- Email: [email protected]
Combined tracheal sleeve and superior vena cava resections for non–small cell lung cancer
Combined Tracheal Sleeve and Superior Vena Cava Resections for Non–Small Cell Lung Cancer Lorenzo Spaggiari, MD, PhD, and Ugo Pastorino, MD Department of Thoracic Surgery, European Institute of Oncology, Milan, Italy
Background. Combined superior vena cava and tracheal sleeve resections are occasionally indicated in the treatment of non–small cell lung cancer. However, more effective induction therapy may potentially expand the benefit of locally extended resections. Methods. From January 1998 to December 1999, 6 consecutive patients had combined tracheal sleeve and superior vena cava resections for non–small cell lung cancer after induction treatment. Surgical approach was musclesparing lateral thoracotomy in 4 patients and hemiclamshell approach in 2 patients. There were four tracheal sleeve pneumonectomies, one tracheal sleeve bilobectomy, and one tracheal sleeve lobectomy. Three patients (50%) had complete superior vena cava resection with
graft replacement, whereas the other patients had partial superior vena cava resection using vascular staplers. Results. There were no perioperative complications. Three patients (50%) had major postoperative complications, but there were no postoperative deaths. Four patients are still alive, 2 without evidence of disease. The median survival was 14.5 months (range, 3 to 17 months). Conclusions. These combined resections are technically feasible with no postoperative mortality but high morbidity (50%). This aggressive surgery may be useful in highly selected patients where adequate local control can achieve long-term survival. (Ann Thorac Surg 2000;70:1172–5) © 2000 by The Society of Thoracic Surgeons
A
(T4) by the tumor, whereas in the remaining case the resection was done for N2 involvement. Patients with T4 involvement had the SVC resection as the first procedure, and in the patient with N2 involvement the tracheal sleeve resection was done first (Figs 1, 2, and 3). Tracheal anastomosis in pneumonectomized patients used two running 3/0 polypropylene sutures and were covered by a pericardial flap. In patients with tracheal sleeve lobectomy or upper bilobectomy, the airway was reconstructed by the Mathey [4] technique (neo-carina created by the anastomosis of the main left bronchus and the intermediate or right lower bronchus with the trachea). Three running 3/0 polypropylene sutures were used for anastomoses. Three patients had more than two thirds of the SVC circumference involved by the tumor (Fig 4), and they had SVC replacement with polytetrafluoroethylene (PTFE) graft. No patients had SVC syndrome from SVC occlusion before resection. Complete clamping of the SVC system was done after having widely opened the pericardium without positioning any venous shunts. An anticoagulation therapy of 0.5 mg/kg intravenous sodium heparin was given before clamping. The clamping time during graft replacement was short (27, 35, and 38 minutes), and this is the most important factor to avoid perioperative neurologic complications. The brain pressure gradient was maintained by moderate fluid implementation (10 mL/kg during clamping). No steroids or hyperventilation was used. The distal anastomosis between both SVC or the left brachiocephalic vein and the PTFE prosthesis was first done during revascularization with a single 5/0 running
lthough the resection of the superior vena cava (SVC) for non–small cell lung cancer (NSCLC) is a topic of debate [1], two recent studies reported technical feasibility, low postoperative mortality rate, and noteworthy 5-year survival in patients with T4, N0-N1 disease [2, 3]. However, combined extended resections (tracheal sleeve and SVC resections) in advanced NSCLC have not been investigated yet. In this report we present our preliminary experience with combined extended resection for NSCLC in patients with concomitant SVC and carinal involvement, analyzing technical feasibility and early and late postoperative outcomes.
Material and Methods From January 1998 to December 1999, 11 patients (9 men and 2 women, median age 62 years, range 45 to 77 years) had SVC resection for NSCLC. These patients comprise 4.4% (11 of 250) of all patients who had radical lung resection for NSCLC in that period. Six of these patients had associated carinal resection and comprise 16.6% (6 of 36) of all tracheobronchial sleeve resections done in that period. During the same period there were 12 (4.8%) exploratory thoracotomies. All patients in the present series had induction treatment (five cases of chemotherapy, one case of chemotherapy, associated with thrice-daily hyperfractionated radiotherapy). In five cases, the indication for both tracheal sleeve and SVC resections was the direct invasion Accepted for publication April 25, 2000. Address reprint requests to Dr Spaggiari, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy; e-mail: [email protected].
© 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
0003-4975/00/$20.00 PII S0003-4975(00)01724-0
Ann Thorac Surg 2000:70:1172–5
Fig 1. Infiltration of the superior vena cava (SCV) by N2 non–small cell lung carcinoma after induction treatment. The SVC and right main pulmonary artery (PA) are isolated.
polypropylene suture (Fig 2). The diameter and the length of the prosthesis depended on the degree of SVC involvement, the native diameter of the SVC, and the site of the distal anastomosis. When the distal anastomosis was done on the left brachiocephalic vein, a 10- or 12-mm ringed PTFE graft was preferred, whereas a 12- to 14-mm ringed PTFE graft replacement was used for truncular revascularization. Three patients had partial resection of the SVC without complete clamping and tangential suture using a vascular stapler.
Results Tables 1, 2, and 3 report the main data of the present series. There were no perioperative complications
Fig 2. Same case as in Figure 1. The tracheal sleeve resection has been done, and the tracheal anastomosis is covered by a pericardial flap. A truncular substitution of the superior vena cava by a 12-mm ringed polytetrafluoroethylene graft is in progress. The distal anastomosis was done first.
SPAGGIARI AND PASTORINO TRACHEAL SLEEVE AND SVC RESECTION FOR NSCLC
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Fig 3. Same case as in Figures 1 and 2. The proximal anastomosis is done, and the superior vena cava replacement is completed. (PTFE ⫽ polytetrafluoroethylene.)
resulting from SVC clamping and no postoperative deaths. Three patients (50%) had major complications. One patient had postpneumonectomy pulmonary edema; she had SVC resection after tracheal sleeve pneumonectomy and extended mediastinal lymph node dissection. To maintain brain pressure gradient, an excessive fluid implementation was done during clamping, which led to postoperative noncardiogenic edema that was treated successfully with medication in the intensive care unit. Another patient had adult respiratory distress syndrome after a second thoracotomy for bleeding, and he was successfully medically treated. The third patient had an early postoperative graft occlusion that was successfully treated by heparin infusion. Four patients are still alive, two without evidence of disease. One patient died without disease. The median survival was 14.5 months (range, 3 to 17 months).
Fig 4. Prechemotherapy computed tomographic thoracic scan showing the degree of superior vena caval involvement requiring graft replacement.
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SPAGGIARI AND PASTORINO TRACHEAL SLEEVE AND SVC RESECTION FOR NSCLC
Ann Thorac Surg 2000:70:1172–5
Table 1. Main Clinicopathologic Data Resection Patient No.
Sex
Age (y)
Histology
Clinical TNM/ Med/N
1 2
M M
45 49
ADC EP
T4N0/yes/N⫺ T4N2/yes/N⫹
3 4 5 6
F M M M
62 67 66 54
EP EP ADC EP
T3N2/nob T4Nx/yes/N⫺ T4Nx/nob T4Nx/yes/N⫺
Induction Treatment CDDP/GCT (3 cy) CDDP/GCT (3 cy) RT (64Gy) CDDP/TAX (4 cy) CDDP/GCT (2 cy) CDDP/GCT (4 cy) CDDP/GCT (3 cy)
Approach
Type
Length of SVC/ Trachea (cm)
Pathologic TNM
HC MSLT
TS Pn TS Pn
4/2 2.8/1.2
T4N2a (R0) T4N2 (R1)
MSLT HC MSLT MSLT
TS TS TS TS
3/1.7 5/3 3/2.5 2/3.2
T1N2 T4N1 T2N1 T4N1
a Only one station (no. 7), microscopical infiltration after radical lymph node dissection. mediastinoscopy because they were referred us after induction treatment.
b
Pn Lb Pn biLb
(R0) (R0) (R0) (R0)
These patients did not undergo pretreatment
ADC ⫽ adenocarcinoma; biLb ⫽ bilobectomy; CDDP ⫽ cisplatin; EP ⫽ squamous cell carcinoma; GCT ⫽ gemcitabine; HC ⫽ hemiclamshell; Lb ⫽ lobectomy; Med ⫽ mediastinoscopy; MSLT ⫽ muscle sparing lateral thoracotomy; N ⫽ mediastinal lymph node status; Pn ⫽ pneumonectomy; R0 ⫽ radical resection; R1 ⫽ microscopical residual tumor; RT ⫽ radiotherapy; SVC ⫽ superior vena cava; TAX ⫽ taxole; TS ⫽ tracheal sleeve.
Comment Combined tracheal sleeve and SVC resections are technically demanding procedures in which major difficulties are associated with uncertain oncologic benefits. These extended resections for NSCLC have been done only occasionally and rarely reported in the literature. To the best of our knowledge, and with the exception of some case reports, only three series with more than 4 patients are cited in the English-language literature with some 5-year survivors, including six cases by Dartevelle and colleagues [5] followed up over a 16-year period, 12 cases by Tsuchiya and associates [6], and 4 cases by Spaggiari and colleagues [3]. However, no data concerning postoperative morbidity, mortality, and outcome were reported. Survival after SVC resection as well as tracheal sleeve pneumonectomy has been proved noteworthy mainly in patients without mediastinal lymph node involvement [2, 3]; however, patients with combined SVC and tracheal sleeve resection comprise a subgroup of patients in whom oncologic benefits of surgical resections are far from being proved. Furthermore, anesthesiologic and surgical feasibility and postoperative morbidity are still under investigation.
From an anesthesiologic point of view, combined extended resections for T4 NSCLC are a challenge; in fact, tracheal sleeve resection with mediastinectomy for radical lymph node dissection requires an accurate fluid balance in terms of fluid restriction. By contrast, complete SVC replacement without internal or external shunts requires fluid implementation during clamping to increase arterial pressure and to maintain a brain pressure gradient to avoid cerebral edema. However, such fluid implementation might facilitate postoperative pulmonary edema mainly in pneumonectomized patients. In our opinion, this serious complication might be avoided by reducing clamping time and then by performing SVC resection before lung resection. In this way, appropriate administration of diuretics could easily remove the surplus of fluids before pulmonary resection. From a technical point of view, limited SVC involvement can be resected easily by tangentially clamping the vessels and by suturing the SVC using a vascular stapler or a running suture. Superior vena caval involvement exceeding one third of the circumference requires graft replacement. The choice of the site of proximal anastomosis depends on the degree of SVC involvement and the surgical approach used. When brachiocephalic vein confluence is involved, we prefer to revascularize the left
Table 2. Perioperative Data Patient No. 1 2 3 4 5 6
SVC Resection
SVC Clamping Type/Time (min)
Prosthesis Type/Diameter (mm)
Anastomosis (Proximal/Distal)
Peroperative Heparin
Partial Complete Complete Complete Partial Partial
... Complete/27 Complete/35 Complete/38 ... ...
... PTFE ringed/14 PTFE ringed/12 PTFE/10 ... ...
... SVC/SVC SVC/SVC SVC/LBCV ... ...
No Yes Yes Yes No No
LBCV ⫽ left brachiocephalic vein;
PTFE ⫽ polytetrafluoroethylene;
SVC ⫽ superior vena cava.
Ann Thorac Surg 2000:70:1172–5
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Table 3. Postoperative Outcome and Follow up Patient No. 1 2 3 4 5 6
Postoperative Complications No No Postpneumonectomy edema Early graft occlusion Rethoracotomy for bleeding, ARDS, tracheostomy No
ICU/Hospital Stay (days)
Anticoagulation
Graft Patency
Time to Relapse (mo)
Outcome
1/9 1/15 42/56 4/35 29/52
... Coumadin Low weight heparin Coumadin ...
... Yes Yes No ...
... 3 (diff) ... 11 (mediast) 6 (BM)
Alive, NED, 14 mo Dead, WD, 7 mo Dead, NED, 3 mo Alive, WD, 17 mo Alive, WD, 16 mo
...
Alive, NED, 15 mo
2/9
...
...
ARDS ⫽ adult respiratory distress syndrome; BM ⫽ brain metastasis; diff ⫽ diffuse recurrences; mediastinal recurrence; NED ⫽ no evidence of disease; WD ⫽ with disease.
brachiocephalic vein closing the right one. In this case, a 12-mm diameter ringed PTFE graft is sufficient; for truncular substitution a 12- or 14-mm-diameter ringed PTFE graft is the choice. In our series of SVC resections and graft replacement for lung and mediastinal neoplasm (nine cases) during the past two years, the median clamping time was 34 minutes (range, 24 to 38 minutes). In our experience, the PTFE graft has remained patent at long-term assessment (Fig 5) [1]. The postoperative morbidity rate was higher (50%) than in other studies (36%, Spaggiari and colleagues [3]; 26.6%, Thomas and associates [2]), but there were no postoperative deaths. The combination of two extended resections might account for that. The postoperative morbidity and mortality rates of the 11 patients who had only SVC resection for NSCLC were 36% and 0%, respectively. The use of a small-diameter, no-ringed prosthesis and the presence of a previous subclavian vein thrombosis might explain the early graft thrombosis that occurred in one patient of our series.
ICU ⫽ intensive care unit;
mediast ⫽
Concerning the use of anticoagulant agents, we maintained patients who had SVC resection with graft replacement on coumadin for at least for 6 months. However, the ideal anticoagulant regimen at discharge after SVC replacement is still not determined. From a prognostic point of view, it has been suggested that only patients without mediastinal lymph node involvement should undergo SVC resection. However, that suggestion was based on data from surgical series in which most patients did not benefit from new chemotherapy regimens. All our patients underwent preoperative cisplatin-based chemotherapy and had a good response. Although the curative potential of extended resection for locally advanced NSCLC has yet to be defined, in selected T4N0 patients with SVC involvement, a radical resection, with or without bronchoplastic procedures, can achieve excellent local control. However, in N2 disease, induction treatment is mandatory and the benefit of surgical resection versus radical radiotherapy has to be tested in prospective trials. In any case, pretreatment mediastinoscopy is an essential staging procedure to determine the optimal treatment of these highly selected patients.
References
Fig 5. Spiral computed tomographic thoracic scan after injection of contrast dye during follow-up. Note the graft patency.
1. Dartevelle PG, Chapelier A, Pastorino U, et al. Long-term follow-up after prosthetic replacement of the superior vena cava combined with the resection of mediastinal-pulmonary malignant tumors. J Thorac Cardiovasc Surg 1991;102:259– 65. 2. Thomas P, Magnan PE, Moulin G, Giudicelli R, Fuentes P. Extended operation for lung cancer invading the superior vena cava. Eur J Cardiothorac Surg 1994;8:177–182. 3. Spaggiari L, Regnard JF, Magdeleinat P, Jauffret B, Puyo P, Levasseur P. Extended resections for bronchogenic carcinoma invading the superior vena cava system. Ann Thorac Surg 2000;69:233– 6. 4. Mathey J. Tumeur benigne de leperon tracheal, resection et refection du carrefour tracheo-bronchique. Semin Hopital Paris 1951;27:2699 –703. 5. Dartevelle PG. Extended operations for the treatment of lung cancer. Ann Thorac Surg 1997;63:12–9. 6. Tsuchiya R, Asamura H, Kondo H, Goya T, Naruke T. Extended resection of the left atrium, great vessels, or both for lung cancer. Ann Thorac Surg 1994;57:960–5.
Background. Combined superior vena cava and tracheal sleeve resections are occasionally indicated in the treatment of non–small cell lung cancer. However, more effective induction therapy may potentially expand the benefit of locally extended resections. Methods. From January 1998 to December 1999, 6 consecutive patients had combined tracheal sleeve and superior vena cava resections for non–small cell lung cancer after induction treatment. Surgical approach was musclesparing lateral thoracotomy in 4 patients and hemiclamshell approach in 2 patients. There were four tracheal sleeve pneumonectomies, one tracheal sleeve bilobectomy, and one tracheal sleeve lobectomy. Three patients (50%) had complete superior vena cava resection with
graft replacement, whereas the other patients had partial superior vena cava resection using vascular staplers. Results. There were no perioperative complications. Three patients (50%) had major postoperative complications, but there were no postoperative deaths. Four patients are still alive, 2 without evidence of disease. The median survival was 14.5 months (range, 3 to 17 months). Conclusions. These combined resections are technically feasible with no postoperative mortality but high morbidity (50%). This aggressive surgery may be useful in highly selected patients where adequate local control can achieve long-term survival. (Ann Thorac Surg 2000;70:1172–5) © 2000 by The Society of Thoracic Surgeons
A
(T4) by the tumor, whereas in the remaining case the resection was done for N2 involvement. Patients with T4 involvement had the SVC resection as the first procedure, and in the patient with N2 involvement the tracheal sleeve resection was done first (Figs 1, 2, and 3). Tracheal anastomosis in pneumonectomized patients used two running 3/0 polypropylene sutures and were covered by a pericardial flap. In patients with tracheal sleeve lobectomy or upper bilobectomy, the airway was reconstructed by the Mathey [4] technique (neo-carina created by the anastomosis of the main left bronchus and the intermediate or right lower bronchus with the trachea). Three running 3/0 polypropylene sutures were used for anastomoses. Three patients had more than two thirds of the SVC circumference involved by the tumor (Fig 4), and they had SVC replacement with polytetrafluoroethylene (PTFE) graft. No patients had SVC syndrome from SVC occlusion before resection. Complete clamping of the SVC system was done after having widely opened the pericardium without positioning any venous shunts. An anticoagulation therapy of 0.5 mg/kg intravenous sodium heparin was given before clamping. The clamping time during graft replacement was short (27, 35, and 38 minutes), and this is the most important factor to avoid perioperative neurologic complications. The brain pressure gradient was maintained by moderate fluid implementation (10 mL/kg during clamping). No steroids or hyperventilation was used. The distal anastomosis between both SVC or the left brachiocephalic vein and the PTFE prosthesis was first done during revascularization with a single 5/0 running
lthough the resection of the superior vena cava (SVC) for non–small cell lung cancer (NSCLC) is a topic of debate [1], two recent studies reported technical feasibility, low postoperative mortality rate, and noteworthy 5-year survival in patients with T4, N0-N1 disease [2, 3]. However, combined extended resections (tracheal sleeve and SVC resections) in advanced NSCLC have not been investigated yet. In this report we present our preliminary experience with combined extended resection for NSCLC in patients with concomitant SVC and carinal involvement, analyzing technical feasibility and early and late postoperative outcomes.
Material and Methods From January 1998 to December 1999, 11 patients (9 men and 2 women, median age 62 years, range 45 to 77 years) had SVC resection for NSCLC. These patients comprise 4.4% (11 of 250) of all patients who had radical lung resection for NSCLC in that period. Six of these patients had associated carinal resection and comprise 16.6% (6 of 36) of all tracheobronchial sleeve resections done in that period. During the same period there were 12 (4.8%) exploratory thoracotomies. All patients in the present series had induction treatment (five cases of chemotherapy, one case of chemotherapy, associated with thrice-daily hyperfractionated radiotherapy). In five cases, the indication for both tracheal sleeve and SVC resections was the direct invasion Accepted for publication April 25, 2000. Address reprint requests to Dr Spaggiari, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy; e-mail: [email protected].
© 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
0003-4975/00/$20.00 PII S0003-4975(00)01724-0
Ann Thorac Surg 2000:70:1172–5
Fig 1. Infiltration of the superior vena cava (SCV) by N2 non–small cell lung carcinoma after induction treatment. The SVC and right main pulmonary artery (PA) are isolated.
polypropylene suture (Fig 2). The diameter and the length of the prosthesis depended on the degree of SVC involvement, the native diameter of the SVC, and the site of the distal anastomosis. When the distal anastomosis was done on the left brachiocephalic vein, a 10- or 12-mm ringed PTFE graft was preferred, whereas a 12- to 14-mm ringed PTFE graft replacement was used for truncular revascularization. Three patients had partial resection of the SVC without complete clamping and tangential suture using a vascular stapler.
Results Tables 1, 2, and 3 report the main data of the present series. There were no perioperative complications
Fig 2. Same case as in Figure 1. The tracheal sleeve resection has been done, and the tracheal anastomosis is covered by a pericardial flap. A truncular substitution of the superior vena cava by a 12-mm ringed polytetrafluoroethylene graft is in progress. The distal anastomosis was done first.
SPAGGIARI AND PASTORINO TRACHEAL SLEEVE AND SVC RESECTION FOR NSCLC
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Fig 3. Same case as in Figures 1 and 2. The proximal anastomosis is done, and the superior vena cava replacement is completed. (PTFE ⫽ polytetrafluoroethylene.)
resulting from SVC clamping and no postoperative deaths. Three patients (50%) had major complications. One patient had postpneumonectomy pulmonary edema; she had SVC resection after tracheal sleeve pneumonectomy and extended mediastinal lymph node dissection. To maintain brain pressure gradient, an excessive fluid implementation was done during clamping, which led to postoperative noncardiogenic edema that was treated successfully with medication in the intensive care unit. Another patient had adult respiratory distress syndrome after a second thoracotomy for bleeding, and he was successfully medically treated. The third patient had an early postoperative graft occlusion that was successfully treated by heparin infusion. Four patients are still alive, two without evidence of disease. One patient died without disease. The median survival was 14.5 months (range, 3 to 17 months).
Fig 4. Prechemotherapy computed tomographic thoracic scan showing the degree of superior vena caval involvement requiring graft replacement.
1174
SPAGGIARI AND PASTORINO TRACHEAL SLEEVE AND SVC RESECTION FOR NSCLC
Ann Thorac Surg 2000:70:1172–5
Table 1. Main Clinicopathologic Data Resection Patient No.
Sex
Age (y)
Histology
Clinical TNM/ Med/N
1 2
M M
45 49
ADC EP
T4N0/yes/N⫺ T4N2/yes/N⫹
3 4 5 6
F M M M
62 67 66 54
EP EP ADC EP
T3N2/nob T4Nx/yes/N⫺ T4Nx/nob T4Nx/yes/N⫺
Induction Treatment CDDP/GCT (3 cy) CDDP/GCT (3 cy) RT (64Gy) CDDP/TAX (4 cy) CDDP/GCT (2 cy) CDDP/GCT (4 cy) CDDP/GCT (3 cy)
Approach
Type
Length of SVC/ Trachea (cm)
Pathologic TNM
HC MSLT
TS Pn TS Pn
4/2 2.8/1.2
T4N2a (R0) T4N2 (R1)
MSLT HC MSLT MSLT
TS TS TS TS
3/1.7 5/3 3/2.5 2/3.2
T1N2 T4N1 T2N1 T4N1
a Only one station (no. 7), microscopical infiltration after radical lymph node dissection. mediastinoscopy because they were referred us after induction treatment.
b
Pn Lb Pn biLb
(R0) (R0) (R0) (R0)
These patients did not undergo pretreatment
ADC ⫽ adenocarcinoma; biLb ⫽ bilobectomy; CDDP ⫽ cisplatin; EP ⫽ squamous cell carcinoma; GCT ⫽ gemcitabine; HC ⫽ hemiclamshell; Lb ⫽ lobectomy; Med ⫽ mediastinoscopy; MSLT ⫽ muscle sparing lateral thoracotomy; N ⫽ mediastinal lymph node status; Pn ⫽ pneumonectomy; R0 ⫽ radical resection; R1 ⫽ microscopical residual tumor; RT ⫽ radiotherapy; SVC ⫽ superior vena cava; TAX ⫽ taxole; TS ⫽ tracheal sleeve.
Comment Combined tracheal sleeve and SVC resections are technically demanding procedures in which major difficulties are associated with uncertain oncologic benefits. These extended resections for NSCLC have been done only occasionally and rarely reported in the literature. To the best of our knowledge, and with the exception of some case reports, only three series with more than 4 patients are cited in the English-language literature with some 5-year survivors, including six cases by Dartevelle and colleagues [5] followed up over a 16-year period, 12 cases by Tsuchiya and associates [6], and 4 cases by Spaggiari and colleagues [3]. However, no data concerning postoperative morbidity, mortality, and outcome were reported. Survival after SVC resection as well as tracheal sleeve pneumonectomy has been proved noteworthy mainly in patients without mediastinal lymph node involvement [2, 3]; however, patients with combined SVC and tracheal sleeve resection comprise a subgroup of patients in whom oncologic benefits of surgical resections are far from being proved. Furthermore, anesthesiologic and surgical feasibility and postoperative morbidity are still under investigation.
From an anesthesiologic point of view, combined extended resections for T4 NSCLC are a challenge; in fact, tracheal sleeve resection with mediastinectomy for radical lymph node dissection requires an accurate fluid balance in terms of fluid restriction. By contrast, complete SVC replacement without internal or external shunts requires fluid implementation during clamping to increase arterial pressure and to maintain a brain pressure gradient to avoid cerebral edema. However, such fluid implementation might facilitate postoperative pulmonary edema mainly in pneumonectomized patients. In our opinion, this serious complication might be avoided by reducing clamping time and then by performing SVC resection before lung resection. In this way, appropriate administration of diuretics could easily remove the surplus of fluids before pulmonary resection. From a technical point of view, limited SVC involvement can be resected easily by tangentially clamping the vessels and by suturing the SVC using a vascular stapler or a running suture. Superior vena caval involvement exceeding one third of the circumference requires graft replacement. The choice of the site of proximal anastomosis depends on the degree of SVC involvement and the surgical approach used. When brachiocephalic vein confluence is involved, we prefer to revascularize the left
Table 2. Perioperative Data Patient No. 1 2 3 4 5 6
SVC Resection
SVC Clamping Type/Time (min)
Prosthesis Type/Diameter (mm)
Anastomosis (Proximal/Distal)
Peroperative Heparin
Partial Complete Complete Complete Partial Partial
... Complete/27 Complete/35 Complete/38 ... ...
... PTFE ringed/14 PTFE ringed/12 PTFE/10 ... ...
... SVC/SVC SVC/SVC SVC/LBCV ... ...
No Yes Yes Yes No No
LBCV ⫽ left brachiocephalic vein;
PTFE ⫽ polytetrafluoroethylene;
SVC ⫽ superior vena cava.
Ann Thorac Surg 2000:70:1172–5
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Table 3. Postoperative Outcome and Follow up Patient No. 1 2 3 4 5 6
Postoperative Complications No No Postpneumonectomy edema Early graft occlusion Rethoracotomy for bleeding, ARDS, tracheostomy No
ICU/Hospital Stay (days)
Anticoagulation
Graft Patency
Time to Relapse (mo)
Outcome
1/9 1/15 42/56 4/35 29/52
... Coumadin Low weight heparin Coumadin ...
... Yes Yes No ...
... 3 (diff) ... 11 (mediast) 6 (BM)
Alive, NED, 14 mo Dead, WD, 7 mo Dead, NED, 3 mo Alive, WD, 17 mo Alive, WD, 16 mo
...
Alive, NED, 15 mo
2/9
...
...
ARDS ⫽ adult respiratory distress syndrome; BM ⫽ brain metastasis; diff ⫽ diffuse recurrences; mediastinal recurrence; NED ⫽ no evidence of disease; WD ⫽ with disease.
brachiocephalic vein closing the right one. In this case, a 12-mm diameter ringed PTFE graft is sufficient; for truncular substitution a 12- or 14-mm-diameter ringed PTFE graft is the choice. In our series of SVC resections and graft replacement for lung and mediastinal neoplasm (nine cases) during the past two years, the median clamping time was 34 minutes (range, 24 to 38 minutes). In our experience, the PTFE graft has remained patent at long-term assessment (Fig 5) [1]. The postoperative morbidity rate was higher (50%) than in other studies (36%, Spaggiari and colleagues [3]; 26.6%, Thomas and associates [2]), but there were no postoperative deaths. The combination of two extended resections might account for that. The postoperative morbidity and mortality rates of the 11 patients who had only SVC resection for NSCLC were 36% and 0%, respectively. The use of a small-diameter, no-ringed prosthesis and the presence of a previous subclavian vein thrombosis might explain the early graft thrombosis that occurred in one patient of our series.
ICU ⫽ intensive care unit;
mediast ⫽
Concerning the use of anticoagulant agents, we maintained patients who had SVC resection with graft replacement on coumadin for at least for 6 months. However, the ideal anticoagulant regimen at discharge after SVC replacement is still not determined. From a prognostic point of view, it has been suggested that only patients without mediastinal lymph node involvement should undergo SVC resection. However, that suggestion was based on data from surgical series in which most patients did not benefit from new chemotherapy regimens. All our patients underwent preoperative cisplatin-based chemotherapy and had a good response. Although the curative potential of extended resection for locally advanced NSCLC has yet to be defined, in selected T4N0 patients with SVC involvement, a radical resection, with or without bronchoplastic procedures, can achieve excellent local control. However, in N2 disease, induction treatment is mandatory and the benefit of surgical resection versus radical radiotherapy has to be tested in prospective trials. In any case, pretreatment mediastinoscopy is an essential staging procedure to determine the optimal treatment of these highly selected patients.
References
Fig 5. Spiral computed tomographic thoracic scan after injection of contrast dye during follow-up. Note the graft patency.
1. Dartevelle PG, Chapelier A, Pastorino U, et al. Long-term follow-up after prosthetic replacement of the superior vena cava combined with the resection of mediastinal-pulmonary malignant tumors. J Thorac Cardiovasc Surg 1991;102:259– 65. 2. Thomas P, Magnan PE, Moulin G, Giudicelli R, Fuentes P. Extended operation for lung cancer invading the superior vena cava. Eur J Cardiothorac Surg 1994;8:177–182. 3. Spaggiari L, Regnard JF, Magdeleinat P, Jauffret B, Puyo P, Levasseur P. Extended resections for bronchogenic carcinoma invading the superior vena cava system. Ann Thorac Surg 2000;69:233– 6. 4. Mathey J. Tumeur benigne de leperon tracheal, resection et refection du carrefour tracheo-bronchique. Semin Hopital Paris 1951;27:2699 –703. 5. Dartevelle PG. Extended operations for the treatment of lung cancer. Ann Thorac Surg 1997;63:12–9. 6. Tsuchiya R, Asamura H, Kondo H, Goya T, Naruke T. Extended resection of the left atrium, great vessels, or both for lung cancer. Ann Thorac Surg 1994;57:960–5.