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

Chapter 9

Lung Resection

CRITICAL ELEMENTS

Surgical Approach

Chest Exploration

Flexible Bronchoscopy

Lung Isolation

Mediastinal Exploration for Gross Nodal Disease

1. SURGICAL APPROACH

Recommendation: Pulmonary resection can be approached safely through a thoracotomy or thoracoscopically depending on the extent of the disease and the surgeon’s experience and preference.

Type of Data: Retrospective, Prospective.

Strength of Recommendation: Weak.

Rationale

Video-assisted thoracoscopic surgery (VATS) approaches, which are being used with increasing frequency, can

be performed safely by experienced thoracic surgeons.1,2,3 Compared with standard thoracotomy, VATS may

cause less postoperative pain and morbidity while offering equivalent survival and recurrence rates.4,5,6 VATS lobectomy has become a standard approach for early-stage lung cancer and is being used increasingly for more advanced disease. According to the American College of Chest Physicians Clinical Practice Guidelines, a minimally invasive approach is preferable to a thoracotomy for anatomic pulmonary resection for stage I non-

small cell lung carcinomas in experienced centers.7 In addition, VATS may enable patients to receive adjuvant

chemotherapy earlier.8 Relative contraindications to VATS include the

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tumors, and N2 or N3 disease.9 The incisions used in thoracoscopic lobectomy include incisions for an inferior port for the camera and for one or two additional ports anteriorly or posteriorly in the sixth intercostal space for the retraction and passage of the stapler (Fig. 9-1). A 6- to 8-cm utility incision for removal of the specimen is made in the fourth intercostal space overlying the hilum. A specimen retrieval bag should be used to decrease

the risk of tumor seeding at the incision.10 Rib spreading should not be used.

Although thoracotomy or thoracoscopic approaches can be used to safely perform pulmonary resection, experienced surgeons must know which approach to use for each patient and when it is necessary to convert a thoracoscopic surgery to an open thoracotomy.

Regardless of VATS or open approach, the patient is positioned in the lateral decubitus position, and the operating table is flexed to help widen the intercostal spaces. All pressure points should be padded. The thoracotomy incision is positioned for optimal exposure of the hilum and should have the capacity to be

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rapidly extended if needed. An oblique skin incision is made 1 or 2 fingerbreadths below the scapular tip.

identified preoperatively is infrequent and in one study occurred in only 45 of 1,279 (3.5%) patients undergoing lung resection. Of these 45 patients, 24 (53%) had positive pleural lavage cytology findings and 5-year survival rates of 6% to 8%, whereas the patients with negative cytology findings had outcomes similar to those of patients

without an effusion.16 In contrast, Naruke et al17 found that 364 of 2,055 (17.7%) patients had previously unidentified pleural effusion at thoracotomy and that of these 364 patients, 74 (20.3%) had positive cytology findings. Pleural fluid or lavage cytology should be obtained and pleurodesis considered in patients found to have an unexpected pleural effusion. However, the use of pleural lavage cytology in the absence of pleural effusion remains controversial; in the American College of Surgeons Oncology Group Z0040 trial, only 29 of

1,047 (2.8%) lung cancer patients had a positive preresection intraoperative pleural lavage.18

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3. FLEXIBLE BRONCHOSCOPY

Recommendation: If not performed preoperatively, flexible bronchoscopy should be performed following anesthesia induction for surgery to assess the segmental anatomy and determine whether endobronchial disease is present.

Type of Data: Retrospective.

Strength of Recommendation: Weak.

Rationale

Flexible bronchoscopy should be performed preoperatively or intraoperatively prior to pulmonary resection to assess the bronchial anatomy, suction any secretions, and determine whether, and if so, the extent to which endobronchial disease is present. In patients with central tumors, bronchoscopy findings may reveal that a more extensive resection, such as a bilobectomy, is necessary. In one study, flexible bronchoscopy in the preoperative work-up of 225 patients with solitary pulmonary nodules revealed unexpected endobronchial involvement in 10

(4.4%) patients.19 In four of these patients, surgery was aborted owing to small cell lung cancer, pneumonia, or involvement of the right mainstem bronchus that caused inadequate pulmonary function precluding

pneumonectomy. On the other hand, Goldberg et al20 and Torrington et al21 found that bronchoscopy did not provide additional benefits, although these series were smaller, including only 91 patients and 33 patients, respectively.

4. LUNG ISOLATION

Recommendation: Single-lung ventilation with a double-lumen endotracheal tube or bronchial blocker should be used to maintain lung isolation during pulmonary resection.

Type of Data: Retrospective, Prospective.

Strength of Recommendation: Weak.

Rationale

Lung isolation, which is performed after flexible bronchoscopy, has been possible since the introduction of the

red rubber Robert-Shaw double-lumen endotracheal tube.22 A left-sided double-lumen tube is generally used for lung isolation unless the left mainstem bronchus is distorted owing to the tumor or a descending aortic aneurysm or must be transected for left pneumonectomy or sleeve resection. A right-sided double-lumen tube has an opening for ventilation of the right upper lobe. Although an airway exchange catheter, which is especially useful in the difficult-to-intubate patient, can be used to place a double-lumen tube, care must be taken to avoid injuring

the airway during the tube exchange.23,24 Tube position should be confirmed by bronchoscopy, as one study

4.Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010;139:366-

5.Tomaszek SC, Cassivi SD, Shen KR, et al. Clinical outcomes of video-assisted thoracoscopic lobectomy.

Mayo Clin Proc 2009;84:509-513.

6.Walker WS, Codispoti M, Soon SY, et al. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothorac Surg 2003;23:397-402.

7.Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e278S-e313S.

8.Petersen RP, Pham D, Burfeind WR, et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer. Ann Thorac Surg 2007;83:1245-1249; discussion 1250.

9.Hanna JM, Berry MF, D’Amico TA. Contraindications of video-assisted thoracoscopic surgical lobectomy and determinants of conversion to open. J Thorac Dis 2013;5:S182-S189.

10.Yim AP. Port-site recurrence following video-assisted thoracoscopic surgery. Surg Endosc 1995;9:11331135.

11.Hazelrigg SR, Landreneau RJ, Boley TM, et al. The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain. J Thorac Cardiovasc Surg 1991;101:394-401.

12.Lemmer JH Jr, Gomez MN, Symreng T, et al. Limited lateral thoracotomy. Improved postoperative pulmonary function. Arch Surg 1990;125:873-877.

13.Landreneau RJ, Pigula F, Luketich JD, et al. Acute and chronic morbidity differences between musclesparing and standard lateral thoracotomies. J Thorac Cardiovasc Surg 1996;112: 1346-1350.

14.Cerfolio RJ, Bryant AS, Maniscalco LM. A nondivided intercostal muscle flap further reduces pain of thoracotomy: a prospective randomized trial. Ann Thorac Surg 2008;85:1901-1906; discussion 1906-1907.

15.Cerfolio RJ, Price TN, Bryant AS, et al. Intracostal sutures decrease the pain of thoracotomy. Ann Thorac Surg 2003;76:407-411; discussion 411-412.

16.Ruffini E, Rena O, Bongiovanni M, et al. The significance of intraoperative pleural effusion during surgery for bronchogenic carcinoma. Eur J Cardiothorac Surg 2002;21:508-513.

17.Naruke T, Tsuchiya R, Kondo H, et al. Implications of staging in lung cancer. Chest 1997;112: 242S248S.

18.Rusch VW, Hawes D, Decker PA, et al. Occult metastases in lymph nodes predict survival in resectable non-small-cell lung cancer: report of the ACOSOG Z0040 trial. J Clin Oncol 2011;29:4313-4319.

19.Schwarz C, Schonfeld N, Bittner RC, et al. Value of flexible bronchoscopy in the pre-operative work-up of solitary pulmonary nodules. Eur Respir J 2013;41:177-182.

20.Goldberg SK, Walkenstein MD, Steinbach A, et al. The role of staging bronchoscopy in the preoperative assessment of a solitary pulmonary nodule. Chest 1993;104:94-97.

21.Torrington KG, Kern JD. The utility of fiberoptic bronchoscopy in the evaluation of the solitary pulmonary nodule. Chest 1993;104:1021-1024.

22.Bjork VO, Carlens E. The prevention of spread during pulmonary resection by the use of a double lumen catheter. J Thorac Surg 1950;20:151.

23.Abdulatif M, Ismail E. Use of the Aintree intubation and airway exchange catheters through LMA-ProSeal for double-lumen tube placement in a morbidly obese patient with right main stem bronchus tumour. Br J Anaesth 2012;108:1038-1039.

24.Thomas V, Neustein SM. Tracheal laceration after the use of an airway exchange catheter for doublelumen tube placement. J Cardiothorac Vasc Anesth 2007;21:718-719.

25.Klein U, Karzai W, Bloos F, et al. Role of fiberoptic bronchoscopy in conjunction with the use of doublelumen tubes for thoracic anesthesia: a prospective study. Anesthesiology 1998;88: 346-350.

26.Campos JH. An update on bronchial blockers during lung separation techniques in adults. Anesth Analg

2003;97:1266-1274.

27.Campos JH, Kernstine KH. A comparison of a left-sided Broncho-Cath with the torque control blocker univent and the wire-guided blocker. Anesth Analg 2003;96:283-289.

28.Depierre A, Milleron B, Moro-Sibilot D, et al; French Thoracic Cooperative Group. Preoperative chemotherapy followed by surgery compared with primary surgery in resectable stage I (except T1N0), II, and IIIa non-small-cell lung cancer. J Clin Oncol 2002;20(1):247-253.

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29. Nagai K, Tsuchiya R, Mori T, et al; Lung Cancer Surgical Study Group of the Japan Clinical Oncology Group. A randomized trial comparing induction chemotherapy followed by surgery with surgery alone for patients with stage IIIA N2 non-small cell lung cancer (JCOG 9209). J Thorac Cardiovasc Surg

2003;125(2):254-260.

30. Roth JA, Fossella F, Komaki R, et al. A randomized trial comparing perioperative chemotherapy and surgery with surgery alone in resectable stage IIIA non-small-cell lung cancer. J Natl Cancer Inst

1994;86(9):673-680.

31.Rosell R, Gómez-Codina J, Camps C, et al. A randomized trial comparing preoperative chemotherapy plus surgery with surgery alone in patients with non-small-cell lung cancer. N Engl J Med 1994;330(3):153-

32.Wagner H Jr, Lad T, Piantadosi S, et al. Randomized phase 2 evaluation of preoperative radiation therapy and preoperative chemotherapy with mitomycin, vinblastine, and cisplatin in patients with technically unresectable stage IIIA and IIIB non-small cell cancer of the lung LCSG 881. Chest 1994;106(6)(suppl):348S354S.

33.Elias AD, Skarin AT, Leong T, et al. Neoadjuvant therapy for surgically staged IIIA N2 nonsmall cell lung cancer (NSCLC). Lung Cancer 1997;17(1):147-161.

34.Pass HI, Pogrebniak HW, Steinberg SM, et al. Randomized trial of neoadjuvant therapy for lung cancer: interim analysis. Ann Thorac Surg 1992;53(6):992-998.

35.Burdett SS, Stewart LA, Rydzewska L. Chemotherapy and surgery versus surgery alone in nonsmall cell lung cancer. Cochrane Database Syst Rev 2007;(3):CD006157.

36.Ramnath N, Dilling TJ, Harris LJ, et al. Treatment of stage III non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143(5)(suppl):e314S-e340S.

Chapter 10

Segmentectomy

CRITICAL ELEMENT

Patient Selection for Segmentectomy

Recommendation: Segmentectomy should be an option in only select node-negative patients and is dependent on being able to achieve an adequate parenchymal margin.

Type of Data: Retrospective.

Strength of Recommendation: Weak.

Rationale

Sublobar resections are a treatment modality primarily used for early-stage non-small cell lung cancer (NSCLC) in patients with limited pulmonary reserve, where a larger anatomic resection would not be tolerated. Sublobar resections are also currently under prospective randomized evaluation in two independent trials as an alternative treatment strategy for healthy patients with small, peripheral, node-negative tumors. Lobectomy is currently the recommended treatment for stage I and II NSCLC according to the American College of Chest Physicians (ACCP) evidence-based guidelines for the

diagnosis and management of lung cancer1 and the National Comprehensive Cancer Network (NCCN) guidelines.2 These recommendations are based primarily on results from the only randomized trial completed to date which compared lobectomy to sublobar resection for stage I NSCLC and noted a

threefold increase in local recurrence and trend toward worse survival in those undergoing sublobar resection.3

A sublobar resection for NSCLC is defined as either an anatomic segmentectomy or a wide wedge resection. Segmentectomy is generally considered to

be the oncologically superior of the two approaches, typically with wider margins and greater numbers of harvested lymph nodes than wedge resection.4

Segmentectomy is therefore the preferred sublobar approach for primary resection of NSCLC when technically and medically

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feasible. A systematic evaluation of the mediastinal lymph nodes is recommended for all sublobar resections performed for NSCLC.

Surgeons undertaking segmentectomy need to be familiar with segmental anatomy. There are 19 pulmonary segments, 10 on the right and 9 on the left, with the anterior basal and medial basal on the left considered a single segment. Although segmental resections have been described for nearly all

bronchial segments, generally accepted segmental resections are outlined in Figure 10-1.5,6 Suggested criteria for use of segmentectomy include small

tumors (<3 cm), location in the peripheral one-third of the lung, and no endobronchial involvement. Such conditions allow for adequate surgical margins.7,8

Careful review of the chest computed tomography (CT) is suggested preoperatively. This allows the surgeon to ascertain if the tumor is confined within the

segmental boundary and appropriate for sublobar techniques.5,6,9,10 It is also helpful for determining the adequacy of margins and identification of

aberrant anatomy. Flexible bronchoscopy is indicated to ensure absence of endobronchial disease and delineating bronchial anatomy prior to division.10

General anesthesia with single lung ventilation is beneficial to maintain a quiet operative field for open

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approaches and is mandatory to obtain the pneumothorax required for minimally invasive approaches. Lateral decubitus positioning with flexion is recommended. Thoracotomy, video-assisted thoracoscopic surgery (VATS), or robotic-assisted approaches are all acceptable for sublobar resections,

and the approach should not alter the technical aspects of the procedure.6 The optimal approach depends on the patient and tumor characteristics and

the surgeon’s expertise. The efficacy of minimally invasive techniques for wedge resection has been long accepted.11 Numerous nonrandomized trials and single institution case series have demonstrated equivalent shortand long-term oncologic outcome for segmental resections by VATS and open

techniques.12,13,14,15,16,17,18,19 Although no prospective randomized trials comparing the different approaches have been completed, limited evidence

suggests VATS may be better tolerated with reduced pain and length of stay and greater postoperative independence.19,20,21,22,23,24 The greatest benefit from minimally invasive approaches appears to be in those patients with severe medical comorbidity. Data from the Society of Thoracic Surgery General Thoracic Surgery Database suggest significant reductions in perioperative morbidity and mortality with minimally invasive approaches to lung resections in

high-risk population.25,26 The robotic approach is the most novel and has the least evidence for efficacy for segmental resections, but a recent series

reports safety and feasibility for the approach.27

FIGURE 10-1 Pulmonary segments amenable to anatomic resection.

Intraoperative Technical Suggestions

Segmentectomy is an anatomic resection, defined by removal of one or more of the pulmonary parenchymal segments and their corresponding

bronchovascular supply.2,3,6,7 By definition, segmentectomy requires individual ligation of the segmental vein, artery, and bronchus and parenchymal division through the intersegmental fissure.

Surgeons should begin with the hilar dissection and removal of hilar and segmental lymph nodes to allow for identification of the segmental bronchovascular structures and to provide adequate length for their individual ligation. As stressed previously, frozen section assessment of these lymph nodes is essential, as this procedure is only indicated for node-negative patients. The segmental vein is typically divided first, especially in minimally

invasive approaches, because it facilitates exposure of the segmental artery and bronchus.3,6,7 The techniques for identification and the order of division of the artery and bronchus vary with the individual segment being resected.

The parenchyma is typically divided last with a number of the techniques being utilized for anatomical demarcation. Techniques include following the line

of the intact adjacent vein,9 providing gentle traction on the divided segmental vein to delineate plane,5 partial ventilation of remaining lung after division of

the segmental bronchus,5,9 and partial ventilation of the lung, prior to stapling, then reisolation with the stapler or clamp across the bronchus to leave

resected segment inflated.10 Parenchymal division can be completed with a stapling device, electrocautery, or by using energy-based coagulative fusion technology (LigaSure, Valley Labs, Boulder, CO). There are limited data comparing the different techniques of parenchymal division, but there appear to

be equivalent results with the various techniques, and no clear recommendation in favor of one technique can be made.28 The parenchymal division plane should be inspected for large air leaks and a pleural drainage tube is recommended. The most important aspect of parenchymal division is maintaining a minimum distance of 1 cm or larger diameter of the tumor should be maintained between the tumor and the parenchymal division line for oncologic

efficacy.25,26,27 The evidence for decreased local control with narrow resection margins is outlined in Table 10-1.

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TABLE 10-1 Evidence for Decreased Local Control with Narrow Resection Margins