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Communications to the Editor |

Value of Fiberoptic Bronchoscopy in Patients Undergoing Surgery for Solitary Pulmonary Nodules FREE TO VIEW

Hugo Esteva, MD, FCCP; Heinrich Becker, MD, FCCP
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Affiliations: Hospital de Clínicas, Buenos Aires, Argentina,  Thoraxclinc, Heidelberg University School of Medicine, Heidelberg, Germany

Correspondence to: Hugo Esteva, MD, FCCP, Associate Professor of Thoracic Surgery, Thoracic Surgery Division, Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires, Argentina; e-mail: hesteva@intramed.net.ar



Chest. 2005;128(1):474. doi:10.1378/chest.128.1.474
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To the Editor:

The American College of Chest Physicians evidence-based guidelines on the diagnosis and management of lung cancer do not recommend preoperative fiberoptic bronchoscopy (FB) in patients undergoing surgery for solitary pulmonary nodules (SPNs), qualifying the level of evidence as Good, None, D.1 Based on experience with real patients, we disagree. Preoperative FB is able to avoid serious mistakes on account of any of the not-so-unusual findings, as follow:

1. FB can detect subclinical disorders in vocal cords related to inferior laryngeal nerve compromise, changing staging and therapy.

2. Unexpected variations in bronchial anatomy could lead to difficult intraoperative situations (ie, double right-upper-lobe bronchial and vessels branching).

3. Subtle extrinsic compression of the bronchial wall, usually undetectable by CT scan, could change strategy. Endobronchial ultrasonography can be useful to guide histologic diagnosis.

4. Simultaneous central endobronchial lesions could be diagnosed. Dramatic changes in surgical approach could be necessary. Autofluorescence bronchoscopy can be useful when available.

5. Fluoroscopy-guided BF, even when not obtaining a cytologic or histologic diagnosis, is extremely important in localizing the segment where the SPN is placed in case it is not palpable during surgery. This can lead to an adequate “blind” segmental resection instead of a useless operation.

Randomized trials to base these kinds of observations on evidence could be unachievable. However, clinical mistakes can be cumbersome when a safe procedure such as FB is missing in the individual patient

ACCP evidence-based guidelines: diagnosis and management of lung cancer.Chest2003;123(suppl),1S-337S
 

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ACCP evidence-based guidelines: diagnosis and management of lung cancer.Chest2003;123(suppl),1S-337S
 
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