новая папка / Operative Standards for Cancer Surgery Volume I 1st Edition

CT, computed tomography; EBUS, endobronchial ultrasonography; MED, mediastinoscopy; PET, positron emission tomography; SUV, standardized uptake value; SVC, superior vena cava; VID, video mediastinoscopy.

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2.Mineo TC, Ambrogi V, Nofroni I, et al. Mediastinoscopy in superior vena cava obstruction: analysis of 80 consecutive patients. Ann Thorac Surg 1999;68(1):223-226.

3.Dosios T, Theakos N, Chatziantoniou C. Cervical mediastinoscopy and anterior mediastinotomy in superior vena cava obstruction. Chest 2005;128(3):1551-1556.

4.Lemaire A, Nikolic I, Petersen T, et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate. Ann Thorac Surg 2006;82(4):1185-1189.

5.Roberts JR, Wadsworth J. Recurrent laryngeal nerve monitoring during mediastinoscopy: predictors of injury. Ann Thorac Surg 2007;83(2):388-391.

6.Cho JH, Kim J, Kim K, et al. A comparative analysis of video-assisted mediastinoscopy and conventional mediastinoscopy. Ann Thorac Surg 2011;92(3):1007-1011.

7.Yasufuku K, Pierre A, Darling G, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovas Surg 2011;142(6):1393-1400.

8.Anraku M, Miyata R, Compeau C, et al. Video-assisted mediastinoscopy compared with conventional mediastinoscopy: are we doing better? Ann Thorac Surg 2010; 89(5):1577-1587.

9.Venissac N, Alifano M. Mouroux J. Video-assisted mediastinoscopy: experience from 240 consecutive cases. Ann Thorac Surg 2003;71(1):208-212.

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11.Turna A, Demirkaya A, Özkul S, et al. Video-assisted mediastinoscopic lymphadenectomy is associated with better survival than mediastinoscopy in patients with resected non-small cell lung cancer. J Thorac Cardiovas Surg 2013;146:774-780.

12.Zakkar M, Tan C, Hunt I. Is mediastinoscopy a safer and more effective procedure than conventional mediastinoscopy? Interact Cardiovasc Thorac Surg 2012;14(1):81-84.

13.Kanzaki R, Higashiyama M, Fujiwara A, et al. Occult mediastinal lymph node metastasis in NSCLC patients diagnosed as clinical N0-1 by preoperative integrated FDG-PET/CT and CT: risk factors, pattern, and histopathological study. Lung Cancer 2011;71(3):333-337.

14.Al-Sarraf N, Aziz R, Gately K, et al. Pattern and predictors of occult mediastinal lymph node involvement in non-small cell lung cancer patients with negative mediastinal uptake on positron emission tomography. Eur J Cardiothorac Surg 2008;33(1):104-109.

15.Upadhyaya PK, Bertelotti R, Laeeg A, et al. Beware of the aberrant innominate artery. Ann Thorac Surg

2008;85(2):653-654.

16.Marra A, Hillejan L, Fechner S, et al. Remediastinoscopy in restaging of lung cancer after induction therapy. J Thorac Cardiovasc Surg 2008;135(4):843-849.

17.Lee PC, Port JL, Korst JRJ, et al. Risk factors for occult mediastinal metastases in clinical stage I nonsmall cell lung cancer. Ann Thorac Surg 2007;84(1):177-181.

18.de Langen AJ, Raijmakers P, Riphagen I, et al. The size of mediastinal lymph nodes and its relation with metastatic involvement: a meta-analysis. Eur J Cardiothorac Surg 2006;29(1):26-29.

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2005;59(12):862-866.

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25.Riquet M, Darse-Derippe J, Saab M, et al. Chylomediastinum after mediastinoscopy: apropos of a case. Rev Mal Respir 1993;10(5):473-476.

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Chapter 8

Minimally Invasive and Open Approaches to Mediastinal Nodal Assessment

CRITICAL ELEMENT

Lymph Node Dissection or Systematic Lymph Node Sampling in the Chest

Recommendation: The proper technique enables surgeons to access all lymph node stations using either a minimally invasive or an open approach.

Type of Data: Retrospective.

Strength of Recommendation: Weak.

Rationale

The staging and surgical treatment of lung cancer depends on the evaluation of both N1 and N2 nodal stations. Sampled or dissected nodes should include 9R, 8R, 7, 10R, 4R, and 2R nodes on the right side and 9L, 8L, 7, 6,

and 5 nodes (and 4L and 2L nodes, if accessible) on the left side.1 Specific strategies for accessing these nodal stations, as well as some technical maneuvers for avoiding complications during nodal assessment, are

described below.1,2,3,4,5,6,7,8,9,10

Adequate lymph node dissection can be achieved using either a minimally invasive or open technique. Surgeons performing video-assisted thoracic surgery (VATS) may find it easier to approach a lymph node examination in an inferior-to-superior fashion. Details on lymph node dissection are outlined in Table 8-1.

Level 8 and 9 lymph nodes, which are adjacent to the inferior pulmonary vein, are exposed by releasing the inferior ligament and extending the dissection anteriorly and posteriorly to the hilum (Fig. 8-1A,B). The number and consistency of the nodal groups, especially those of stations 8 and 9, vary considerably. Nodes may be completely absent, discrete, or lumped in a fibrofatty tissue amenable to block dissection. To expose the 8R nodes, the surgeon opens the pleura between the esophagus and pericardium by extending the dissection from the inferior ligament to the esophageal hiatus (Fig. 8-2). The 8L and 9L stations are approached in a similar manner,

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with care taken to avoid any hiatal hernias and preserve the vagus nerve in its medial location to the aorta.

FIGURE 8-1 A,B: Thoracoscopic view of right-sided nodal dissection for stations 8 and 9. (Courtesy of Khalid Amer, FRCS [CTh].)

Station 7 nodes are located between the right and left main bronchi. Nodes on the right are approached between the right main bronchus and the esophagus. The right lung is retracted anteriorly, and the pleural reflection at the back of the hilum is opened from the inferior ligament to the concavity of the azygos vein, medial to the vagus nerve (Fig. 8-3). In this step, all vagal bronchial branches could be divided with

P.125 impunity. (If diathermy is used, cutting these branches usually induces a cough reflex.) The bronchus intermedius and right main bronchus are identified and dissected proximally until the left main bronchus is identified. The subcarinal nodes are lifted off the pericardium (usually an avascular plane) and then dissected from their blood supply, with care taken to avoid injury to the membranous bronchus or esophagus (Fig. 8-4).

P.126 The nodes should be carefully labeled, as paraesophageal 8R and parabronchial 10R nodes could easily be mistaken for 7R nodes. In this location, injury to the thoracic duct is prevented by tucking the duct under the esophagus; lifting the esophagus off the vertebral bed may injure the thoracic duct. At the completion of this dissection, the right main bronchus, left main bronchus, and subcarinal space should be readily visible (Fig. 8-5).

FIGURE 8-2 Exposure of station 8R by right thoracoscopy. IVC, inferior vena cava. (Courtesy of Khalid Amer,

FRCS [CTh].)

FIGURE 8-3 Right lung retracted forward to expose subcarinal nodes (level 7) via VATS approach. Small vagal branches towards lung can be divided without concern. (Courtesy of Khalid Amer, FRCS [CTh].)

FIGURE 8-4 Mobilization of the subcarinal nodal packet via the right chest. The pericardium is the anterior border of the dissection plane. (Courtesy of Khalid Amer, FRCS [CTh].)

FIGURE 8-5 View of the subcarinal space after complete nodal dissection. (Courtesy of Khalid Amer, FRCS

[CTh].)

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FIGURE 8-6 Subcarinal node dissection from the left chest. (Courtesy of Khalid Amer, FRCS [CTh].)

Accessing subcarinal station 7 nodes from the left is accomplished by following the lower lobe bronchus proximally, as it leads to the subcarinal space and right main bronchus (Fig. 8.6). One useful technique for bringing the carina forward from a deep level is to use a sturdy tape from an anterior port to retract the lower lobe bronchus. Dissection of the posterior aspect of the left hilum facilitates access to the nodes but places the recurrent laryngeal nerve at risk of injury. The location of the separation of the recurrent laryngeal nerve from the vagus nerve varies, and preserving the pleura between the vagus nerve and aorta may lessen the risk of injury to the laryngeal nerve.

Preand paratracheal station 2R and 4R nodes are located in a fibrofatty nodal block that can usually be dissected en bloc. These nodes are located in an anatomical triangle bound by the phrenic nerve, vagus nerve,

and azygos vein (Fig. 8-7). The apex of the triangle is at the level of the brachiocephalic artery as it crosses the trachea towards the first rib. The lung is retracted downward to expose this triangle, and releasing the pleura between the azygos vein and main bronchus facilitates this exposure. Opening the pleura just lateral to the superior vena cava (SVC) instead of in the middle of the triangle also facilitates this dissection (Figs. 8-8 and 8- 9). The right vagus nerve, as well as veins draining directly into the SVC, are present in the triangle, and small veins in this area should be actively sought out and controlled to prevent bleeding complications. In almost all cases, a single vein can be found draining directly into the posterior aspect of the SVC. If inadvertently cut, the vein may retract and bleed profusely, making it difficult to control. The left paratracheal nodes are perhaps the most challenging to expose because the aortic arch, ligamentum arteriosum, and recurrent nerve all hinder dissection. The most lateral of the 4L nodes lie on the tracheobronchial junction and are accessible from the back of the hilum. To expose these nodes, the main pulmonary artery is freed from the bronchus, and

P.128 a vessel loop is passed around the artery to facilitate its retraction. Gentle retraction of the carina in a downward direction and the artery in a cephalad direction exposes station 4L.

FIGURE 8-7 View of the right upper mediastinum with anatomical boundaries of paratracheal node dissection. (Courtesy of Khalid Amer, FRCS [CTh].)

Similarly, station 5 and 6 nodes on the left exist in an anatomical triangle whose boundaries are the vagus nerve, phrenic nerve, and aortic arch. Dissection begins by retracting the lung posteriorly and downward. The fibrofatty nodal block is lifted off

P.129 the main pulmonary artery into the aortopulmonary space, medial to the vagus nerve (Fig. 8-10). The phrenic nerve is identified on the most medial aspect of the triangle. The nodal block is dissected up to the origin of the left subclavian artery, and all nodes and fatty tissue superficial to the ligamentum are harvested. As long as the dissection is kept to the medial side of the vagus, the recurrent laryngeal nerve is free from potential injury.

FIGURE 8-8 Black arrows indicate ideal sites for incising the mediastinal pleura, then performing an anterior to posterior mobilization of all soft tissue (blue arrow), including nodes behind the superior vena cava towards the vagus nerve. (Courtesy of Khalid Amer, FRCS [CTh].)

FIGURE 8-9 Right paratracheal node dissection basin after removal of all 2R and 4R nodal tissue. (Courtesy of Khalid Amer, FRCS [CTh].)