Systematic mediastinal nodal dissection and video-assisted thoracic surgery.

We appreciate the comments by Nezic et al. [1] regarding our article [2]. Nezic et al. pointed out the pinholes of the everting mattress sutures on the flange as the potential sites of bleeding. However, a recent Gelatin-sealed woven Dacron graft was considered because the problem was rare. In addition, we injected fibrin glue around the proximal suture line after sewing the Valsalva sinus skirt to the residual aortic wall to prevent bleeding of the pinholes. Actually, no patient required re-exploration for bleeding. Therefore, we think that the flange side pinholes of everting mattress sutures are not the potential sites of bleeding. As stated in their letter, sewing the residual aortic wall to the prosthetic sewing cuff or the prosthetic tube is a simple technique [3]. However, their technique is difficult to wrap tightly all of the proximal anastomosis line in case with the thin and fragile residual aortic wall or the inadequate length to contact the cuff after resection of coronary ostia. To prevent this problem, Chen et al. [4] made the corresponding portions of the flange long enough in order to sew between the residual aortic wall and the flange. We used the Valsalva sinus skirt as the flange, which is soft and stretchable. This characteristic is useful to sew tightly the skirt to the residual aortic wall even in the cases.