LAUSR

To the Editor, We read with great interest the article by Feldman et al. regarding simultaneous versus staged resections for bilateral pulmonary metastases. It may be appreciated that several studies have suggested that one‐stage bilateral surgery in managing bilateral pulmonary metastases is as safe as unilateral‐side surgery. Although an increased operative time was observed in the bilateral groups compared to the unilateral groups, the duration of the postoperative hospital stay and complications were comparable between the groups. Furthermore, in appropriately‐ matched comparisons, one‐stage bilateral surgery may confer benefits due to reduction in hospitalization costs as well as medical resources restrained by situations such as during the recent COVID‐19 pandemic. In the reported study, among the included 36 patients, the authors found no significant difference in postoperative pain between patients undergoing simultaneous and staged procedures, possibly due to implementation of pain‐management as a part of enhanced recovery after surgery program. One of the most challenging aspects of pain research is the objective evaluation of pain since pain is an individual experience. Upon closer examination of the subgroup reported by Feldman et al., 23 patients (23/36, 64%) underwent video‐assisted thoracic surgery (VATS) and thoracotomy simultaneously. Theoretically, a comparison of the postoperative pain associated with the two approaches in the same patients should reduce some bias arising from comparing the use of one approach on one group of patients with the use of the other approach on a different group of patients.We would appreciate any response from the authors as to whether they made intragroup comparisons using the same patients to assess postoperative pain associated with both VATS and thoracotomy. In addition, despite VATS being a minimal access surgical technique, as much as one‐third of patients receiving these procedures report chronic pain (lasting 2–3 months), possibly due to compression of the intercostal nerve. It is reasonable that subxiphoid uniportal VATS, an approach that avoids intercostal spaces, could reduce postoperative pain. From a surgical standpoint, this approach allows easier access to the anterior mediastinum for thymectomy along with better access to both sides of the chest with only a single incision. In 2014, Suda et al. performed a subxiphoid uniportal bilateral pulmonary metastasectomy, and recently this group reported their collective experiences in a series of patients receiving one‐stage subxiphoid uniportal VATS for bilateral pulmonary metastases. In the subxiphoid approach group, patients tended to consume fewer analgesics thereby entailing reduced medical costs. Therefore, this promising procedure might enable surgeons to perform one‐stage bilateral pulmonary metastasectomy without causing intercostal pain in suitable patients. In recent years, simultaneous bilateral surgery has gained attention and proven efficacious for the treatment of primary spontaneous pneumothorax (PSP) with contralateral blebectomy and resection of bilateral multifocal ground‐glass nodules (GGOs) suggestive of early primary lung cancer. Hence, we consider this surgical approach is feasible and safe in appropriately selected patients for a wide array of thoracic diseases (e.g., lung metastases, PSP with contralateral blebs, and multiple GGOs). This approach is also coupled with advantages of not only reductions in the contralateral occurrence of PSP and progression of the contralateral tumor, but also in circumventing the psychological burden as well as medical expenditures.