First of all, I would like to congratulate Özkara et. al. (1) for the study published in the October 2008 issue of the journal. Results they have obtained in the study and, accordingly, positive effects of intact pleura on lung functions, have been indicated in former studies as well (1-4). However, there are some points that has gone unnoticed in this study.
When we consider the patient population in the study, the number of female patients especially in the group that pleura were opened (Group 2) is quantitatively larger than in the first group. As we know from clinical observations, pleura’s opening incident is higher in female patients group. Is the fact that the patient population is high in Group 2 may affect the results of this is  randomized study due to pleura’s opening?
Postoperative drainage has been found lower in the group with intact pleura.  Was there a difference between the groups in terms of pericardial fluid accumulation in the postoperative period?. Did authors see any case of pericardial effusion and/or tamponade?
Intact pleura is eventually closely related with skeletonized extraction of internal thoracic artery (ITA) (2). Even though this seems to be a desired technique, some thinks on the contrary (possibly due to the concern that ITA damage will be higher) and believes that it is better to extract as button.
Did authors observe postoperative pneumothorax in the group  with intact pleura?
In most situations, it is not up to the surgeon to open pleura or keep it intact. Do you have any foresight as to how will this limited gain on lung functions in the early period change in late period?
To conclude, although keeping pleura intact seems to be a right choice, skeletonized ITA will always be subject to more traumas (2- 4). Would it be right to try and keep pleura intact nevertheless?
I would like to thank authors for their study and send my regards.

Address for Correspondence/Yazışma Adresi: Dr. Osman Tiryakioğlu, Bursa Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Kalp ve Damar Cerrahisi Bölümü, Bursa, Türkiye Phone: +90 224 360 50 50 Fax: +90 224 360 50 55 E-mail: osmantiryaki@gmail.com

References

1. Ozkara A, Hatemi A, Mert M, Köner O, Çetin G, Gürsoy M, et al. The effects of internal thoracic artery preparation with intact pleura on respiratory function and patients' early outcomes. Anadolu Kardiyol Derg 2008; 8:368-73.
2. Bonacchi M, Prifti E, Giunti G, Salica A, Frati G, Sani G. Respiratory dysfunction after coronary artery bypass grafting employing bilateral internal mammary arteries: the influence of intact pleura. Eur J Cardiothorac Surg 2001;19: 827-33.
3. Gökflin I, Baltalarl› A, Sacar M, Sungurtekin H, Özcan V, Gürses E, et al. Preservation of pleural integrity in patients undergoing coronary artery bypass grafting: effect on postoperative bleeding and respiratory function. Acta Cardiol 2006; 61: 89-94.
4. Türk T,  Tiryakio€lu O,  Vural AH,  Ata Y,  Selimo€lu Ö,  Yavuz fi. Effect of skeletonization on flow and length of internal thoracic artery. Türk Gö€üs Kalp Damar Cerrahisi Derg 2005; 13: 112-4.

Author Reply

Dear Editor,

First of all, we would like to thank the authors for their comments. We would like to answer their important questions.
In a study design, patients were allocated into two groups according to random numbers technique and patients genders were omitted, nevermore difference of males/females ratio of the two groups  was  not statistically significant. We also believe, this mild difference might have an influence on study results. But as mentioned above this difference is completely related to study design and randomization method.
We used same technique during internal thoracic artery (ITA) harvest in both groups, in pleurotomy group pleura was opened after ITA harvest so we compared semi-sceletonized ITA’s.
Thank you very much for your comments. 

Ahmet Özkara, Ali Can Hatemi*, Gürkan Çetin*, Mete Gürsoy*
Department of Cardiovascular Surgery, School of Medicine, İstanbul Bilim University, İstanbul
 *Department of  Cardiovascular Surgery, İstanbul University Institute of Cardiology, İstanbul, Turkey