- Email: [email protected]
Decortication
Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma: Extrapleural Pneumonectomy and Pleurectomy/Decortication Andrea S. Wolf, MD, Jonathan Daniel, MD, and David J. Sugarbaker, MD Trimodality treatment of malignant pleural mesothelioma with cytoreductive surgery followed by radiation and chemotherapy has resulted in long-term survival for a select group of patients. Knowledge of the similarities and differences between the two operations that have evolved— extrapleural pneumonectomy and pleurectomy/decortication—is prerequisite to understanding the complex issues associated with patient selection, diagnosis, pathologic staging, preoperative assessment, perioperative management, and adjuvant treatment. Both operations are technically complex and should only be performed at experienced high-volume centers. Semin Thorac Cardiovasc Surg 21:132-148 © 2009 Elsevier Inc. All rights reserved. KEYWORDS extrapleural pneumonectomy, pleurectomy/decortication, management of procedure-related complications
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he goal of surgery in the multimodality treatment of malignant pleural mesothelioma (MPM) is to achieve maximum cytoreduction. Two operations have evolved: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). A misconception persists that one operation is better than the other. In fact, the indications for each operation are distinct and patient selection depends on the same type of factors one would apply to select the appropriate operation for any thoracic malignancy. Early high operative mortality with EPP in the 1970s, when it was first converted from a surgery for tuberculous empyema to a surgery for MPM, has declined to 3.4% at our institution with aggressive perioperative management of procedure-related complications.1 P/D, an operation that spares the lung, is associated with a 1.8% mortality rate,2 but is suitable for achieving macroscopic complete resection (MCR) only in patients with disease confined to the outer surface of the parietal pleura. Invasive involvement of mediastinal structures or extension into the lung fissures precludes P/D for intentions other than symptom palliation. Patients who undergo P/D also have a shorter disease-free interval and higher rate of recurrence. Factors that affect operative choice and patient selection are discussed by Dr. Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, Massachusettes. Address reprints to David J. Sugarbaker, MD, Division of Thoracic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail: [email protected]
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1043-0679/09/$-see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1053/j.semtcvs.2009.07.007
Flores in this issue. This chapter describes the technical conduct of each operation and the approach to management and prevention of procedure-related complications.
Part I: Technique of Right EPP EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. Fusion of the pleura at the central tendon of the diaphragm and the lateral portion of the pericardium mandates resection and subsequent reconstruction with a prosthetic patch. The right EPP is described first followed by key modifications for a left-sided resection. The operation is performed through a single extended right posterolateral thoracotomy in the following sequence: (1) incision and exposure; (2) anterior and posterior extrapleural dissection; (3) separation of the lateral attachments of the diaphragm; (4) opening of the pericardium; (5) division of the hilar vessels; (6) division of the posterior crus of the diaphragm and posterior pericardium; (7) division of the right mainstem bronchus with en bloc removal of the tumor; (8) mediastinal lymphadenectomy; (9) optional administration of heated bicavitary intraoperative chemotherapy (HIOC); (10) reconstruction of diaphragm and pericardium; and (11) closure. EPP is a complex operation that should be performed only at experienced surgical centers with an experienced thoracic anesthesia team.
Operative techniques
Preoperative Assessment Patients undergoing EPP or P/D undergo the same protocol for preoperative assessment. Foremost, this includes pulmonary function tests to assess the patient’s respiratory status, chest computed tomography (CT) scan to define abnormalities of the lung parenchyma, and magnetic resonance imaging (MRI) to assess for transdiaphragmatic, mediastinal or diffuse chest wall invasion. [18F] Fluorodeoxyglucose positron emission tomography (FDG-PET) can detect infradiaphragmatic or supraclavicular lymphadenopathy, liver metastases, or other unusual metastatic patterns. Many centers now use combination PET-CT for correlating FDG-avidity with anatomic-specific CT findings. The level of avidity of the pleural rind has been found to correlate with survival in retrospective studies.3 In addition to assessing global ventricular function, echocardiogram is performed to evaluate pulmonary artery pressure because of the potential for pulmonary hypertension and right heart strain induced by pneumonectomy. We also have found that duplex studies of the lower extremity veins are useful because mesothelioma patients are hypercoagulable and at high risk for occult deep vein thrombosis (DVT). Treatment of DVT with anticoagulation (and, if appropriate, inferior caval filter) before surgery is thought to reduce the risk of life-threatening pulmonary embolus (PE) after pneumonectomy. Patients are considered fit for surgery if they have a Karnofsky performance status of greater than 70, normal liver and renal function tests, a room air arterial pCO2 of less than 45 mm Hg, and a room air arterial PO2 of greater than 65 mm Hg. Pulmonary function testing that reveals a forced expiratory volume in 1 second (FEV1) of greater than 2 L is generally adequate for pneumonectomy for all but the largest patients. Quantitative ventilation/perfusion scanning is indicated to estimate postoperative lung function. The product of the perfusion to the unaffected lung and the preoperative FEV1 yields the predicted postoperative (ppo) FEV1. While this value ideally exceeds 1.2 L, patients with a ppo-FEV1 greater than 800 cc are acceptable candidates for EPP depending on their body mass. Patients with ppo-FEV1 of less than 800 cc may be considered for P/D (Table 1). Chest CT and MRI are performed to rule out advanced locally invasive disease. Clearcut radiologic evidence of transdiaphragmatic, mediastinal, or diffuse chest wall extension precludes surgical resection. Likewise, involvement of the contralateral hemithorax generally contraindicates cytoreductive surgery. When there is indisputable evidence of extensive chest wall invasion or if the tumor is palpable on physical examination, most of such patients are unresectable. The presence of extensive pain and the use of narcotics preoperatively is a clinical indicator of extensive chest wall invasion and likely unresectability. Chest CT and MRI can be misleading and often the resectability of a tumor is not known until surgery. The differentiation between radiographic evidence for the displacement of mediastinal structures versus the invasion of mediastinal structures is an important distinction, as many patients have been erroneously ruled out for surgery based on the displace-
133 Table 1 Patient Selection Criteria Karnofsky performance Renal function Liver function Pulmonary function Cardiac function
Extent of disease
>70 Creatinine <2 AST <80 IU/L, total bilirubin <1.9 mg/ dL, PT <15 s Postoperative FEV1 >0.8 L, as per PFTs and quantitative ventilationperfusion scans Grossly normal cardiac function as per ECG and echocardiography (EF preferably >45%) Limited to ipsilateral hemithorax with no transdiaphragmatic, transpericardial, or extensive chest wall involvement
Reprinted with permission from Sugarbaker et al.1 AST, aspartate aminotransfersase; PT, prothrombin time; FEV1, forced expiratory volume in 1 second; PFTs, pulmonary function tests; ECG, electrocardiography; EF, ejection fraction.
ment of mediastinal structures by a resectable tumor. Likewise, chest CT and MRI have limited value in distinguishing compression of tumor on the diaphragm from transdiaphragmatic abdominal invasion. Therefore, if there is radiologic evidence of transdiaphragmatic extension, intra-abdominal tumor, or ascites, this is an indication for staging laparoscopy to evaluate the peritoneum before potential thoracic resection. Finally, patients with limited chest wall invasion on imaging without evidence of advanced locally invasive disease or metastasis may be amenable to a surgical resection, and these patients should therefore be explored. Histologic diagnosis of mesothelioma by pleural biopsy is a mandatory component of all multimodality treatment protocols. Cytologic diagnosis is limited because of the difficulty of distinguishing MPM from lung adenocarcinoma or sarcoma. Thoracoscopic pleural biopsy is recommended via a single port placed in the location of a future thoracotomy (such that this tract can be excised at the time of future resection). If the pleural biopsy is positive, a staging cervical mediastinoscopy is performed to rule out involvement of the mediastinal nodes. Patients who have mediastinal lymph node involvement are offered chemotherapy up-front and may undergo a reassessment for surgery after two to four cycles of chemotherapy.
Anesthesia A thoracic epidural catheter is placed for intraoperative and postoperative pain control. Standard lines and probes are placed for continuous intraoperative assessment, including arterial and central venous pressure monitoring, continuous pulse-oximetry, and a Swan-Ganz catheter in most patients. The central line is placed preferably on the operative side to avoid pneumothorax in the nonoperative chest. After general anesthesia is induced, a left-sided double-lumen endotracheal tube is inserted for single-lung ventilation. The patient is placed in left lateral decubitus position for an extended
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Extrapleural Dissection
Figure 1 Extended right posterolateral thoracotomy. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
right posterolateral thoracotomy. A nasogastric tube is inserted for aid in identifying the esophagus during the extrapleural dissection. This tube is left in place postoperatively and used to decompress the stomach and prevent aspiration.
Operative Technique
The extrapleural dissection is performed with a combination of blunt and sharp dissection to separate tumor from the chest wall. A plane is initiated along the anterior and posterior edges of the incision. Once started, finger fracture can be used to extend the planes between the endothoracic fascia and the parietal pleura. The presence of skeletal muscle on the parietal pleura is indicative of a tumor with invasive characteristics. If extensive invasion of chest wall is encountered such that it obliterates the extrapleural plane, surgical resection is precluded. Frequent administration of sterile water during this stage of the dissection may aid in the lysis of adhesions, which, in turn, may aid in the blunt dissection of tumor off the endothoracic fascia. After blunt dissection is performed for a single handbreadth superior and inferior to the incision, one may then place the rib spreader. One or two rib spreaders may be used; however, a single posterior rib spreader will provide sufficient aid for dissection. The dissection is begun posterolaterally to the apex, over the apex down the mediastinum, and along the mediastinum to the midhilum. At this point the dissection is continued inferiorly and laterally and posteriorly to the diaphragmatic insertions into the chest wall. The anterolateral aspect of the pleura is dissected first. A chest retractor is positioned anteriorly and posteriorly to optimize exposure (Fig. 2). The internal mammary vessels are identified anteriorly and must be approached with attention to technique to avoid blunt avulsive injury. Evidence of tumor invasion of the internal mammary vessels is also indicative of an invasive tumor that may not lend itself to complete resection. For this reason, whenever the dissection approaches a vessel, sharp technique is recommended. As the plane is extended, all previous areas of dissection are packed with laparotomy pads for hemostasis.
Flexible bronchoscopy is performed to survey the right and left tracheobronchial tree to rule out clot, hemorrhage, anatomic variation, active infection, or the presence of unexpected pathology. Patients who have radiologic evidence of intra-abdominal tumor are explored laparoscopically or through a limited subcostal incision along the line of the planned thoracotomy incision before definitive resection. If there is evidence of intra-abdominal disease, histologic diagnosis is confirmed by biopsy, and attempted resection is generally not continued.
Incision and Exposure The posterolateral thoracotomy begins midway between the scapular tip and the spine and extends along the bed of the sixth rib to the costochondral junction (Fig. 1). To prevent tumor seeding, previous biopsy scars are included in the incision or separately excised leaving a minimum 1-cm margin to the depth of the chest wall fascia. The latissimus dorsi and serratus anterior muscles are divided. The sixth rib is resected and the posterior periosteum in the bed of the sixth rib is incised to expose the extrapleural plane.
Figure 2 During the anterior parietal dissection, it is important to avoid injury to the internal mammary vessels. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Operative techniques
Figure 3 Appearance of subclavian vessels at the lung apex. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
The dissection progresses to the apex, where the subclavian vessels are identified and also approached with caution to avoid avulsion (Fig. 3). As the dissection advances over the apex, the tumor is brought down from the posterior and superior mediastinum, where the azygos vein and superior vena cava are approached carefully (Fig. 4). After adequate anterolateral exposure, the posterior dissection is performed. Unexpected invasion of vital mediastinal structures (e.g., aorta, vena cava, esophagus, epicardium, vertebrae, or trachea) precludes resection and the operation is concluded. After the right upper lobe and right mainstem bronchus are exposed, attention turns to the esophagus. The esophagus is identified with aid of the nasogastric tube placed preoperatively and gently resected away from the tumor above the hiatus (Fig. 5). The pericardium is incised anteriorly and the pericardial space is palpated for evidence of myocardial invasion (Fig. 6). If the heart is free of tumor, the dissection proceeds to the diaphragm.
Figure 4 The pleural dissection proceeds inferiorly after advancing over the lung apex with attention to the azygos vein and superior vena cava. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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Figure 5 Esophageal dissection is aided by palpating the NG tube placed perioperatively. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
The diaphragm is incised first at its lateral margin, followed by circumferential resection anteriorly and posteriorly (Fig. 7). The diaphragmatic muscle attachments to the chest wall are manually avulsed (Fig. 8) and cauterized, and the peritoneum is dissected off the undersurface of the diaphragm (Fig. 9). If heated intraoperative chemotherapy (HIOC) is planned, the peritoneum is not preserved as the intention is for bicavitary lavage to reduce the risk of locoregional (including abdominal) recurrence. Diaphragmatic dissection is performed carefully at the inferior vena cava and esophageal hiatus (Fig. 10). The pericardial incision made earlier is extended and the junction of the pericardium and the medial aspect of the diaphragm is divided. With release of the diaphragmatic attachments medially and posteriorly, the esophagus is dissected away from the specimen.
Figure 6 After opening the pericardial space, it is palpated manually to assess for tumor invasion. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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Figure 9 The diaphragm is dissected from the underlying peritoneum. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.) Figure 7 The diaphragm is incised circumferentially. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Opening the Pericardium The pericardium is opened anteromedially and the pericardiotomy is extended superiorly from medial to lateral to the azygos recess (Fig. 11). Visualization of the quality of pericardial fluid is important. Clear pericardial fluid indicates
Figure 8 Blunt separation of the diaphragm from chest wall. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
lack of tumor invasion. Bloody pericardial fluid may indicate transpericardial and/or myocardial invasion by tumor. At this time, the surgeon also explores the pericardial cavity digitally to identify transpericardial or myocardial invasion. It is critical to carry the dissection well into the azygos recess for later dissection of the right main pulmonary artery.
Control of Pulmonary Vessels Dissection is continued by extending the pericardiotomy from medial to lateral superficial to the inferior vena cava, which is directly visualized during this dissection. Care is taken to visualize and ligate the phrenic veins as one divides the pericardium superficial to the inferior vena cava. The tumor and diaphragm are then retracted superiorly and the pericardiotomy is continued from inferiorly to superiorly, to the region of the inferior pulmonary vein. The specimen is
Figure 10 Careful dissection around the esophageal hiatus and inferior vena cava. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Operative techniques
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Figure 11 The posterior pericardium and medial aspect of the diaphragm are divided. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
then retracted laterally by placing trocar clamps directly lateral to the superior and inferior pulmonary veins. Traction on the specimen laterally facilitates dissection of the right main pulmonary artery by grasping the superior vena cava and retracting it medially, and dividing the fibrinous adhesions between the superior vena cava and right main pulmonary artery. Dissection around the right main pulmonary artery is then completed and a 0 silk ligature is passed around the right main pulmonary artery with the use of a Harken No. 2 clamp. Following this, the endoleader is used to divide the right main pulmonary artery in the standard fashion using an endo-45 stapler with a vascular load (Fig. 12). In similar fashion, the superior and
Figure 12 Passing the endoleader around the pulmonary artery to guide passage of the endovascular stapler. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Figure 13 Dissection of right pulmonary artery. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
inferior pulmonary veins are dissected free from surrounding tissue and divided using the endoleader and endovascular stapler technique. The pericardiotomy is completed by extending it from inferior to superior over the right main bronchus, which is exposed at the completion of the pericardiotomy (Fig. 13). A radical lymphadenectomy is completed at this time to include inferior pulmonary ligament, periesophageal, and subcarinal nodes (Fig. 14). These nodes are either swept up with the specimen or they are sent separately with appropriate labels for pathologic examination.
Figure 14 Lymphadenectomy is performed for clinical staging. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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A.S. Wolf, J. Daniel, and D.J. Sugarbaker disease are marked with radiopaque clips to guide adjuvant radiation therapy. The wound is then packed and additional intraoperative procedures, such as HIOC, may be completed at this time. Patients receiving HIOC are prepared for a 1-hour lavage of cisplatin-based chemotherapy with sodium thiosulfate and amifostine for renal protection. The set-up and procedure for HIOC have been previously described.4
Reconstruction
Figure 15 Right mainstem bronchus is encircled with heavy-gauge wire stapler before it is divided as close to the carina as possible. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Division of Bronchus While preparing to divide the right mainstem bronchus, it is critical to ask the anesthesia team to place a pediatric bronchoscope down the right-sided tube. A heavy-gauge wire bronchial stapler (TA-30, Ethicon, Johnson and Johnson, Cincinnati, OH) (Fig. 15) is placed around the right main bronchus after the subcarinal nodal packet has been removed. With direct intraoperative endoscopic visualization of the right main bronchus via video bronchoscopy, the bronchus is divided by firing the stapler at the carina. The mainstem bronchus must be divided right at the carina to avoid excessive length to the bronchial stump. Even a short bronchial stump will allow secretions to pool, which can precipitate infection and cause a bronchopleural fistula (BPF) in the late postoperative period. The specimen is sent off to pathology and frozen section of the bronchial margin is performed to determine whether there is any evidence of peribronchial invasion of tumor. The empty chest cavity is instilled with warm saline and handbag ventilated to 30 mm Hg to check for air leaks along the bronchial staple line. An omental flap from the abdomen is prepared to buttress the bronchial closure. Alternatively, if the perithymic/pericardial fat pad is generous in size, this can be dissected on a proximal vascular pedicle and placed over the bronchial stump for coverage. Likewise, intercostal muscle can be used. Although other vascularized tissues may be used, we prefer the omentum because of its greater vascularity. The omental flap based on the gastroepiploic vascular supply can be fashioned efficiently with multiple firings of the endo-60 and endo-45 staplers with vascular loads. A tongue of vascularized omentum (Fig. 16) can be brought through an aperture created in the diaphragmatic patch and sutured to the bronchial staple line (see below). The argon beam coagulator (Valleylab, Boulder, CO), bovie electrocautery, and surgical clips are used to ensure complete hemostasis. Areas of concern for microscopic residual
The defects in the diaphragm and pericardium are reconstructed with a prosthetic patch made of Gore-Tex (W.L. Gore and Associates, Flagstaff, AZ). If there is evidence of pre-existing infection in the chest, we generally use biomaterial for reconstruction, such as bovine pericardial patch for the pericardium and micromesh, such as vicryl, for the diaphragm. For the noninfected chest, the diaphragmatic patch is constructed from two pieces of 2-mm-thick Gore-Tex dual mesh, 20 ⫻ 30 cm in dimension stapled together along the longer dimension, with a slight overlap at the center as shown in Fig. 17. This dual patch is contoured to the hemithorax and creates a loose, floppy patch at the center and minimizes tension along the suture line. The dynamic nature of this patch reduces the likelihood of dehiscence along the chest wall and prevents herniation of the abdominal contents into the pneumonectomy cavity. The diaphragmatic patch is sutured anteriorly, laterally, and posteriorly to the chest wall by using an awl and transmural Gore-Tex suture secured outside the chest wall to a 14-mm polypropylene button (Fig. 18). This is one of several maneuvers that has been developed
Figure 16 Harvesting the omental flap for later use as a bronchial buttress. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Operative techniques
Figure 17 Constructing the diaphragmatic patch from two pieces of 2-mm-thick Gore-Tex dual mesh. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
to prevent herniation of intra-abdominal contents postoperatively. Pericardial fixation of the patch to the cut edge of pericardium inferiorly is also critical to prevent diaphragmatic hernia. Early diaphragmatic hernia is difficult to diagnose radiographically and may present with subtle right heart failure leading to hypoxia in the immediate postoperative period.
Figure 18 Securing the patch to the chest wall with (A) polypropylene buttons (14 mm) and (B) suture. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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Figure 19 A small opening is made in the midportion of the diaphragmatic patch for the omenatal flap. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Before completing the diaphragmatic patch reconstruction, a small opening is created in the medial midportion of the patch for the omental flap, which is brought into the pneumonectomy cavity for later use as a buttress for the bronchial staple line (Fig. 19). The patch is sewn medially to the pericardial edge and diaphragmatic crus. Both the diaphragmatic and pericardial patches are sutured to the cut edge of the native pericardium and to each other medially. A pericardial patch is fashioned from .1-mm non-wettable PTFE to prevent cardiac herniation as well as to prevent the epicarditis that has been shown to develop in patients who develop a fibrinous inflamed peel over the heart following EPP without pericardial prosthetic reconstruction.5 The pericardial patch is fenestrated to ensure easy drainage of intrapericardial blood or other fluid to prevent the development of tamponade physiology (Fig. 20A). The pericardial patch is sutured to the cut native pericardial edge with interrupted Gore-Tex or other soft nonabsorbable suture (Fig. 20B). The pericardial patch is sized generously to accommodate potential postoperative cardiac enlargement and prevent the development of tamponade. A tight patch can be avoided by first securing the prosthetic posteriorly, which is the deepest part of the reconstruction. After the suture is placed, it retracts posteriorly, thus permitting better sizing of the patch when it is sutured to the anterior pericardium. Care should also be taken to suture the patch to the cut edge of the pericardium instead of other weaker tissues to avoid cardiac herniation. The omental flap mobilized earlier is sutured to the bronchial closure to minimize risk of BPF (Fig. 21). A 14 F Robnell red rubber catheter is placed into the pneumonectomy space and brought out through a separate stab wound below the medial aspect of the incision. The chest wall is closed in layers. The catheter is connected to a three-way stopcock and
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Figure 20 (A) The pericardial patch is fenestrated and sewn to the pericardial edge. (B) The patches are sutured in the cut edge of the pericardium and to each other medially. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
air is removed to reposition the mediastinum to midline (1000 mL of air in men and 750 mL in women). After the chest is closed, the patient is placed in supine position and flexible bronchoscopy is performed to assess the bronchial closure and to evacuate secretions. The patient is extubated in the OR.
Key Differences in Operative Technique for Left EPP
Figure 22 Structures at risk for a left-sided EPP. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
eration is technically similar to right EPP with a few key differences: ●
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Patients with tumor involving the left hemithorax are approached through a left posterolateral thoracotomy. The op●
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Figure 21 The omental flap is sutured to the bronchial stump. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
The approach to anesthesia includes placement of a right-sided double-lumen endotracheal tube or leftsided endobronchial blocker. When dissecting the pleura off the aorta during the posterior extrapleural dissection, it is vital to begin in the preaortic plane, since it is easy to inadvertently start dissecting behind the aorta, thereby injuring the intercostal branches. Beginning this part of the dissection on the arch reduces this risk (Fig. 22). Caution must also be exercised around the thoracic duct and recurrent laryngeal nerve while dissecting in the area between the aortopulmonary window and the takeoff of the subclavian vessel from the aortic arch (Fig. 22). During the diaphragmatic resection, it is important to leave a 1 to 2-cm rim of left diaphragmatic crus over the incisura (Fig. 23). Sutures are placed in this rim during patch reconstruction to prevent gastric herniation into the pneumonectomy space. As the left main pulmonary artery is short relative to the right, the left main pulmonary artery is divided in the extrapericardial/extrapleural plane just as it exits the pericardium (Fig. 24). This is facilitated by retracting the lung medially and inferiorly to expose the left main pulmonary artery. The pulmonary artery again is encircled with the Harken No. 2 clamp and the vessel is divided by a single firing of the endo-45 stapler using the endoleader technique described for the right-sided resection. The left pulmonary veins are divided intrapericardially, as in right-sided resection.
Operative techniques
141 Table 2 Post-EPP Morbidity
Figure 23 A 2 cm rim of diaphragm is left around the esophagus. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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The left mainstem bronchus should be dissected deep to the aortic arch and as close to the carina as possible. This ensures a short bronchial stump after division (Fig. 24). After mediastinal lymph node dissection, the aortopulmonary nodes are removed as well. The risk of cardiac herniation is less with left-sided EPP because the axis of the left ventricle lies toward the left chest. Historically, it was thought that this lower risk of cardiac herniation obviated the need for pericardial reconstruction for left-sided resection. Our experience, however, has shown that postoperative cardiac function is more stable with pericardial reconstruction and we therefore recommend reconstructing the left side with a .1-mm patch of polytetrafluoride (PTFE) prosthetic as described above for the right.
Figure 24 Left pulmonary artery is divided pericardially because it is shorter in comparison with the right pulmonary artery. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Atrial fibrillation Myocardial infarction Constrictive physiology Reoperation for constrictive physiology Tamponade Cardiac arrest Prolonged intubation Aspiration ARDS Tracheostomy Vocal cord paralysis Renal failure Deep vein thrombosis Pulmonary embolus CVA (33 days postop) Empyema Bronchopleural fistula Technical complications (Patch failure and bleeding) Reprinted with permission from Sugarbaker et al.1
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Less air is removed from the left pneumonectomy space (750 mL in men and 500 mL in women) since it is smaller than the right.
Complications EPP is a physically rigorous operation that produces significant morbidity for which early and aggressive intervention is requisite to achieving a safe outcome. Recognizing the significance of potential complications and meeting that challenge with appropriate strategies for management has reduced perioperative mortality at our institution to 3.4%. This summary is based on the pneumonectomy literature and detailed morbidity data from 328 patients who underwent EPP for MPM at our institution between 1980 and 2000. The median age of our series was 58 years (range 28 to 77 years). Overall minor and major morbidity was 60.4% (Table 2). The physiologic stresses induced by pneumonectomy require careful management of the ipsilateral thoracic space to maintain hemodynamic and respiratory stability. Rapid filling of the pneumonectomy space can compromise function of the remaining lung. In contrast, rapid fluid evacuation of the pneumonectomy space can cause contralateral lung hyperexpansion, compromise of caval blood return, a precipitous drop in cardiac output, and hypotension. We routinely transduce ipsilateral intrathoracic pressure postoperatively by using the 14 F Robnell (red rubber) catheter placed in the pneumonectomy space at the time of EPP (Fig. 25). The same catheter is used to withdraw fluid as necessary, generally in increments of 150 cc. In our recent series of 47 mesothelioma patients who underwent EPP in 2008, we found that intrathoracic pressure monitoring can effectively guide intermittent fluid evacuation of the pneumonectomy space before onset of clinical signs or symptoms, thereby avoiding the cardiopulmonary risks of rapid fluid removal (abstract presented orally at the 17th European Conference on General
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Figure 25 System for transducing the ipsilateral intrathoracic pressure by means of a 14 F Robnell catheter placed during resection. The same catheter is used to withdraw fluid postoperatively to maintain hemodynamic and respiratory stability.
Thoracic Surgery of the European Society of Thoracic Surgeons, Krakow 6/1/2009).
Cardiac The cardiac complications associated with EPP range in severity from reversible atrial fibrillation (AF) to inflammatory epicarditis (leading to constrictive physiology), cardiac tamponade, myocardial infarction, and cardiac arrest. A pericardial patch that is improperly sized or secured can cause constrictive physiology leading to inflammatory epicarditis, tamponade, cardiac herniation, or other catastrophic consequences. AF was also the most common overall complication in our EPP series, occurring in approximately 45% (44.2%; 145/ 328) of patients. It is important to treat this arrhythmia aggressively because of the risk of stroke and other hemodynamic consequences. We have attempted various prophylactic strategies to control AF, including the use of beta blockers (metoprolol, atenolol, and bisoprolol) and calcium channel blockers (diltiazem, verapamil), but none has successfully reduced the incidence of AF in patients undergoing EPP. The arrhythmia is diagnosed either by ECG or transthoracic echocardiography (TEE) and is reversible with medication or, if necessary, synchronized electrical cardioversion. Although a recent report indicates that amiodarone can be used successfully to control AF after cardiac surgery,6 it is not recommended after EPP or other lung operations because of the high associated risk of inducing acute respiratory distress syndrome (ARDS).7,8 The pulmonary toxicity associated with amiodarone is thought to result from high concentrations of drug in the operated lung, which is reduced in volume after pulmonary resection, or in the contralateral lung, after EPP. The effect is characterized by acute alveolar consolidation in the remaining lung parenchyma that leads to respiratory failure and the necessity for mechanical ventilation. In 1994, a pro-
spective study (verapamil versus amiodarone versus control) was prematurely interrupted when three patients receiving amiodarone developed ARDS.7 Inflammatory epicarditis is a serious early complication that can lead to constrictive physiology necessitating reoperation. Nine patients in our series (2.7%; 9/328) experienced constrictive physiology, of which eight had to be taken back to the operating room.5 This complication can present as hypotension when turning the patient from lateral to supine position and must be managed urgently since it can cause major hemodynamic instability. All patients with inflammatory epicarditis in our series had evidence of constrictive physiology on cardiac catheterization or TEE. This complication was associated exclusively with left EPP, and occurred before we began routinely reconstructing the pericardium on both sides. After beginning this practice, we experienced only one additional case of constrictive physiology. The importance of attention to the mechanics of creating and placing the patch should not be underestimated. Cardiac tamponade (3.6%; 12/328) can result either from a retained pericardial effusion or a constrictive patch. This condition can present immediately at the conclusion of EPP when the patient is turned from lateral to supine at the end of the case and thus it is critical for the surgeon to be present when the patient is repositioned. Although it is not uncommon to have a pericardial effusion after an operation of this nature, it is more likely to be the result of a tight or poorly fenestrated patch. Tamponade physiology, which can occur on postoperative day 2, 3, or 4 with catastrophic results, can be very difficult to assess. This diagnosis must therefore be pursued aggressively with TEE for subtle signs or symptoms postoperatively, such as decreased urine output or reduced diuretic response. On echocardiogram, the ultrasonographer should be asked specifically to examine the diastolic function of the right ventricle, as tamponade physiology manifests as poor ventricular diastolic filling. The diaphragmatic patch
Operative techniques can also cause such physiology if it impinges on the inferior vena cava. This is especially pronounced after the heart is displaced into the right chest after right EPP. The recommended treatment for cardiac tamponade is operative exploration and replacement of the reconstructed pericardium with a looser patch. Myocardial infarction is a rare complication of EPP (1.5%; 5/328), but can be distinguished from pericarditis, as the latter is associated with diffuse ST-segment changes, high creatine phosphokinase, low MB fraction, and high troponin levels. These aberrations tend to resolve within 48 hours. Cardiac arrest within 10 days postoperatively (3%; 10/ 328) requires emergency thoracotomy (even in the ICU) with open cardiac massage and pericardial patch removal. Closed chest compressions are not effective because the heart has shifted from midline and cannot be compressed between the sternum and vertebral column. Emergency thoracotomy permits immediate drainage of the pericardial fluid, removal of constrictive patch material, or reduction of cardiac herniation, if one or more of these is present. Following resuscitation in the ICU, the patient must be returned to the OR for pulse irrigation to wash out the chest and definitive repair of the etiology of the arrest.
Pulmonary In our EPP series, patients experienced the same pulmonary complications one would observe with pneumonectomy or lobectomy: prolonged intubation (7.9%; 26/328), aspiration (2.7%; (9/328), ARDS (3.6%; 12/238); and central airway obstruction necessitating tracheostomy (1.8%; 6/328). To minimize pulmonary morbidity, EPP patients are managed with aggressive diuresis and frequent bronchoscopy as needed to maximize clearance of secretions. Often pulmonary complications after EPP arise in association with or as a result of vocal cord paralysis. This morbidity is common in patients with extensive disease in areas at high risk for injury to the recurrent laryngeal nerve, namely, the aortopulmonary region and in or around the subclavian vessels. Vocal cord paresis is a life-threatening complication, and these high-risk patients should undergo laryngoscopy in the immediate postoperative period, even when symptoms, such as hoarse voice or poor cough, are absent. Patients with vocal cord palsy are treated with immediate gel foam injection to improve vocal cord coaptation to prevent aspiration.
Renal, Hematologic, Infectious In our series, renal failure was associated with ARDS, multiple organ failure, and death (2.7%; 9/328). The most severe hematologic complication was DVT leading to PE, which occurred in 6.4% (21/328) of patients. Aggressive management of DVT is paramount since PE in a patient with a single lung is a life-threatening complication. Our approach is to obtain noninvasive vascular studies on all patients on postoperative day 7. This is another diagnosis that should be pursued aggressively to prevent life-threatening complications. Pulmonary embolus computed tomography (PE-CT)
143 should be performed even for minimal signs or symptoms of PE, such as hypoxia, tachycardia, and/or fever. Empyema (2.4%; 8/328) is the principal infectious complication after EPP and tends to present in an occult manner with minimal clinical signs and cultures that fail to reveal indolent anaerobic infection. Intraoperative high pressure high volume (9 L) lavage of the pneumonectomy cavity and 5 days of prophylactic triple antibiotic coverage with cefazolin, levofloxacin, and metronidazole are measures we use to prevent potential contamination of the prosthetic pericardial and diaphragmatic patches. Empyema without BPF that develops within 30 days postoperatively may be managed with patch removal and creation of a Clagett window, but these maneuvers delay the administration of adjuvant chemoradiotherapy. We, therefore, often avoid patch removal in favor of closed thoracoscopically guided debridement of the chest and pulse irrigation of the pleural space, followed by 5 days of postoperative intrathoracic irrigation. For those patients with early empyema (within 1-2 weeks) who are managed with Clagett window, the graft must be removed in staged procedures to avoid sudden mediastinal shift. Patients who develop late empyema (months to years after surgery) are managed with a traditional Clagett window. Empyema associated with BPF was rare in our series (0.6%; 2/328) and necessitated drainage of the cavity with a Clagett window to protect the contralateral lung from pneumonia.
Technical Other potential complications of EPP include diaphragmatic hernia, bleeding, and chylothorax. In addition to the operative techniques described above, careful postoperative monitoring should be performed with daily chest X-rays to identify subtle signs of gastric or intestinal herniation, including unusual gas patterns in the operative hemithorax. Any sign of herniation warrants immediate chest CT assessment, and if confirmed, reoperation. Excessive bleeding may be detected with intermittent drainage, occasionally warranting hemoglobin measurement in the fluid withdrawn. If correction of coagulopathy does not decrease postoperative bleeding, operative exploration may be necessary. Finally, chylothorax may develop very rarely following EPP. This should be suspected if there is a large quantity and cloudy character of the ipsilateral fluid drainage and can be confirmed by comparing the triglyceride content of this fluid with that in the serum. Chyle leak may be managed with fat-restricted diet, percutaneous embolization, or, if refractory, surgical thoracic duct ligation.
Part II: Pleurectomy/ Decortication P/D is a lung-sparing operation in which the diseased pleural envelope that encases and constricts the lung is mobilized off the chest wall, mediastinum, diaphragm and pericardium,
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Figure 26 To control bleeding during the decortication, a hilar noose is fashioned from an endoleader and used to control the hilar vessels. With a rongeur, a hole is created in the side of a funnel-tipped endoleader and suture is attached to the opposite end. After the hilum is encircled with the endoleader, the free end of the suture is brought through the hole and tightened, thereby creating a noose around the hilum. The thin end of the catheter then is secured with a Kelly clamp. The noose can be tightened in the event of significant bleeding.
and then meticulously stripped from the surface of the lung. P/D is generally well tolerated with low morbidity. The mortality rate is approximately 1.8% when the procedure is performed at a high-volume center. Reports of median survival in the literature range from 9 to 20 months. However, the technical challenge of separating tumor and visceral pleura from the lung parenchyma may result in suboptimal cytoreduction.
Anesthesia A thoracic epidural catheter also is placed for intraoperative and postoperative analgesia. Standard lines are placed in all patients for intraoperative monitoring including arterial and central venous pressure monitoring. Invasive monitoring is vital because blood loss is often significant (approximately 1-2 L). After anesthesia is induced, a double-lumen endotracheal tube is inserted for single-lung ventilation. A nasogastric tube is placed to aid in identification of the esophagus during the posterior dissection. The patient is placed in lateral decubitus position in preparation for a posterolateral thoracotomy.
Operative Technique Incision and Exposure The S-shaped posterolateral thoracotomy incision is smaller than that for EPP. It begins at the level of the posterior border of the scapula, follows the bed of the sixth rib, and terminates in a downward curve at the costal margin. The sixth rib is resected and the underlying periosteum is incised.
Pleurectomy The technique for extrapleural dissection for P/D is similar to that used for EPP. Briefly, the resection is initiated in the plane between the endothoracic fascia and the parietal pleura. The tumor is dissected bluntly away from the chest wall and the dissection progresses cephalad up and over the apex. The subclavian vessels are approached cautiously to avoid avulsive injury. As the dissection progresses, surgical pads are placed for hemostasis. The dissection begins in the anterolateral plane and continues inferiorly and posteriorly down the azygos recess and laterally and inferiorly to the diaphragmatic insertion into the chest wall. After a sufficient area of chest wall has been mo-
Operative techniques
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Figure 27 The tumor is incised posteriorly to the hilum. A plane is then developed between the visceral pleura and the underlying lung parenchyma superiorly by applying pressure to the outer cuff of tumor and allowing the lung to fall away.
bilized, a chest retractor may be inserted to optimize exposure. Once the apex has been mobilized, the superior and posterior hilar structures are exposed. If operating on the left side, the aorta and esophagus are identified and carefully dissected away from the tumor. On the right side, the superior vena cava must be dissected gently away from the specimen. The specimen is mobilized en bloc anteriorly toward the mediastinum. The dissection is carried along the pericardium either from superior to inferior or inferior to superior, stripping the tumor off the pericardium to the hilar cuff. If resection of the pericardium is required, it is delayed until the tumor is mobilized as much as possible to avoid excessive manipulation, which can cause arrthymias. If necessary, the pericardium is opened gradually and traction sutures are placed on the nonspecimen edge to maintain the position of the heart and to prevent retraction of the pericardium into the opposite hemithorax.
Decortication Attention is given to the visceral pleurectomy of the underlying lung. The decortication can result in substantial blood loss, particularly when there is direct invasion of the lung by tumor. If there is evidence of parenchymal invasion, we use an endoleader technique to create a noose for control of the hilar vessels. The same type of red rubber catheter used for the endoleader in EPP is fashioned with a stitch at the end. A rongeur is used to punch a hole in the wide funnel-shaped end of the catheter. A plane is cleared around the hilum and a Harken or large right-angle clamp is used to grasp the free end of the endoleader suture to bring the catheter around the
vessels. The free end of the suture is then brought through the hole created in the funnel tip of the endoleader. The thin end of the catheter is brought through and a Kelly clamp is used to secure the hilar “noose” (Fig. 26). This noose can be tightened as necessary to restrict blood flow in the event of significant bleeding during the internal decortication. To begin the decortication, a scalpel is used to incise the tumor overlying the lung along the line of the thoracotomy incision, with care taken not to injure the underlying lung parenchyma. A plane is developed between the visceral pleura, which is adherent to the tumor, and the underlying lung parenchyma superiorly by applying pressure to the outer cuff of tumor and allowing the lung to fall away (Fig. 27). Intermittent irrigation of the plane of dissection with sterile water aids in lysis of adhesions in this area by denaturing adherent proteins. The dissection is carried superiorly up over the apex of the lung and inferiorly circumferentially to the hilar cuff. If the diaphragm is densely involved with tumor, tumor on the lower lobe is bluntly dissected off the basilar segments wherever they come in contact with the diaphragm. The resection is continued inferiorly at the inferior pulmonary ligament; superiorly and anteriorly; and then posteriorly and superiorly to encircle the hilum. The incision in the tumor cap is extended sharply with scissors or blade anteriorly down to the hilar reflection of the pleura. Here the pleura is very thin and does not adhere to the hilum. Blunt dissection is used to carefully unwrap the upper cap anteriorly, superiorly, and then posteriorly. Inferiorly, the lower lobe is dissected free and can often then be re-
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Figure 28 The decorticated lung has been retracted out of the lower tumor shell.
tracted out of the tumor shell (Fig. 28). The inferior tumor shell is stripped down to the diaphragm. At the level of the diaphragm, attention is returned to the parietal pleura. The amount of diaphragmatic invasion determines whether or not the diaphragm requires resection here. If the parietal pleura separates easily from the diaphragm, the latter can remain intact (Fig. 29). If, however, there is significant diaphragmatic invasion, the diaphragm is resected (Fig. 30) by bluntly avulsing it radially off the chest wall. Inferi-
Figure 29 If the parietal pleura separates easily from the diaphragm, the diaphragm can remain intact.
orly, the surgeon’s fingers sweep the peritoneum away from the undersurface of the diaphragm. The blunt dissection continues to the portion of the central tendon of the diaphragm adherent to the anterior inferior border of the pericardium. The anterior part of the pericardium in this area is then swept away and the diaphragm is divided inferior to the pericar-
Figure 30 Significant diaphragmatic invasion calls for diaphragmatic resection which begins by bluntly avulsing the diaphragm radially off the chest wall.
Operative techniques dium, leading the dissection medial to the pleural reflection. It is important to keep the dissection outside of this envelope of pleural reflection and to divide the diaphragm such that it is resected en bloc with the remainder of the tumor. Defects in the peritoneum, which are common during diaphragmatic resection, should be repaired with absorbable suture. Mediastinal lymphadenectomy is completed as in EPP. Hemostasis is obtained by using argon beam coagulation on the chest wall and lung surfaces. We have also found that a biologic sealant, such as Tisseel (Baxter) or Evicel (Ethicon), can protect the raw lung surface from bleeding. If diaphragmatic and/or pericardial resection is required, reconstruction is performed using the same materials and technique described for EPP. When the pericardium has been preserved but the diaphragm requires reconstruction, the transmural button technique is used to secure the dualpatch laterally. Posteriorly, the prosthesis is sutured to the crus or tacked to the prevertebral fascia. The medial aspect is sewn to the remaining edge of the diaphragm at its confluence with the pericardium (Fig. 31). The diaphragmatic prosthesis should be made absolutely taut to prevent upward motion of the abdominal contents and subsequent atelectasis of the lower lobe. Three chest tubes are placed for optimal drainage of air and fluid (Fig. 32). The most anterior drain is a right-angled chest tube placed over the dome of the diaphragm. The middle drain is a straight chest tube placed anteriorly toward the apex. Finally, a straight chest tube is tunneled to lie posteri-
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Figure 32 Placements of chest tubes for optimal drainage of air and fluid after pleurectomy and decortication.
orly along the vertebral column to maximize drainage of fluid and/or blood. The thoracotomy is closed in standard fashion in layers.
Postoperative Management and Complications
Figure 31 The technique for attaching the diaphragmatic patch to the pericardium during pleurectomy and decortication differs somewhat in comparison with EPP. The diaphragmatic prosthesis should be made absolutely taut to prevent upward motion of the abdominal contents and subsequent atelectasis of the lower lobe.
Postoperative ventilation for 24-48 hours is critical to maintain lung expansion, and the use of 5-10 cm H2O of positive end expiratory pressure (PEEP) is necessary. The same cardiac, pulmonary, infectious, renal, and hematologic complications that apply to other extensive thoracic procedures, including EPP, may result from pleurectomy. These include AF, myocardial infarction, DVT/PE, pneumonia, acute renal failure, and empyema, among others. The serious postoperative complications that are more common in pleurectomy are bleeding and prolonged air leak. Immediate postoperative hemorrhage is frequently nonsurgical in that it is usually the result of extensive raw surface oozing and best managed with increased PEEP on the ventilator and reversal of any coagulopathy. Intraoperative coagulopathy must be avoided and liberal use of fresh frozen plasma, platelets, and recombinant clotting factors may be necessary to accomplish this. We have occasionally required factor VII in severe cases to slow significant bleeding successfully. Delayed hemorrhage 8-10 hours postoperatively is often due to regional hyperfibrinolysis and consumptive coagulopathy. Mesothelioma patients are initially hypercoagulable
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148 because of the tumor necrosis factor and other procoagulants produced by the tumor. This in turn causes an upregulation of plasminogen and fibrinolytic pathways. Shortly after surgery, extensive clot is formed in the broad areas of dissection, but these are lysed immediately because of the upregulated fibrinolytic enzymes present in these patients. Unopposed fibrinolysis results, as the procoagulant drive of the tumor has been removed with resection. The fibrin split-products in turn activate more plasminogen, amplifying the effect, resulting in massive hyperfibrinolysis regionally. Moreover, platelets and other clotting factors are consumed in the process of clot formation and these proteins are lost altogether with chest tube drainage. Massive bleeding 2-30 hours postoperatively can result. Treatment with intravenous aminocaproic acid, which inhibits conversion of plasminogen to its active form plasmin, can be life-saving in this situation. Prolonged air leak is common and occurs in approximately 10% of pleurectomy patients. This is managed by maintaining chest tubes on mild suction, then weaning to water seal, and finally using pneumostats for portability if needed. Patients can have chest tubes that remain attached to pneumostats up to one month postoperatively. Most tubes are pulled empirically 3 weeks after the surgery if the lung is fully expanded, whether or not there is a peristent air leak.
Discussion Cytoreductive surgery is the cornerstone of the multimodality approach to treating patients with diffuse MPM. Maximal cytoreduction is critical to extend long-term survival. EPP can achieve MCR in most cases of tumor confined to the ipsilateral chest. P/D is effective if disease is confined to
the parietal pleura without extension into the lung parenchyma or fissures. P/D may also be appropriate as a palliative procedure for patients who cannot tolerate pneumonectomy due to limited cardiac and/or pulmonary reserve. The physiologic stresses with either operation are numerous and appropriate patient selection facilitated by thorough preoperative testing is mandatory. Likewise, the diagnosis of postoperative complications must be pursued vigilantly to facilitate rapid treatment. Many of these complications can be prevented with careful attention to detail in managing the physiologic consequences of surgery, particularly with EPP.
References 1. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al: Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg 128:138-146, 2004 2. McCormack PM, Nagasaki F, Hilaris BS, et al: Surgical treatment of pleural mesothelioma. J Thorac Cardiovasc Surg 84:834-842, 1982 3. Patz EJ, Shaffer K, Piwnica-Worms D, et al: Malignant pleural mesothelioma: value of CT and MR imaging in predicting resectability. AJR Am J Roentgenol 159:961-966, 1992 4. Mujoomdar AA, Sugarbaker DJ: Hyperthermic chemoperfusion for the treatment of malignant pleural mesothelioma. Semin Thorac Cardiovasc Surg 20:298-304, 2008 5. Byrne JG, Karavas AN, Colson YL, et al: Cardiac decortication (epicardiectomy) for occult constrictive cardiac physiology after left extrapleural pneumonectomy. Chest 122:2256-2259, 2002 6. Bagshaw SM, Galbraith PD, Mitchell LB, et al: Prophylactic amiodarone for prevention of atrial fibrillation after cardiac surgery: a meta-analysis. Ann Thorac Surg 82:1927-1937, 2006 7. Van Mieghem W, Coolen L, Malysse I, et al: Amiodarone and the development of ARDS after lung surgery. Chest 105:1642-1645, 1994 8. Handschin AE, Lardinois D, Schneiter D, et al: Acute amiodarone-induced pulmonary toxicity following lung resection. Respiration 70:310312, 2003
T
he goal of surgery in the multimodality treatment of malignant pleural mesothelioma (MPM) is to achieve maximum cytoreduction. Two operations have evolved: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). A misconception persists that one operation is better than the other. In fact, the indications for each operation are distinct and patient selection depends on the same type of factors one would apply to select the appropriate operation for any thoracic malignancy. Early high operative mortality with EPP in the 1970s, when it was first converted from a surgery for tuberculous empyema to a surgery for MPM, has declined to 3.4% at our institution with aggressive perioperative management of procedure-related complications.1 P/D, an operation that spares the lung, is associated with a 1.8% mortality rate,2 but is suitable for achieving macroscopic complete resection (MCR) only in patients with disease confined to the outer surface of the parietal pleura. Invasive involvement of mediastinal structures or extension into the lung fissures precludes P/D for intentions other than symptom palliation. Patients who undergo P/D also have a shorter disease-free interval and higher rate of recurrence. Factors that affect operative choice and patient selection are discussed by Dr. Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, Massachusettes. Address reprints to David J. Sugarbaker, MD, Division of Thoracic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail: [email protected]
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Flores in this issue. This chapter describes the technical conduct of each operation and the approach to management and prevention of procedure-related complications.
Part I: Technique of Right EPP EPP is the radical en bloc resection of the lung, pleura, diaphragm, and pericardium. Fusion of the pleura at the central tendon of the diaphragm and the lateral portion of the pericardium mandates resection and subsequent reconstruction with a prosthetic patch. The right EPP is described first followed by key modifications for a left-sided resection. The operation is performed through a single extended right posterolateral thoracotomy in the following sequence: (1) incision and exposure; (2) anterior and posterior extrapleural dissection; (3) separation of the lateral attachments of the diaphragm; (4) opening of the pericardium; (5) division of the hilar vessels; (6) division of the posterior crus of the diaphragm and posterior pericardium; (7) division of the right mainstem bronchus with en bloc removal of the tumor; (8) mediastinal lymphadenectomy; (9) optional administration of heated bicavitary intraoperative chemotherapy (HIOC); (10) reconstruction of diaphragm and pericardium; and (11) closure. EPP is a complex operation that should be performed only at experienced surgical centers with an experienced thoracic anesthesia team.
Operative techniques
Preoperative Assessment Patients undergoing EPP or P/D undergo the same protocol for preoperative assessment. Foremost, this includes pulmonary function tests to assess the patient’s respiratory status, chest computed tomography (CT) scan to define abnormalities of the lung parenchyma, and magnetic resonance imaging (MRI) to assess for transdiaphragmatic, mediastinal or diffuse chest wall invasion. [18F] Fluorodeoxyglucose positron emission tomography (FDG-PET) can detect infradiaphragmatic or supraclavicular lymphadenopathy, liver metastases, or other unusual metastatic patterns. Many centers now use combination PET-CT for correlating FDG-avidity with anatomic-specific CT findings. The level of avidity of the pleural rind has been found to correlate with survival in retrospective studies.3 In addition to assessing global ventricular function, echocardiogram is performed to evaluate pulmonary artery pressure because of the potential for pulmonary hypertension and right heart strain induced by pneumonectomy. We also have found that duplex studies of the lower extremity veins are useful because mesothelioma patients are hypercoagulable and at high risk for occult deep vein thrombosis (DVT). Treatment of DVT with anticoagulation (and, if appropriate, inferior caval filter) before surgery is thought to reduce the risk of life-threatening pulmonary embolus (PE) after pneumonectomy. Patients are considered fit for surgery if they have a Karnofsky performance status of greater than 70, normal liver and renal function tests, a room air arterial pCO2 of less than 45 mm Hg, and a room air arterial PO2 of greater than 65 mm Hg. Pulmonary function testing that reveals a forced expiratory volume in 1 second (FEV1) of greater than 2 L is generally adequate for pneumonectomy for all but the largest patients. Quantitative ventilation/perfusion scanning is indicated to estimate postoperative lung function. The product of the perfusion to the unaffected lung and the preoperative FEV1 yields the predicted postoperative (ppo) FEV1. While this value ideally exceeds 1.2 L, patients with a ppo-FEV1 greater than 800 cc are acceptable candidates for EPP depending on their body mass. Patients with ppo-FEV1 of less than 800 cc may be considered for P/D (Table 1). Chest CT and MRI are performed to rule out advanced locally invasive disease. Clearcut radiologic evidence of transdiaphragmatic, mediastinal, or diffuse chest wall extension precludes surgical resection. Likewise, involvement of the contralateral hemithorax generally contraindicates cytoreductive surgery. When there is indisputable evidence of extensive chest wall invasion or if the tumor is palpable on physical examination, most of such patients are unresectable. The presence of extensive pain and the use of narcotics preoperatively is a clinical indicator of extensive chest wall invasion and likely unresectability. Chest CT and MRI can be misleading and often the resectability of a tumor is not known until surgery. The differentiation between radiographic evidence for the displacement of mediastinal structures versus the invasion of mediastinal structures is an important distinction, as many patients have been erroneously ruled out for surgery based on the displace-
133 Table 1 Patient Selection Criteria Karnofsky performance Renal function Liver function Pulmonary function Cardiac function
Extent of disease
>70 Creatinine <2 AST <80 IU/L, total bilirubin <1.9 mg/ dL, PT <15 s Postoperative FEV1 >0.8 L, as per PFTs and quantitative ventilationperfusion scans Grossly normal cardiac function as per ECG and echocardiography (EF preferably >45%) Limited to ipsilateral hemithorax with no transdiaphragmatic, transpericardial, or extensive chest wall involvement
Reprinted with permission from Sugarbaker et al.1 AST, aspartate aminotransfersase; PT, prothrombin time; FEV1, forced expiratory volume in 1 second; PFTs, pulmonary function tests; ECG, electrocardiography; EF, ejection fraction.
ment of mediastinal structures by a resectable tumor. Likewise, chest CT and MRI have limited value in distinguishing compression of tumor on the diaphragm from transdiaphragmatic abdominal invasion. Therefore, if there is radiologic evidence of transdiaphragmatic extension, intra-abdominal tumor, or ascites, this is an indication for staging laparoscopy to evaluate the peritoneum before potential thoracic resection. Finally, patients with limited chest wall invasion on imaging without evidence of advanced locally invasive disease or metastasis may be amenable to a surgical resection, and these patients should therefore be explored. Histologic diagnosis of mesothelioma by pleural biopsy is a mandatory component of all multimodality treatment protocols. Cytologic diagnosis is limited because of the difficulty of distinguishing MPM from lung adenocarcinoma or sarcoma. Thoracoscopic pleural biopsy is recommended via a single port placed in the location of a future thoracotomy (such that this tract can be excised at the time of future resection). If the pleural biopsy is positive, a staging cervical mediastinoscopy is performed to rule out involvement of the mediastinal nodes. Patients who have mediastinal lymph node involvement are offered chemotherapy up-front and may undergo a reassessment for surgery after two to four cycles of chemotherapy.
Anesthesia A thoracic epidural catheter is placed for intraoperative and postoperative pain control. Standard lines and probes are placed for continuous intraoperative assessment, including arterial and central venous pressure monitoring, continuous pulse-oximetry, and a Swan-Ganz catheter in most patients. The central line is placed preferably on the operative side to avoid pneumothorax in the nonoperative chest. After general anesthesia is induced, a left-sided double-lumen endotracheal tube is inserted for single-lung ventilation. The patient is placed in left lateral decubitus position for an extended
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Extrapleural Dissection
Figure 1 Extended right posterolateral thoracotomy. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
right posterolateral thoracotomy. A nasogastric tube is inserted for aid in identifying the esophagus during the extrapleural dissection. This tube is left in place postoperatively and used to decompress the stomach and prevent aspiration.
Operative Technique
The extrapleural dissection is performed with a combination of blunt and sharp dissection to separate tumor from the chest wall. A plane is initiated along the anterior and posterior edges of the incision. Once started, finger fracture can be used to extend the planes between the endothoracic fascia and the parietal pleura. The presence of skeletal muscle on the parietal pleura is indicative of a tumor with invasive characteristics. If extensive invasion of chest wall is encountered such that it obliterates the extrapleural plane, surgical resection is precluded. Frequent administration of sterile water during this stage of the dissection may aid in the lysis of adhesions, which, in turn, may aid in the blunt dissection of tumor off the endothoracic fascia. After blunt dissection is performed for a single handbreadth superior and inferior to the incision, one may then place the rib spreader. One or two rib spreaders may be used; however, a single posterior rib spreader will provide sufficient aid for dissection. The dissection is begun posterolaterally to the apex, over the apex down the mediastinum, and along the mediastinum to the midhilum. At this point the dissection is continued inferiorly and laterally and posteriorly to the diaphragmatic insertions into the chest wall. The anterolateral aspect of the pleura is dissected first. A chest retractor is positioned anteriorly and posteriorly to optimize exposure (Fig. 2). The internal mammary vessels are identified anteriorly and must be approached with attention to technique to avoid blunt avulsive injury. Evidence of tumor invasion of the internal mammary vessels is also indicative of an invasive tumor that may not lend itself to complete resection. For this reason, whenever the dissection approaches a vessel, sharp technique is recommended. As the plane is extended, all previous areas of dissection are packed with laparotomy pads for hemostasis.
Flexible bronchoscopy is performed to survey the right and left tracheobronchial tree to rule out clot, hemorrhage, anatomic variation, active infection, or the presence of unexpected pathology. Patients who have radiologic evidence of intra-abdominal tumor are explored laparoscopically or through a limited subcostal incision along the line of the planned thoracotomy incision before definitive resection. If there is evidence of intra-abdominal disease, histologic diagnosis is confirmed by biopsy, and attempted resection is generally not continued.
Incision and Exposure The posterolateral thoracotomy begins midway between the scapular tip and the spine and extends along the bed of the sixth rib to the costochondral junction (Fig. 1). To prevent tumor seeding, previous biopsy scars are included in the incision or separately excised leaving a minimum 1-cm margin to the depth of the chest wall fascia. The latissimus dorsi and serratus anterior muscles are divided. The sixth rib is resected and the posterior periosteum in the bed of the sixth rib is incised to expose the extrapleural plane.
Figure 2 During the anterior parietal dissection, it is important to avoid injury to the internal mammary vessels. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Operative techniques
Figure 3 Appearance of subclavian vessels at the lung apex. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
The dissection progresses to the apex, where the subclavian vessels are identified and also approached with caution to avoid avulsion (Fig. 3). As the dissection advances over the apex, the tumor is brought down from the posterior and superior mediastinum, where the azygos vein and superior vena cava are approached carefully (Fig. 4). After adequate anterolateral exposure, the posterior dissection is performed. Unexpected invasion of vital mediastinal structures (e.g., aorta, vena cava, esophagus, epicardium, vertebrae, or trachea) precludes resection and the operation is concluded. After the right upper lobe and right mainstem bronchus are exposed, attention turns to the esophagus. The esophagus is identified with aid of the nasogastric tube placed preoperatively and gently resected away from the tumor above the hiatus (Fig. 5). The pericardium is incised anteriorly and the pericardial space is palpated for evidence of myocardial invasion (Fig. 6). If the heart is free of tumor, the dissection proceeds to the diaphragm.
Figure 4 The pleural dissection proceeds inferiorly after advancing over the lung apex with attention to the azygos vein and superior vena cava. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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Figure 5 Esophageal dissection is aided by palpating the NG tube placed perioperatively. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
The diaphragm is incised first at its lateral margin, followed by circumferential resection anteriorly and posteriorly (Fig. 7). The diaphragmatic muscle attachments to the chest wall are manually avulsed (Fig. 8) and cauterized, and the peritoneum is dissected off the undersurface of the diaphragm (Fig. 9). If heated intraoperative chemotherapy (HIOC) is planned, the peritoneum is not preserved as the intention is for bicavitary lavage to reduce the risk of locoregional (including abdominal) recurrence. Diaphragmatic dissection is performed carefully at the inferior vena cava and esophageal hiatus (Fig. 10). The pericardial incision made earlier is extended and the junction of the pericardium and the medial aspect of the diaphragm is divided. With release of the diaphragmatic attachments medially and posteriorly, the esophagus is dissected away from the specimen.
Figure 6 After opening the pericardial space, it is palpated manually to assess for tumor invasion. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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Figure 9 The diaphragm is dissected from the underlying peritoneum. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.) Figure 7 The diaphragm is incised circumferentially. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Opening the Pericardium The pericardium is opened anteromedially and the pericardiotomy is extended superiorly from medial to lateral to the azygos recess (Fig. 11). Visualization of the quality of pericardial fluid is important. Clear pericardial fluid indicates
Figure 8 Blunt separation of the diaphragm from chest wall. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
lack of tumor invasion. Bloody pericardial fluid may indicate transpericardial and/or myocardial invasion by tumor. At this time, the surgeon also explores the pericardial cavity digitally to identify transpericardial or myocardial invasion. It is critical to carry the dissection well into the azygos recess for later dissection of the right main pulmonary artery.
Control of Pulmonary Vessels Dissection is continued by extending the pericardiotomy from medial to lateral superficial to the inferior vena cava, which is directly visualized during this dissection. Care is taken to visualize and ligate the phrenic veins as one divides the pericardium superficial to the inferior vena cava. The tumor and diaphragm are then retracted superiorly and the pericardiotomy is continued from inferiorly to superiorly, to the region of the inferior pulmonary vein. The specimen is
Figure 10 Careful dissection around the esophageal hiatus and inferior vena cava. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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Figure 11 The posterior pericardium and medial aspect of the diaphragm are divided. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
then retracted laterally by placing trocar clamps directly lateral to the superior and inferior pulmonary veins. Traction on the specimen laterally facilitates dissection of the right main pulmonary artery by grasping the superior vena cava and retracting it medially, and dividing the fibrinous adhesions between the superior vena cava and right main pulmonary artery. Dissection around the right main pulmonary artery is then completed and a 0 silk ligature is passed around the right main pulmonary artery with the use of a Harken No. 2 clamp. Following this, the endoleader is used to divide the right main pulmonary artery in the standard fashion using an endo-45 stapler with a vascular load (Fig. 12). In similar fashion, the superior and
Figure 12 Passing the endoleader around the pulmonary artery to guide passage of the endovascular stapler. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Figure 13 Dissection of right pulmonary artery. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
inferior pulmonary veins are dissected free from surrounding tissue and divided using the endoleader and endovascular stapler technique. The pericardiotomy is completed by extending it from inferior to superior over the right main bronchus, which is exposed at the completion of the pericardiotomy (Fig. 13). A radical lymphadenectomy is completed at this time to include inferior pulmonary ligament, periesophageal, and subcarinal nodes (Fig. 14). These nodes are either swept up with the specimen or they are sent separately with appropriate labels for pathologic examination.
Figure 14 Lymphadenectomy is performed for clinical staging. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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A.S. Wolf, J. Daniel, and D.J. Sugarbaker disease are marked with radiopaque clips to guide adjuvant radiation therapy. The wound is then packed and additional intraoperative procedures, such as HIOC, may be completed at this time. Patients receiving HIOC are prepared for a 1-hour lavage of cisplatin-based chemotherapy with sodium thiosulfate and amifostine for renal protection. The set-up and procedure for HIOC have been previously described.4
Reconstruction
Figure 15 Right mainstem bronchus is encircled with heavy-gauge wire stapler before it is divided as close to the carina as possible. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Division of Bronchus While preparing to divide the right mainstem bronchus, it is critical to ask the anesthesia team to place a pediatric bronchoscope down the right-sided tube. A heavy-gauge wire bronchial stapler (TA-30, Ethicon, Johnson and Johnson, Cincinnati, OH) (Fig. 15) is placed around the right main bronchus after the subcarinal nodal packet has been removed. With direct intraoperative endoscopic visualization of the right main bronchus via video bronchoscopy, the bronchus is divided by firing the stapler at the carina. The mainstem bronchus must be divided right at the carina to avoid excessive length to the bronchial stump. Even a short bronchial stump will allow secretions to pool, which can precipitate infection and cause a bronchopleural fistula (BPF) in the late postoperative period. The specimen is sent off to pathology and frozen section of the bronchial margin is performed to determine whether there is any evidence of peribronchial invasion of tumor. The empty chest cavity is instilled with warm saline and handbag ventilated to 30 mm Hg to check for air leaks along the bronchial staple line. An omental flap from the abdomen is prepared to buttress the bronchial closure. Alternatively, if the perithymic/pericardial fat pad is generous in size, this can be dissected on a proximal vascular pedicle and placed over the bronchial stump for coverage. Likewise, intercostal muscle can be used. Although other vascularized tissues may be used, we prefer the omentum because of its greater vascularity. The omental flap based on the gastroepiploic vascular supply can be fashioned efficiently with multiple firings of the endo-60 and endo-45 staplers with vascular loads. A tongue of vascularized omentum (Fig. 16) can be brought through an aperture created in the diaphragmatic patch and sutured to the bronchial staple line (see below). The argon beam coagulator (Valleylab, Boulder, CO), bovie electrocautery, and surgical clips are used to ensure complete hemostasis. Areas of concern for microscopic residual
The defects in the diaphragm and pericardium are reconstructed with a prosthetic patch made of Gore-Tex (W.L. Gore and Associates, Flagstaff, AZ). If there is evidence of pre-existing infection in the chest, we generally use biomaterial for reconstruction, such as bovine pericardial patch for the pericardium and micromesh, such as vicryl, for the diaphragm. For the noninfected chest, the diaphragmatic patch is constructed from two pieces of 2-mm-thick Gore-Tex dual mesh, 20 ⫻ 30 cm in dimension stapled together along the longer dimension, with a slight overlap at the center as shown in Fig. 17. This dual patch is contoured to the hemithorax and creates a loose, floppy patch at the center and minimizes tension along the suture line. The dynamic nature of this patch reduces the likelihood of dehiscence along the chest wall and prevents herniation of the abdominal contents into the pneumonectomy cavity. The diaphragmatic patch is sutured anteriorly, laterally, and posteriorly to the chest wall by using an awl and transmural Gore-Tex suture secured outside the chest wall to a 14-mm polypropylene button (Fig. 18). This is one of several maneuvers that has been developed
Figure 16 Harvesting the omental flap for later use as a bronchial buttress. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Operative techniques
Figure 17 Constructing the diaphragmatic patch from two pieces of 2-mm-thick Gore-Tex dual mesh. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
to prevent herniation of intra-abdominal contents postoperatively. Pericardial fixation of the patch to the cut edge of pericardium inferiorly is also critical to prevent diaphragmatic hernia. Early diaphragmatic hernia is difficult to diagnose radiographically and may present with subtle right heart failure leading to hypoxia in the immediate postoperative period.
Figure 18 Securing the patch to the chest wall with (A) polypropylene buttons (14 mm) and (B) suture. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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Figure 19 A small opening is made in the midportion of the diaphragmatic patch for the omenatal flap. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Before completing the diaphragmatic patch reconstruction, a small opening is created in the medial midportion of the patch for the omental flap, which is brought into the pneumonectomy cavity for later use as a buttress for the bronchial staple line (Fig. 19). The patch is sewn medially to the pericardial edge and diaphragmatic crus. Both the diaphragmatic and pericardial patches are sutured to the cut edge of the native pericardium and to each other medially. A pericardial patch is fashioned from .1-mm non-wettable PTFE to prevent cardiac herniation as well as to prevent the epicarditis that has been shown to develop in patients who develop a fibrinous inflamed peel over the heart following EPP without pericardial prosthetic reconstruction.5 The pericardial patch is fenestrated to ensure easy drainage of intrapericardial blood or other fluid to prevent the development of tamponade physiology (Fig. 20A). The pericardial patch is sutured to the cut native pericardial edge with interrupted Gore-Tex or other soft nonabsorbable suture (Fig. 20B). The pericardial patch is sized generously to accommodate potential postoperative cardiac enlargement and prevent the development of tamponade. A tight patch can be avoided by first securing the prosthetic posteriorly, which is the deepest part of the reconstruction. After the suture is placed, it retracts posteriorly, thus permitting better sizing of the patch when it is sutured to the anterior pericardium. Care should also be taken to suture the patch to the cut edge of the pericardium instead of other weaker tissues to avoid cardiac herniation. The omental flap mobilized earlier is sutured to the bronchial closure to minimize risk of BPF (Fig. 21). A 14 F Robnell red rubber catheter is placed into the pneumonectomy space and brought out through a separate stab wound below the medial aspect of the incision. The chest wall is closed in layers. The catheter is connected to a three-way stopcock and
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Figure 20 (A) The pericardial patch is fenestrated and sewn to the pericardial edge. (B) The patches are sutured in the cut edge of the pericardium and to each other medially. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
air is removed to reposition the mediastinum to midline (1000 mL of air in men and 750 mL in women). After the chest is closed, the patient is placed in supine position and flexible bronchoscopy is performed to assess the bronchial closure and to evacuate secretions. The patient is extubated in the OR.
Key Differences in Operative Technique for Left EPP
Figure 22 Structures at risk for a left-sided EPP. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
eration is technically similar to right EPP with a few key differences: ●
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Patients with tumor involving the left hemithorax are approached through a left posterolateral thoracotomy. The op●
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Figure 21 The omental flap is sutured to the bronchial stump. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
The approach to anesthesia includes placement of a right-sided double-lumen endotracheal tube or leftsided endobronchial blocker. When dissecting the pleura off the aorta during the posterior extrapleural dissection, it is vital to begin in the preaortic plane, since it is easy to inadvertently start dissecting behind the aorta, thereby injuring the intercostal branches. Beginning this part of the dissection on the arch reduces this risk (Fig. 22). Caution must also be exercised around the thoracic duct and recurrent laryngeal nerve while dissecting in the area between the aortopulmonary window and the takeoff of the subclavian vessel from the aortic arch (Fig. 22). During the diaphragmatic resection, it is important to leave a 1 to 2-cm rim of left diaphragmatic crus over the incisura (Fig. 23). Sutures are placed in this rim during patch reconstruction to prevent gastric herniation into the pneumonectomy space. As the left main pulmonary artery is short relative to the right, the left main pulmonary artery is divided in the extrapericardial/extrapleural plane just as it exits the pericardium (Fig. 24). This is facilitated by retracting the lung medially and inferiorly to expose the left main pulmonary artery. The pulmonary artery again is encircled with the Harken No. 2 clamp and the vessel is divided by a single firing of the endo-45 stapler using the endoleader technique described for the right-sided resection. The left pulmonary veins are divided intrapericardially, as in right-sided resection.
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141 Table 2 Post-EPP Morbidity
Figure 23 A 2 cm rim of diaphragm is left around the esophagus. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
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The left mainstem bronchus should be dissected deep to the aortic arch and as close to the carina as possible. This ensures a short bronchial stump after division (Fig. 24). After mediastinal lymph node dissection, the aortopulmonary nodes are removed as well. The risk of cardiac herniation is less with left-sided EPP because the axis of the left ventricle lies toward the left chest. Historically, it was thought that this lower risk of cardiac herniation obviated the need for pericardial reconstruction for left-sided resection. Our experience, however, has shown that postoperative cardiac function is more stable with pericardial reconstruction and we therefore recommend reconstructing the left side with a .1-mm patch of polytetrafluoride (PTFE) prosthetic as described above for the right.
Figure 24 Left pulmonary artery is divided pericardially because it is shorter in comparison with the right pulmonary artery. (Reprinted with permission from Sugarbaker DJ, Bueno R, Krasna MJ, et al (eds): Adult Chest Surgery. New York, The McGraw-Hill Companies, 2009.)
Atrial fibrillation Myocardial infarction Constrictive physiology Reoperation for constrictive physiology Tamponade Cardiac arrest Prolonged intubation Aspiration ARDS Tracheostomy Vocal cord paralysis Renal failure Deep vein thrombosis Pulmonary embolus CVA (33 days postop) Empyema Bronchopleural fistula Technical complications (Patch failure and bleeding) Reprinted with permission from Sugarbaker et al.1
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Less air is removed from the left pneumonectomy space (750 mL in men and 500 mL in women) since it is smaller than the right.
Complications EPP is a physically rigorous operation that produces significant morbidity for which early and aggressive intervention is requisite to achieving a safe outcome. Recognizing the significance of potential complications and meeting that challenge with appropriate strategies for management has reduced perioperative mortality at our institution to 3.4%. This summary is based on the pneumonectomy literature and detailed morbidity data from 328 patients who underwent EPP for MPM at our institution between 1980 and 2000. The median age of our series was 58 years (range 28 to 77 years). Overall minor and major morbidity was 60.4% (Table 2). The physiologic stresses induced by pneumonectomy require careful management of the ipsilateral thoracic space to maintain hemodynamic and respiratory stability. Rapid filling of the pneumonectomy space can compromise function of the remaining lung. In contrast, rapid fluid evacuation of the pneumonectomy space can cause contralateral lung hyperexpansion, compromise of caval blood return, a precipitous drop in cardiac output, and hypotension. We routinely transduce ipsilateral intrathoracic pressure postoperatively by using the 14 F Robnell (red rubber) catheter placed in the pneumonectomy space at the time of EPP (Fig. 25). The same catheter is used to withdraw fluid as necessary, generally in increments of 150 cc. In our recent series of 47 mesothelioma patients who underwent EPP in 2008, we found that intrathoracic pressure monitoring can effectively guide intermittent fluid evacuation of the pneumonectomy space before onset of clinical signs or symptoms, thereby avoiding the cardiopulmonary risks of rapid fluid removal (abstract presented orally at the 17th European Conference on General
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Figure 25 System for transducing the ipsilateral intrathoracic pressure by means of a 14 F Robnell catheter placed during resection. The same catheter is used to withdraw fluid postoperatively to maintain hemodynamic and respiratory stability.
Thoracic Surgery of the European Society of Thoracic Surgeons, Krakow 6/1/2009).
Cardiac The cardiac complications associated with EPP range in severity from reversible atrial fibrillation (AF) to inflammatory epicarditis (leading to constrictive physiology), cardiac tamponade, myocardial infarction, and cardiac arrest. A pericardial patch that is improperly sized or secured can cause constrictive physiology leading to inflammatory epicarditis, tamponade, cardiac herniation, or other catastrophic consequences. AF was also the most common overall complication in our EPP series, occurring in approximately 45% (44.2%; 145/ 328) of patients. It is important to treat this arrhythmia aggressively because of the risk of stroke and other hemodynamic consequences. We have attempted various prophylactic strategies to control AF, including the use of beta blockers (metoprolol, atenolol, and bisoprolol) and calcium channel blockers (diltiazem, verapamil), but none has successfully reduced the incidence of AF in patients undergoing EPP. The arrhythmia is diagnosed either by ECG or transthoracic echocardiography (TEE) and is reversible with medication or, if necessary, synchronized electrical cardioversion. Although a recent report indicates that amiodarone can be used successfully to control AF after cardiac surgery,6 it is not recommended after EPP or other lung operations because of the high associated risk of inducing acute respiratory distress syndrome (ARDS).7,8 The pulmonary toxicity associated with amiodarone is thought to result from high concentrations of drug in the operated lung, which is reduced in volume after pulmonary resection, or in the contralateral lung, after EPP. The effect is characterized by acute alveolar consolidation in the remaining lung parenchyma that leads to respiratory failure and the necessity for mechanical ventilation. In 1994, a pro-
spective study (verapamil versus amiodarone versus control) was prematurely interrupted when three patients receiving amiodarone developed ARDS.7 Inflammatory epicarditis is a serious early complication that can lead to constrictive physiology necessitating reoperation. Nine patients in our series (2.7%; 9/328) experienced constrictive physiology, of which eight had to be taken back to the operating room.5 This complication can present as hypotension when turning the patient from lateral to supine position and must be managed urgently since it can cause major hemodynamic instability. All patients with inflammatory epicarditis in our series had evidence of constrictive physiology on cardiac catheterization or TEE. This complication was associated exclusively with left EPP, and occurred before we began routinely reconstructing the pericardium on both sides. After beginning this practice, we experienced only one additional case of constrictive physiology. The importance of attention to the mechanics of creating and placing the patch should not be underestimated. Cardiac tamponade (3.6%; 12/328) can result either from a retained pericardial effusion or a constrictive patch. This condition can present immediately at the conclusion of EPP when the patient is turned from lateral to supine at the end of the case and thus it is critical for the surgeon to be present when the patient is repositioned. Although it is not uncommon to have a pericardial effusion after an operation of this nature, it is more likely to be the result of a tight or poorly fenestrated patch. Tamponade physiology, which can occur on postoperative day 2, 3, or 4 with catastrophic results, can be very difficult to assess. This diagnosis must therefore be pursued aggressively with TEE for subtle signs or symptoms postoperatively, such as decreased urine output or reduced diuretic response. On echocardiogram, the ultrasonographer should be asked specifically to examine the diastolic function of the right ventricle, as tamponade physiology manifests as poor ventricular diastolic filling. The diaphragmatic patch
Operative techniques can also cause such physiology if it impinges on the inferior vena cava. This is especially pronounced after the heart is displaced into the right chest after right EPP. The recommended treatment for cardiac tamponade is operative exploration and replacement of the reconstructed pericardium with a looser patch. Myocardial infarction is a rare complication of EPP (1.5%; 5/328), but can be distinguished from pericarditis, as the latter is associated with diffuse ST-segment changes, high creatine phosphokinase, low MB fraction, and high troponin levels. These aberrations tend to resolve within 48 hours. Cardiac arrest within 10 days postoperatively (3%; 10/ 328) requires emergency thoracotomy (even in the ICU) with open cardiac massage and pericardial patch removal. Closed chest compressions are not effective because the heart has shifted from midline and cannot be compressed between the sternum and vertebral column. Emergency thoracotomy permits immediate drainage of the pericardial fluid, removal of constrictive patch material, or reduction of cardiac herniation, if one or more of these is present. Following resuscitation in the ICU, the patient must be returned to the OR for pulse irrigation to wash out the chest and definitive repair of the etiology of the arrest.
Pulmonary In our EPP series, patients experienced the same pulmonary complications one would observe with pneumonectomy or lobectomy: prolonged intubation (7.9%; 26/328), aspiration (2.7%; (9/328), ARDS (3.6%; 12/238); and central airway obstruction necessitating tracheostomy (1.8%; 6/328). To minimize pulmonary morbidity, EPP patients are managed with aggressive diuresis and frequent bronchoscopy as needed to maximize clearance of secretions. Often pulmonary complications after EPP arise in association with or as a result of vocal cord paralysis. This morbidity is common in patients with extensive disease in areas at high risk for injury to the recurrent laryngeal nerve, namely, the aortopulmonary region and in or around the subclavian vessels. Vocal cord paresis is a life-threatening complication, and these high-risk patients should undergo laryngoscopy in the immediate postoperative period, even when symptoms, such as hoarse voice or poor cough, are absent. Patients with vocal cord palsy are treated with immediate gel foam injection to improve vocal cord coaptation to prevent aspiration.
Renal, Hematologic, Infectious In our series, renal failure was associated with ARDS, multiple organ failure, and death (2.7%; 9/328). The most severe hematologic complication was DVT leading to PE, which occurred in 6.4% (21/328) of patients. Aggressive management of DVT is paramount since PE in a patient with a single lung is a life-threatening complication. Our approach is to obtain noninvasive vascular studies on all patients on postoperative day 7. This is another diagnosis that should be pursued aggressively to prevent life-threatening complications. Pulmonary embolus computed tomography (PE-CT)
143 should be performed even for minimal signs or symptoms of PE, such as hypoxia, tachycardia, and/or fever. Empyema (2.4%; 8/328) is the principal infectious complication after EPP and tends to present in an occult manner with minimal clinical signs and cultures that fail to reveal indolent anaerobic infection. Intraoperative high pressure high volume (9 L) lavage of the pneumonectomy cavity and 5 days of prophylactic triple antibiotic coverage with cefazolin, levofloxacin, and metronidazole are measures we use to prevent potential contamination of the prosthetic pericardial and diaphragmatic patches. Empyema without BPF that develops within 30 days postoperatively may be managed with patch removal and creation of a Clagett window, but these maneuvers delay the administration of adjuvant chemoradiotherapy. We, therefore, often avoid patch removal in favor of closed thoracoscopically guided debridement of the chest and pulse irrigation of the pleural space, followed by 5 days of postoperative intrathoracic irrigation. For those patients with early empyema (within 1-2 weeks) who are managed with Clagett window, the graft must be removed in staged procedures to avoid sudden mediastinal shift. Patients who develop late empyema (months to years after surgery) are managed with a traditional Clagett window. Empyema associated with BPF was rare in our series (0.6%; 2/328) and necessitated drainage of the cavity with a Clagett window to protect the contralateral lung from pneumonia.
Technical Other potential complications of EPP include diaphragmatic hernia, bleeding, and chylothorax. In addition to the operative techniques described above, careful postoperative monitoring should be performed with daily chest X-rays to identify subtle signs of gastric or intestinal herniation, including unusual gas patterns in the operative hemithorax. Any sign of herniation warrants immediate chest CT assessment, and if confirmed, reoperation. Excessive bleeding may be detected with intermittent drainage, occasionally warranting hemoglobin measurement in the fluid withdrawn. If correction of coagulopathy does not decrease postoperative bleeding, operative exploration may be necessary. Finally, chylothorax may develop very rarely following EPP. This should be suspected if there is a large quantity and cloudy character of the ipsilateral fluid drainage and can be confirmed by comparing the triglyceride content of this fluid with that in the serum. Chyle leak may be managed with fat-restricted diet, percutaneous embolization, or, if refractory, surgical thoracic duct ligation.
Part II: Pleurectomy/ Decortication P/D is a lung-sparing operation in which the diseased pleural envelope that encases and constricts the lung is mobilized off the chest wall, mediastinum, diaphragm and pericardium,
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Figure 26 To control bleeding during the decortication, a hilar noose is fashioned from an endoleader and used to control the hilar vessels. With a rongeur, a hole is created in the side of a funnel-tipped endoleader and suture is attached to the opposite end. After the hilum is encircled with the endoleader, the free end of the suture is brought through the hole and tightened, thereby creating a noose around the hilum. The thin end of the catheter then is secured with a Kelly clamp. The noose can be tightened in the event of significant bleeding.
and then meticulously stripped from the surface of the lung. P/D is generally well tolerated with low morbidity. The mortality rate is approximately 1.8% when the procedure is performed at a high-volume center. Reports of median survival in the literature range from 9 to 20 months. However, the technical challenge of separating tumor and visceral pleura from the lung parenchyma may result in suboptimal cytoreduction.
Anesthesia A thoracic epidural catheter also is placed for intraoperative and postoperative analgesia. Standard lines are placed in all patients for intraoperative monitoring including arterial and central venous pressure monitoring. Invasive monitoring is vital because blood loss is often significant (approximately 1-2 L). After anesthesia is induced, a double-lumen endotracheal tube is inserted for single-lung ventilation. A nasogastric tube is placed to aid in identification of the esophagus during the posterior dissection. The patient is placed in lateral decubitus position in preparation for a posterolateral thoracotomy.
Operative Technique Incision and Exposure The S-shaped posterolateral thoracotomy incision is smaller than that for EPP. It begins at the level of the posterior border of the scapula, follows the bed of the sixth rib, and terminates in a downward curve at the costal margin. The sixth rib is resected and the underlying periosteum is incised.
Pleurectomy The technique for extrapleural dissection for P/D is similar to that used for EPP. Briefly, the resection is initiated in the plane between the endothoracic fascia and the parietal pleura. The tumor is dissected bluntly away from the chest wall and the dissection progresses cephalad up and over the apex. The subclavian vessels are approached cautiously to avoid avulsive injury. As the dissection progresses, surgical pads are placed for hemostasis. The dissection begins in the anterolateral plane and continues inferiorly and posteriorly down the azygos recess and laterally and inferiorly to the diaphragmatic insertion into the chest wall. After a sufficient area of chest wall has been mo-
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Figure 27 The tumor is incised posteriorly to the hilum. A plane is then developed between the visceral pleura and the underlying lung parenchyma superiorly by applying pressure to the outer cuff of tumor and allowing the lung to fall away.
bilized, a chest retractor may be inserted to optimize exposure. Once the apex has been mobilized, the superior and posterior hilar structures are exposed. If operating on the left side, the aorta and esophagus are identified and carefully dissected away from the tumor. On the right side, the superior vena cava must be dissected gently away from the specimen. The specimen is mobilized en bloc anteriorly toward the mediastinum. The dissection is carried along the pericardium either from superior to inferior or inferior to superior, stripping the tumor off the pericardium to the hilar cuff. If resection of the pericardium is required, it is delayed until the tumor is mobilized as much as possible to avoid excessive manipulation, which can cause arrthymias. If necessary, the pericardium is opened gradually and traction sutures are placed on the nonspecimen edge to maintain the position of the heart and to prevent retraction of the pericardium into the opposite hemithorax.
Decortication Attention is given to the visceral pleurectomy of the underlying lung. The decortication can result in substantial blood loss, particularly when there is direct invasion of the lung by tumor. If there is evidence of parenchymal invasion, we use an endoleader technique to create a noose for control of the hilar vessels. The same type of red rubber catheter used for the endoleader in EPP is fashioned with a stitch at the end. A rongeur is used to punch a hole in the wide funnel-shaped end of the catheter. A plane is cleared around the hilum and a Harken or large right-angle clamp is used to grasp the free end of the endoleader suture to bring the catheter around the
vessels. The free end of the suture is then brought through the hole created in the funnel tip of the endoleader. The thin end of the catheter is brought through and a Kelly clamp is used to secure the hilar “noose” (Fig. 26). This noose can be tightened as necessary to restrict blood flow in the event of significant bleeding during the internal decortication. To begin the decortication, a scalpel is used to incise the tumor overlying the lung along the line of the thoracotomy incision, with care taken not to injure the underlying lung parenchyma. A plane is developed between the visceral pleura, which is adherent to the tumor, and the underlying lung parenchyma superiorly by applying pressure to the outer cuff of tumor and allowing the lung to fall away (Fig. 27). Intermittent irrigation of the plane of dissection with sterile water aids in lysis of adhesions in this area by denaturing adherent proteins. The dissection is carried superiorly up over the apex of the lung and inferiorly circumferentially to the hilar cuff. If the diaphragm is densely involved with tumor, tumor on the lower lobe is bluntly dissected off the basilar segments wherever they come in contact with the diaphragm. The resection is continued inferiorly at the inferior pulmonary ligament; superiorly and anteriorly; and then posteriorly and superiorly to encircle the hilum. The incision in the tumor cap is extended sharply with scissors or blade anteriorly down to the hilar reflection of the pleura. Here the pleura is very thin and does not adhere to the hilum. Blunt dissection is used to carefully unwrap the upper cap anteriorly, superiorly, and then posteriorly. Inferiorly, the lower lobe is dissected free and can often then be re-
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Figure 28 The decorticated lung has been retracted out of the lower tumor shell.
tracted out of the tumor shell (Fig. 28). The inferior tumor shell is stripped down to the diaphragm. At the level of the diaphragm, attention is returned to the parietal pleura. The amount of diaphragmatic invasion determines whether or not the diaphragm requires resection here. If the parietal pleura separates easily from the diaphragm, the latter can remain intact (Fig. 29). If, however, there is significant diaphragmatic invasion, the diaphragm is resected (Fig. 30) by bluntly avulsing it radially off the chest wall. Inferi-
Figure 29 If the parietal pleura separates easily from the diaphragm, the diaphragm can remain intact.
orly, the surgeon’s fingers sweep the peritoneum away from the undersurface of the diaphragm. The blunt dissection continues to the portion of the central tendon of the diaphragm adherent to the anterior inferior border of the pericardium. The anterior part of the pericardium in this area is then swept away and the diaphragm is divided inferior to the pericar-
Figure 30 Significant diaphragmatic invasion calls for diaphragmatic resection which begins by bluntly avulsing the diaphragm radially off the chest wall.
Operative techniques dium, leading the dissection medial to the pleural reflection. It is important to keep the dissection outside of this envelope of pleural reflection and to divide the diaphragm such that it is resected en bloc with the remainder of the tumor. Defects in the peritoneum, which are common during diaphragmatic resection, should be repaired with absorbable suture. Mediastinal lymphadenectomy is completed as in EPP. Hemostasis is obtained by using argon beam coagulation on the chest wall and lung surfaces. We have also found that a biologic sealant, such as Tisseel (Baxter) or Evicel (Ethicon), can protect the raw lung surface from bleeding. If diaphragmatic and/or pericardial resection is required, reconstruction is performed using the same materials and technique described for EPP. When the pericardium has been preserved but the diaphragm requires reconstruction, the transmural button technique is used to secure the dualpatch laterally. Posteriorly, the prosthesis is sutured to the crus or tacked to the prevertebral fascia. The medial aspect is sewn to the remaining edge of the diaphragm at its confluence with the pericardium (Fig. 31). The diaphragmatic prosthesis should be made absolutely taut to prevent upward motion of the abdominal contents and subsequent atelectasis of the lower lobe. Three chest tubes are placed for optimal drainage of air and fluid (Fig. 32). The most anterior drain is a right-angled chest tube placed over the dome of the diaphragm. The middle drain is a straight chest tube placed anteriorly toward the apex. Finally, a straight chest tube is tunneled to lie posteri-
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Figure 32 Placements of chest tubes for optimal drainage of air and fluid after pleurectomy and decortication.
orly along the vertebral column to maximize drainage of fluid and/or blood. The thoracotomy is closed in standard fashion in layers.
Postoperative Management and Complications
Figure 31 The technique for attaching the diaphragmatic patch to the pericardium during pleurectomy and decortication differs somewhat in comparison with EPP. The diaphragmatic prosthesis should be made absolutely taut to prevent upward motion of the abdominal contents and subsequent atelectasis of the lower lobe.
Postoperative ventilation for 24-48 hours is critical to maintain lung expansion, and the use of 5-10 cm H2O of positive end expiratory pressure (PEEP) is necessary. The same cardiac, pulmonary, infectious, renal, and hematologic complications that apply to other extensive thoracic procedures, including EPP, may result from pleurectomy. These include AF, myocardial infarction, DVT/PE, pneumonia, acute renal failure, and empyema, among others. The serious postoperative complications that are more common in pleurectomy are bleeding and prolonged air leak. Immediate postoperative hemorrhage is frequently nonsurgical in that it is usually the result of extensive raw surface oozing and best managed with increased PEEP on the ventilator and reversal of any coagulopathy. Intraoperative coagulopathy must be avoided and liberal use of fresh frozen plasma, platelets, and recombinant clotting factors may be necessary to accomplish this. We have occasionally required factor VII in severe cases to slow significant bleeding successfully. Delayed hemorrhage 8-10 hours postoperatively is often due to regional hyperfibrinolysis and consumptive coagulopathy. Mesothelioma patients are initially hypercoagulable
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148 because of the tumor necrosis factor and other procoagulants produced by the tumor. This in turn causes an upregulation of plasminogen and fibrinolytic pathways. Shortly after surgery, extensive clot is formed in the broad areas of dissection, but these are lysed immediately because of the upregulated fibrinolytic enzymes present in these patients. Unopposed fibrinolysis results, as the procoagulant drive of the tumor has been removed with resection. The fibrin split-products in turn activate more plasminogen, amplifying the effect, resulting in massive hyperfibrinolysis regionally. Moreover, platelets and other clotting factors are consumed in the process of clot formation and these proteins are lost altogether with chest tube drainage. Massive bleeding 2-30 hours postoperatively can result. Treatment with intravenous aminocaproic acid, which inhibits conversion of plasminogen to its active form plasmin, can be life-saving in this situation. Prolonged air leak is common and occurs in approximately 10% of pleurectomy patients. This is managed by maintaining chest tubes on mild suction, then weaning to water seal, and finally using pneumostats for portability if needed. Patients can have chest tubes that remain attached to pneumostats up to one month postoperatively. Most tubes are pulled empirically 3 weeks after the surgery if the lung is fully expanded, whether or not there is a peristent air leak.
Discussion Cytoreductive surgery is the cornerstone of the multimodality approach to treating patients with diffuse MPM. Maximal cytoreduction is critical to extend long-term survival. EPP can achieve MCR in most cases of tumor confined to the ipsilateral chest. P/D is effective if disease is confined to
the parietal pleura without extension into the lung parenchyma or fissures. P/D may also be appropriate as a palliative procedure for patients who cannot tolerate pneumonectomy due to limited cardiac and/or pulmonary reserve. The physiologic stresses with either operation are numerous and appropriate patient selection facilitated by thorough preoperative testing is mandatory. Likewise, the diagnosis of postoperative complications must be pursued vigilantly to facilitate rapid treatment. Many of these complications can be prevented with careful attention to detail in managing the physiologic consequences of surgery, particularly with EPP.
References 1. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al: Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg 128:138-146, 2004 2. McCormack PM, Nagasaki F, Hilaris BS, et al: Surgical treatment of pleural mesothelioma. J Thorac Cardiovasc Surg 84:834-842, 1982 3. Patz EJ, Shaffer K, Piwnica-Worms D, et al: Malignant pleural mesothelioma: value of CT and MR imaging in predicting resectability. AJR Am J Roentgenol 159:961-966, 1992 4. Mujoomdar AA, Sugarbaker DJ: Hyperthermic chemoperfusion for the treatment of malignant pleural mesothelioma. Semin Thorac Cardiovasc Surg 20:298-304, 2008 5. Byrne JG, Karavas AN, Colson YL, et al: Cardiac decortication (epicardiectomy) for occult constrictive cardiac physiology after left extrapleural pneumonectomy. Chest 122:2256-2259, 2002 6. Bagshaw SM, Galbraith PD, Mitchell LB, et al: Prophylactic amiodarone for prevention of atrial fibrillation after cardiac surgery: a meta-analysis. Ann Thorac Surg 82:1927-1937, 2006 7. Van Mieghem W, Coolen L, Malysse I, et al: Amiodarone and the development of ARDS after lung surgery. Chest 105:1642-1645, 1994 8. Handschin AE, Lardinois D, Schneiter D, et al: Acute amiodarone-induced pulmonary toxicity following lung resection. Respiration 70:310312, 2003