V A Tarasov, E S Pobegalov, V V Stavrovietskiy, Y K
Sharov, M V Vinogradova
Department
of Thoracic Surgery, Medical Academy of Postgraduate Education, St.Petersburg,
Russia
/Reported at
the 12th Congress of the International Society for Cardio-Thoracic
Surgery, in Luzern, Switzerland, March 2002/
BACKGROUND. Up to our days, Stage IIIB lung cancer is regarded as
inoperable in the majority of surgical clinics of the world. Yet, during the
last years, a number of papers reasonably underline heterogeneity of this group
of patients and different causes of their inoperability. In the cases of N2-3
surgery is prevented by poor life duration and survival rate due to generalized
disease; but as for T4, these patients are known to die not so of
generalization of the process but rather of complications caused by local
invasion. The latter is a challenge to surgical technique demanding resections
of the neighboring chest organs and structures, as well as simultaneous complex
reconstructive procedures.
MATERIAL AMD METHODS. 50 patients aged from 32 to 77 (mean 59.9+-1.8 years)
underwent surgery for Stage IIIB non-small-cell lung cancer in the thoracic
clinic of St.Petersburg Medical Academy of Postgraduate Education. In 21, the
tumor was localized in the left lung, in 29 – in the right one.
In 29 patients, the primary tumor spread to one of the neighboring chest organs and
structures; in 21, the tumor involved more than one organ or
structure. Pericardium was invaded in 31 cases, superior vena cava – in 9 (in 4 of them, the tumor
also invaded the trachea), chest wall – in 6, right atrium – in 4, muscular layer of the esophageal wall
– in 4, thoracic aorta – in 3, subclavian vessels – in 1, brachial plexus – in
1, thoracic vertebra – in 1.
47 (94%) patients
underwent combined extended procedures with complete tumor reduction: 42 total
pneumonectomies (including 4 carinal ones), 3 lobectomies, 2 bilobectomies.
Palliative pneumonectomies with incomplete tumor removal appeared only to be
possible in 2 cases, exploratory thoracotomy - in 1.
Technical peculiarities of surgery in Stage IIIB lung
cancer were the following:
1. Intrapericardial division of pulmonary vessels in
central localization of bronchial cancer. A pericardial flap is formed at this
stage, preserving its blood vessels, for future covering of the bronchial stump
or tracheal suture. If the tumor extends to the intrapericardial portion of
right pulmonary artery, it may be transected behind the radix of aorta; in one
case, the artery was transected to the left of the radix. If the tumor extends
along the intrapericardial portions of pulmonary veins to right atrium, the
latter may be resected using either a stapler (“AutoSuture”) or manual suture with
…. The latter is preferable in case of dystrophia of the atrial wall.
2. We always close the bronchial stump using modified
Overholt’s manual suture, provided its length is not less than 5 mm. Additional
coverage of the stump with a pedicled pericardial flap is mandatory in our
clinic. If the pericardial wall is totally infiltrated by the tumor, we cover
the bronchial stump with a pedicled periosteo-muscular flap resecting one rib.
In cases of chest wall invasion combined with metastatic pericardial lesion, we
cover the bronchial stump or tracheobronchial anastomosis with a pedicled
omental flap.This method was always used in circular tracheal resections.
3. In one patient with total excision of invaded
pericardial wall and hemidiaphragm, we reconstructed both with a pedicled flap
of latissimus dorsi muscle, using it at the same time to cover the bronchial
stump. It appeared necessary to fix the wedge of resected diaphragm to the ribs
with a synthetic strip, in order to prevent enormous mediastinal shift.
4. Superior vena cava invasion required wedge resection
in 5 patients and circular resection with PTFE (polytetrafluorethylene) graft
reconstruction in 5.
5. If pericardial resection results in a large defect
which bears the risk of cardiac luxation, such a defect may be closed with a
patch of PTFE mesh.
6. Wedge resection of thoracic aorta and brachiocephalic
trunk was performed in 2 cases. In one case, after circular resection of
invaded descending aorta we performed graft reconstruction using
cardiopulmonary bypass.
7. Subclavian vessels were resected in 1 case, with graft
reconstruction of the artery alone.
8. In the case of vertebral invasion, corpus vertebrae
was resected.
9. Chest wall after major resection was reconstructed
using metal (nickelide-titanium) constructions covered by pedicled
musculocutaneous flaps of latissimus dorsi muscles.
10. Mediastinal lymph
node dissection with frozen-section microscopy of contralateral
tracheobronchial lymph nodes was obligatory, and detection of metastases in these
nodes was an indication for contralateral mediastinal lymph node dissection
through the same access.
RESULTS. Postsurgical N
criterion appeared to be N0 in 6 patients, N1 - in 10, N2 - in 29, N3 - in 5.
Postoperative
morbidity made up 34% (17 patients),
mortality -16% (8 patients). 2 patients died of pneumonia in the single lung, 2
- of pulmonary embolism, 1 - of myocardial infarction, 3 - of cardiac failure.
There was no one bronchial stump dehiscence.
All the patients
who survived surgery were alive 12 months postoperatively, 31% of them being
alive at 24 months. Among the patients with chest wall invasion, median life
quality change was from 46 before surgery to 87 2 months postsurgically, among
those with chest organs involved - 26 and 85 respectively.
CONCLUSION. Improvement of
life quality after surgery for advanced NSCLC vindicates comparatively high
mortality and morbidity rates.
Effective
prevention of both bronchial stump and tracheobronchial anastomosis dehiscence
is achieved by manual interruptive suture with additional closure by
pericardial or muscular flaps with good blood supply. This technique is
mandatory in pneumonectomies for Stage IIIB lung cancer.
Surgery for Stage
IIIB lung cancer may require great vessel replacement, automyoplasty,
alloplasty, pericardio- and omentoplasty.
The only
contraindication for surgery in locally advanced Stage IIIB non-small-cell lung cancer seems to be functional
inability of a patient to tolerate surgery.
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