–43. 2. Sawabata N, Matsumura A, Ohota M, et al. Cytologically malignant margins of wedge resected stage I non-small cell lung cancer. Ann Thorac Surg 2002;74:1953–7. 3. Higashiyama M, Kodama K, Takami K, Higaki N, Nakayama T, Yokouchi H. Intraoperative lavage cytologic analysis of surgical margins in patients undergoing limited surgery for lung cancer. J Thorac Cardiovasc Surg 2003;125:101–7. 4. Sawabata N, Mori T, Iuchi K, Maeda H, Ohta M, Kuwahara O. Cytologic examination of surgical margin of excised malignant pulmonary tumor: methods and early results. J Thorac Cardiovasc Surg 1999;117:618 –9.
Reply To the Editor:
Sabawata and colleagues reference their report  of a technique to detect malignant cells at the cut margin of wedge resections. Their method appears to be more sensitive than routine histological study. In a series of 15 patients with stage I lung cancer undergoing wedge resection, 7 had positive cytological findings at the margin compared with 3 whose tumor cells were identified on histological section. Four of the 7 patients experienced local recurrence 4 to 12 months after resection. None of the 8 patients with negative cytological results had development of local recurrence during follow-up ranging from 38 to 60 months. Using a different cytological technique, Higashiyama and associates  identified tumor cells at the margin of 9 of 105 patients undergoing limited resection for stage I lung cancer. None of the 96 patients with negative cytological margins had local recurrence during a median follow-up of 27 months. Two of our 29 patients with stage I tumors had tumor recurrence at the margin of resection at 40 and 60 months postoperatively . Both had T1 N0 tumors, and both had negative margins by histological study. Given the timing of these local recurrences, it is clear that seeds can prevent or substantially delay the appearance of local recurrence in most patients undergoing wedge resection for stage I tumors. No complications have been observed that can be attributed to the implantation of the seeds. As Sabawata and colleagues and Higashiyama and associates have not observed local recurrence in 113 patients with negative cytological margins, it would seem reasonable to continue to study the reliability of these techniques for predicting local recurrence in a larger group of patients. On the other hand, it is difficult to recommend withholding safe therapy that has been shown to prevent or at least substantially delay local recurrence in patients with stage I lung cancer, particularly when limited resection is performed in compromised patients and when a wider margin of resection is not possible. Benedict D. T. Daly, MD Thomas A. DiPetrillo, MD Division of Cardiothoracic Surgery Boston Medical Center, B-402 88 E Newton St Boston, MA 02118 e-mail: [email protected]
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
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References 1. Sawabata N, Matsumura A, Ohota M, et al. Cytologically malignant margins of wedge resected stage I non-small cell lung cancer. Ann Thorac Surg 2002;74:1953–7. 2. Higashiyama M, Kodama K, Takami K, Higaki N, Nakayama T, Yokouchi H. Intraoperative lavage cytologic analysis of surgical margins in patients undergoing limited surgery for lung cancer. J Thorac Cardiovasc Surg 2003;125:101–7. 3. Lee W, Daly BDT, DiPetrillo TA, et al. Limited resection for non–small cell lung cancer: observed local control with implantation of I-125 brachytherapy seeds. Ann Thorac Surg 2003;75:237–43.
Preserving Infected Pacemaker Systems To the Editor: The article by Yamada and associates  on two surgical lead-preserving procedures for pacemaker pocket infection was of interest. The usual approach to infection of a medically inserted device is to treat the patient with appropriate antibiotics, and if there is not a rapid response, removal of the foreign body is advocated. This policy is used by most physicians for pacemakers, joint prostheses, cranial shunts, vascular grafts, and oncology ports and for us is enhanced by the recommendations of the consulting infectious disease physicians we see in daily practice. Removing the infected foreign body can be a complicated, difficult procedure in a patient whose life or limb could be in jeopardy without that implanted medical prosthesis or instrument. The situation is particularly critical when lifesaving implants such as pacemakers, vascular grafts, or cardiac valve prostheses are present. Yamada and co-workers reviewed their experience with infected pacemaker systems (lead or battery). One of these procedures preserves the full length of the lead and the other, the distal part of the lead. Rather than initially removing the lead and the pacemaker, they developed a method involving wide debridement, saline solution irrigation, rescrubbing, and redraping. After the pocket and lead have been disinfected with povidone-iodine–soaked gauze for 15 minutes, the lead has been retunneled, and a new pacemaker has been implanted in a new pacemaker pocket, concomitant antibiotic usage may obviate removal of the lead. This method led to preservation of the pacemaker lead system in 17 of 18 patients with infection. My colleagues and I read their report and reviewed the results with their method for preserving the original pacemaker lead system with interest. In 1972, we presented our results in 3 patients with infected pacemakers. We  used a combination of povidone-iodine soaking of the pacemaker unit and lead and intravenous antibiotic therapy and we were able to salvage the three pacemaker units without the need to remove any. Since then, we have discussed this concept and a similar successful therapeutic concept for infected vascular graft preservation with a number of individuals, most of whom thought this was not appropriate treatment. We are pleased to see that others have used the technique successfully to treat an infected pacemaker system or such a system suspected to be infected. We congratulate Yamada and colleagues on their excellent results. Raymond A. Dieter, Jr, MD Du Page Medical Group 454 Pennsylvania Ave Glen Ellyn, IL 60137 0003-4975/04/$30.00
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1. Yamada M, Takeuchi S, Shiojiri Y, et al. Surgical leadpreserving procedures for pacemaker pocket infection. Ann Thorac Surg 2002;74:1494 –9. 2. Dieter RA Jr, Asselmeier GH, McCray RM, Grissom JH, Zimmerman RC. An alternative to removal of an infected pacemaker. Geriatrics 1973;28:78 –80.
Reply To the Editor: We greatly appreciate the comments of Dr Dieter. We read with interest the report by him and his colleagues  published in 1973 in which they reported successful treatment of 3 patients in whom infected pacemaker systems were salvaged. We acknowledge their pioneering work on the concept of preservation of the infected pacemaker system. Removal of the entire pacing system is still generally considered necessary to ensure eradication of infection associated with the implanted pacemaker. We agree and have followed this practice. However, it is not only costly but also sometimes disadvantageous to remove a well-functioning lead. Currently, removal of pacemaker leads is often difficult because of the more secure lead-anchoring systems. Although newer methods of transvenous lead extraction have proved to be effective, the complication rate associated with these methods should not be ignored. In our study , 17 patients whose infection was limited to the pacemaker pocket were treated successfully by one of two types of lead-preserving procedure. To date, no recurrent infection has been observed in these patients as well as 1 additional patient who underwent our procedure in 2003. We will prudently continue performing our lead-preserving procedures on a case-by-case basis. We thank Dr Dieter for his thoughts and encouragement. Makoto Yamada, MD Toshihiro Takaba, MD First Department of Surgery Showa University 1-5-8 Hatanodai Shinagawa-ku Tokyo 142-8666, Japan e-mail: [email protected]
References 1. Dieter RA Jr, Asselmeier GH, McCray RM, Grissom JH, Zimmerman RC. An alternative to removal of an infected pacemaker. Geriatrics 1973;28:78 –80. 2. Yamada M, Takeuchi S, Shiojiri Y, et al. Surgical lead-
preserving procedures for pacemaker pocket infection. Ann Thorac Surg 2002;74:1494 –9.
Preservation of Saphenous Vein Endothelium To the Editor: I read with a great deal of interest the article by Thatte and colleagues ; their work is well presented and, in my view, very valuable. I congratulate them for two important contributions to the study of the fate of veins used as arterial grafts: (1) the use of multiphoton microscopy and specific fluorescent stains for calcium and nitric oxide metabolism and (2) the introduction of the newly formulated storage solution GALA (glutathione, ascorbic acid, l-arginine). In 1998, my colleagues and I  published an article on perivascular delivery of NO using a polymer and an NO donor (spermine/NO) applied around a vein graft implanted in the arterial circulation of hypercholesterolemic rabbits. These experiments demonstrated a significant reduction in neointimal hyperplasia in the treated vein grafts as compared with those bathed in saline solution or polymer alone. We noted in our study that the major limitation of this method of NO delivery in humans would be due to technical difficulties in controlling the application of the polymer ⫹ spermine/NO mixture and the inflammatory reaction that it produces in the surrounding tissues. We called for research in other methods of delivery of NO. I hope that further testing of the GALA solution using animal models such as the one we described will demonstrate the beneficial effects of this very simple and readily available modality of delivery and that surgeons soon will be able to use it for the benefit of their patients. Aurelio Chaux, MD Cardiothoracic Surgery Saint Johns Hospital and Health Center 1328 Twenty-Second St Santa Monica, CA 90404 e-mail: [email protected]
References 1. Thatte HS, Biswas KS, Najjar SF, et al. Multi-photon microscopic evaluation of saphenous vein endothelium and its preservation with a new solution, GALA. Ann Thorac Surg 2003;75:1145–52. 2. Chaux A, Ruan XM, Fishbein MC, et al. Perivascular delivery of a nitric oxide donor inhibits neointimal hyperplasia in vein grafts implanted in the arterial circulation. J Thorac Cardiovasc Surg 1998;115:604 –14.
REVIEW OF RECENT BOOKS Advanced Therapy of Cardiac Surgery, 2nd Edition Edited by Kenneth Franco, MD, and Edward Verrier, MD 2003, Hamilton, Ontario, Canada, BC Decker 642 pp, illustrated, $129.00 ISBN: 1-55009-061-5 Reviewed by Verdi J. DiSesa, MD This is the second edition of Franco and Verrier’s Advanced Therapy of Cardiac Surgery. Like the first volume, this book has its focus on new operations, new biological knowledge, new techniques, and new technologies presently available to the heart © 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
surgeon or perhaps to become so in the near future. The topics range from blood conservation, to off-pump surgery, to the inflammatory consequences of cardiopulmonary bypass, to prosthetic valve endocarditis, to aortic surgery, to mechanical devices, to xenotransplantation. The editors have been nothing if not encyclopedic about the scope of their reach. They have succeeded admirably in touching on conceivably every area of active investigation in the biology and technology of early 21st century heart surgery and have tapped a well of national and international expert authors to help them do so. Because the volume has literally dozens of co-authors, there is Ann Thorac Surg 2004;77:1505– 6 • 0003-4975/04/$30.00 doi:10.1016/j.athoracsur.2003.07.039