Selective antegrade three-vessel cerebral perfusion: a technique to protect the brain and the lower body?

We thank Drs Apostolakis and Baikoussis for their comments and suggestions [1]. After pulmonary lobectomies, we recommend using two tubes only in patients in whom a higher incidence of haemorrhage is expected, as we implied in the conclusion section of our article [2]. Patients having dense pleural adhesions (who needed extrapleural dissection or not) or having bleeding diathesis or have undergone chest wall resection are expected to have increased haemorrhagic drainage after lobectomies. For this reason, we recommended two chest tubes in these patients. We do not share the suggestions of Drs Apostolakis and Baikoussis about the necessity of two tubes in those operations when: (1) mechanical stapler is used to divide incomplete fissures, (2) there is suspicion of residual pleural space due to inability of remaining lobe(s) to fill the hemithorax and (3) there is increased pleural fluid secretion due to congestive heart failure, renal or hepatic insufficiency. In our opinion, there is noneed todrain theexcess transudative (orexudative) pleural fluid accumulated in patients with cardiac, hepatic or renal insufficiency in the postoperative period as we never drain such fluid accumulation in non-operative situations. We also have difficulty in understanding the necessity of two chest tubes when a parenchymal stapler is used during lobectomy. Indeed, staplers are used to decrease the parenchymal air leaks, and it does not increase it! In case of a suspicion of residual space after lobectomy, we think that a second chest tubewill not add an advantage to prevent this problem. It may beconsidered if apatienthasmassiveair leak,whichcannotbe controlled by a single drain. In our study, preoperative characteristics of both groups were similar. Patients who had had bleeding diathesis have been excluded from the study (as explained in method section of our article).