|LETTER TO THE EDITOR
|Year : 2013 | Volume
| Issue : 3 | Page : 254-255
To close or not to close: An enduring controversy
Abdulsalam Y Taha
Department of Cardiothoracic and Vascular Surgery, School of Medicine, University of Sulaimani, Sulaimani, Region of Kurdistan, Iraq
|Date of Web Publication||28-Mar-2014|
Abdulsalam Y Taha
Head of Unit of Thoracic and Cardiovascular Surgery, School of Medicine, Faculty of Medical Sciences, University of Sulaimani, Sulaimani, Region of Kurdistan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Taha AY. To close or not to close: An enduring controversy. Arch Int Surg 2013;3:254-5
One of the important considerations after pulmonary hydatid cyst (PHC) surgery is the prolonged air leak. The desire of every surgeon doing this type of surgery is to have no or minimal air leak, early and full lung expansion and quick chest tube removal postoperatively.
Prolonged air leak entails longer stay of patients in the hospital, failure of the lung to expand completely and increased likelihood of empyema as well as the occasional need for re-operation.
The traditional definition of prolonged air leak is persistent drainage of air via the chest tube after one postoperative week. However, there is no general agreement about this definition; different studies reported prolonged air leak as persistent leak of air 4 to 14 days after operation. ,,
The pathogenesis of this potential complication of PHC surgery is multifold. Big cysts with deeply seated bronchial openings are a common cause besides the ruptured and infected cysts in which the sutures may cut through. The most important factor, however, is the surgeon who does not give the necessary time, attention and effort to identify and meticulously close all significant bronchial fistulae.
Is there any role, in the choice of technique in the surgical management of the residual cyst cavity and the development of prolonged air leak? This question is difficult to answer.
There are two methods for management of the residual cyst cavity: Capitonnage that is closure of the cavity after removing its contents with a series of purse string sutures starting from the bottom outwards and cystotomy and closure of bronchial orifices leaving the cavity open. Which option is better? This is a very controversial issue as well.
Saidi et al., from Iran two decades earlier recommended leaving the residual cavity open with intention for the pulmonary parenchyma to automatically obliterate itself, without a compromise to functional lung volume. ,, Later studies by Turna et al., and Erdogan et al., also suggested that capitonnage was not a necessary step in management of residual cavity. ,
Obliteration of the residual cavity along with pericyst capitonnage) has long been the practice to avoid postoperative air leak and empyema formation. However, this practice continued over the years without any convincing statistical evidence since its introduction in 1951.  Recently, Eren et al., Turna et al., and Erdogan et al., challenged this hypothesis and suggested that capitonnage did not offer any additional benefit over cystotomy and bronchial openings closure alone. , These retrospective and prospective findings were convincing and attracted many investigators, as it avoided the disfigurement of lung parenchyma by capitonnage. Interestingly, these findings could not be reproduced by Kosar and Bilgin et al., and they still believe that capitonnage has additional advantage and is associated with better postoperative outcome. ,
The proponents of capitonnage argue that prolonged air leak can be avoided or minimized by their technique as well as other complications such as postoperative empyema. In contrast, the proponents of leaving the cavity open believe that the most important step to avoid the prolonged air leak postoperatively is the meticulous closure of all significant bronchial openings and that capitonnage is not necessary. The natural course of the cavity is to get gradually shallower with lung expansion. They also believe that capitonnage causes lung disfigurement, prolongs the operative time and increase morbidity by further trauma to lung parenchyma resulting from inserting the purse string sutures which themselves can act as foreign materials predisposing to lung abscess development and postoperative hemoptysis.
Sarsam  and Elhassani  from Iraq recommended leaving the residual sac open to obliterate spontaneously after closure of bronchial fistulae and emphasized that no attempt should be made to suture it. Moreover, Sarsam believed that obliteration of the cavities of multiple cysts, particularly when large, may convert the remaining lung tissue into a collapsed and distorted mass, prone to infection and other complications.  Saidi felt that there was no real justification in attempting obliteration of the space, regardless of its size. Extensive clinical and laboratory experience had shown that the defect would in due course disappear anyway, with its raw surfaces becoming repleuralized.  The filling-in process, according to Saidi, might even be more rapid since the non-involved but compressed adjacent normal lobes will rapidly re-expand once the parasite is out.  Internal obliteration of the pericyst cavity by any method cannot improve upon a natural process which is bound to take place spontaneously.  Valid reasons for not suturing the space given by Saidi are creation of dead spaces, snaring of major vessels in the sutures, and leaving behind a large amount of catgut sutures.
To solve this controversy we need a double-blind comparative study on large number of patients. The patients should be divided into two groups; one is to receive capitonnage while the second is managed by cystotomy and bronchial fistulae closure. The two groups should be homogenous in their characteristics such as age (children or adults), type of cysts (intact or ruptured), size of cysts (small or big), location and number of cysts (single or multiple). The postoperative parameters which need monitoring should be specified like prolonged air leak, time of chest tube removal, rate of empyema, the duration of stay in the hospital and the need for re-operation.
We think that comparing one study with another one is not helpful and valid unless both studies agree upon the same definition of prolonged air leak and have homogenous characteristics as mentioned before.
Personally, I used to do capitonnage more than 2 decades ago but I have changed my practice to the second technique influenced by the clinical results and the evidence from the literature. This trend is currently shared by most thoracic surgeons in Iraq. The study of Shehatha et al., is a good example.  In this study, 763 cases of thoracic hydatidosis from Iraq were managed surgically leaving the cavity open after securing air leaks. Mortality was 1% and morbidity was 12.6%. The authors thus concluded that good results could be obtained in uncomplicated cysts by using the non-capitonnage method. In contrast, Al-Ali and Baram from Sulaimani, Iraq claimed that low complication rate was achieved following capitonnage in 72 cases of PHC.  The study, however, had several limitations particularly the lack of a control group and deficient follow-up.
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