Advertisement

Technique of Extrapleural Pneumonectomy

      Since Butchart and coworkers published the first series on pleuropneumonectomy for the treatment of malignant pleural mesothelioma (MPM) in 1976,
      • Butchart E.G.
      • Ashcroft T.
      • Barnsley W.C.
      • et al.
      Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura Experience with 29 patients.
      the perioperative mortality associated with this operation has decreased from 31% to 3.4%, similar to that of mitral valve replacement, coronary artery bypass graft surgery, and Whipple procedure. There are only 3000 new cases of MPM in the US each year compared with an estimated 222,520 new cases of lung cancer.
      • Jemal A.
      • Siegel R.
      • Xu J.
      • et al.
      Cancer statistics, 2010.
      MPM is a very aggressive local/regional disease for which survival without treatment is 4 to 12 months. Single-modality therapy alone (ie, surgery or chemotherapy or radiotherapy) is largely ineffective. Univariate analysis in a case series from Brigham and Women's Hospital identified 3 prognostic variables associated with improved survival: (1) epithelial cell type (52% 2-year survival, 21% 5-year survival, 26-month median survival; P = 0.0001), (2) negative resection margins (44% at 2 years, 25% at 5 years, median 23 months; P = 0.02), and (3) absence of metastases to extrapleural lymph nodes (42% at 2 years, 17% at 5 years, median 21 months; P = 0.004).
      • Sugarbaker D.J.
      • Flores R.M.
      • Jaklitsch M.T.
      • et al.
      Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: Results in 183 patients.
      Therefore, we use multimodality treatment, including chemotherapy, radiotherapy, and surgery consisting of either extrapleural pneumonectomy (EPP) or radical pleurectomy/decortication. The goal of surgery is to achieve a macroscopic complete resection, ie, complete removal of all grossly visible tumor.
      • Sugarbaker D.J.
      Macroscopic complete resection: The goal of primary surgery in multimodality therapy for pleural mesothelioma.
      This article describes the technical aspects of EPP. Full details of our protocol for heated intraoperative chemotherapeutic lavage (HIOC) have been previously described.
      • Mujoomdar A.A.
      • Sugarbaker D.J.
      Hyperthermic chemoperfusion for the treatment of malignant pleural mesothelioma.
      However, a photograph of the perfusion apparatus and the technique for delivering the hyperthermic chemoperfusion into the chest are provided.
      EPP involves en bloc resection of lung, pleura, pericardium, and diaphragm with radical lymph node dissection followed by patch reconstruction of the diaphragm and pericardium. Preoperative evaluation including mediastinoscopy, magnetic resonance imaging, and computed tomographic scan fails to identify locally advanced disease in approximately 25% of cases. Therefore, local invasion of the abdomen, pericardium, chest wall, or vital mediastinal structures may be discovered at surgery and usually renders the patient unresectable. Patients with radiographic signs of intra-abdominal involvement are explored through an open subcostal incision or by laparoscopy before thoracotomy. EPP is a technically challenging operation and should only be performed at experienced centers by experienced surgeons with close attention to the management of perioperative care.

      Operative Technique

      Right Extrapleural Pneumonectomy

      Before performing the operation, a thoracic epidural catheter is placed for intraoperative management and postoperative analgesia. Standard monitoring lines are placed for telemetry, continuous pulse oximetry, central venous access, and urinary Foley catheterization. Additionally, a pulmonary artery catheter is placed for intraoperative monitoring of the PA pressures, and a nasogastric tube is placed to facilitate identification and dissection of the esophagus during the extrapleural dissection. This tube is left in place postoperatively to decompress the stomach and prevent aspiration. The patient is induced by the anesthesiology team, and a left-sided double-lumen endotracheal tube is placed for single-lung ventilation. The patient is positioned in left lateral decubitus position for an extended right posterolateral thoracotomy.Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11, Figure 12, Figure 13
      Figure thumbnail gr1
      Figure 1Before incision, the patient is placed in the left lateral decubitus position, propped, and elevated on pontoons, with the bed slightly flexed in the reverse Trendelenburg position. The position of the operating table will change during various phases of the operation, eg, from steep Trendelenburg (apical dissection) to reverse Trendelenburg (diaphragmatic dissection), to tilted left and right for anterior and posterior mediastinal dissections. Accordingly, the operating room lights must be adjusted frequently to maintain focus on the wound. A posterolateral thoracotomy is performed with division of the latissimus dorsi, serratus anterior, rhomboid, and trapezius muscles. A scapula retractor is inserted, and the chest is entered through the fifth intercostal space after the sixth rib has been excised. In patients with large anterior mediastinal tumors, the incision can be extended to the costochondral margin (dashed line).
      (Reprinted with permission from Erkmen C, Ducko CT, Jaklitsch MT. Thoracic incisions, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr2
      Figure 2Once the sixth rib is removed, an incision is made in the intercostal muscles, thereby exposing the parietal pleura. A Harken retractor (or any other retractor with 1 long blade) effectively keeps the wound open and tethers the scapula. A second, smaller Finochietto retractor is placed anteriorly to allow good exposure of the entire chest cavity. Before the chest retractor is opened widely, the intercostal muscle division is performed anteriorly beneath the pectoralis muscle toward the internal thoracic artery. Posteriorly, the intercostal muscle division stops at the level of the lateral margin of the erector spinae muscle or thoracolumbar fascia overlying this muscle.
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr3
      Figure 3(A) The dissection proceeds over the apex of the lung and cupula of the pleura along the subclavian vessels. The patient should be in gentle Trendelenburg position. At this point, an attempt is made to identify the phrenic nerve. On both sides, the phrenic nerve runs posterior to the subclavian vein and anterior to the internal thoracic artery as it enters the thorax. The internal mammary vessels may be ligated or clipped and the mammary node(s) removed. (B) The dissection proceeds toward the anterior mediastinum along the superior vena cava (SVC) to the cavo-azygos junction.
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr4
      Figure 4(A) Once the apical dissection is completed, the space created by the dissection is packed with sponge gauze and the dissection proceeds posteriorly along the azygos vein with attention to the esophagus. If one finds invasion of vital mediastinal structures, eg, aorta, vena cava, esophagus, epicardium, or trachea, the tumor is deemed unresectable and the chest is closed. Otherwise, the esophagus is identified by palpating the nasogastric tube placed preoperatively. While the surgeon dissects the tumor away from the esophagus, the assistant creates a dissection plane by retracting the tumor and lung anteriorly. This dissection is carried down to the retrocrural space in the retroperitoneum. Often the thoracic duct is found at this location. It should be ligated to prevent postoperative chyle leak. (B) Attention is then turned to the anterior mediastinum and pericardium. The tumor and lung are retracted posteriorly and the pericardium is opened anteriorly. The pericardial sac is palpated. Although pericardial invasion does not preclude resection, if myocardial invasion is found, the operation is terminated. In the absence of myocardial invasion, the surgeon proceeds to the diaphragmatic resection. NG, nasogastric.
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr5
      Figure 5(A) The diaphragm is incised first at its lateral margin. (B) Then it is dissected free by avulsing it circumferentially off the chest wall or cauterizing the muscle fibers and dividing the peritoneal attachments with blunt dissection and Bovie electrocoagulation.
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr6
      Figure 6(A) The diaphragm is dissected bluntly off the underlying peritoneum. The peritoneum is entered during the dissection permitting identification of the hepatic veins and the inferior vena cava as it enters the chest. No attempt is made to close the peritoneum. Later, the inflow cannula for the HIOC lavage will be placed in the pelvis and heated chemotherapy will fill the abdominal and thoracic cavities. (B) Once the diaphragmatic resection reaches the posterior mediastinum, the inferior vena cava and esophageal hiatus should be well visualized in the operative field.
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr7
      Figure 7(A) With the pericardium open, the surgeon performs an intrapericardial dissection of the right pulmonary artery by retracting the superior vena cava medially and dissecting free the right main pulmonary artery. The endoleader is passed around the pulmonary artery to guide both the safe passage of the endovascular stapler and the division of the pulmonary artery. (B) The right pulmonary artery is safely divided with the endovascular stapler.
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      The specimen is then retracted posteriorly and superiorly to expose the pericardium by the phrenopericardial angle. Next, the pericardium is divided inferiorly from a medial to lateral direction to the inferior vena cava–right atrial junction as it enters the pericardium. It is important to proceed cautiously at this point in the operation because the cavo–atrial junction lies close to the line of dissection. The lung, along with its pleural envelope, should be retracted toward the chest wall. After this maneuver, the inferior pulmonary vein, the cavo-atrial junction, and the phrenic veins are clearly visualized. The phrenic veins are ligated. The hepatic veins lie in close proximity to these structures, and, if inadvertent injury occurs to the hepatic veins, they must be immediately repaired.
      Figure thumbnail gr8
      Figure 8(A) The superior and inferior pulmonary veins are divided intrapericardially in the same fashion as shown in . Whenever possible, the pulmonary veins should have a small cuff to avoid tension on the staple lines. After the hilar vessels have been divided, the specimen is lifted toward the chest wall and the pericardiotomy is completed in the retroperitoneum by dividing the right crus and the pericardium lateral to the inferior vena. The right mainstem bronchus is dissected and encircled as close to the carina as possible with a heavy-gauge wire bronchial stapler. The right mainstem bronchus is visualized directly with bronchoscopy by the anesthesia team to ensure a short bronchial stump that will prevent pooling of secretions. The specimen is removed en bloc from the thorax. A frozen-section analysis of the bronchial margin is performed by pathology. (B) A radical lymph node dissection is routinely performed to enable complete pathologic staging. The paratracheal, subcarinal, paraesophageal, and inferior pulmonary ligament lymph nodes are resected (levels 4, 7, 8 and 9, respectively). Argon beam coagulation (Valleylab, Boulder, CO) is performed of the entire chest wall. Any areas of tumor invasion of the chest wall are ablated with the application of the radiofrequency ablation probe and marked with metal clips or wires to facilitate adjuvant radiation therapy.
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr9
      Figure 9(A) Shown here is the Belmont Hyperthermia Pump (Belmont, Inc., Belmont, MA), a modification of the Belmont FMS 2000 rapid infuser. The modified apparatus yields greater maximum flow, higher temperature capabilities, enhanced alarms, and custom screen readouts. The inflow and outflow perfusate tubes deliver HIOC into the empty chest cavity at 42°C. (B) The Omni-flex (Omni-Tract Surgical, St. Paul, MN) retractor is lined up with the edges of the wound. The cannulae and retractor are covered with a clear sheet of plastic adhesive. HIOC is performed for 1 hour. The fluid volume is recovered at the end of the HIOC perfusion.
      (Reprinted with permission from Abdul-Ghani A, Su S, Sugarbaker DJ. Intracavitary hyperthermic chemotherapy for malignant pleural mesothelioma, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr10
      Figure 10(A) The greater omentum is mobilized off the transverse colon and a flap is fashioned of a length sufficient to reach the right mainstem bronchial stump, where it will be used later as a buttress. (B) After the diaphragm and pericardium have been reconstructed with a Gore-Tex patch (W.L. Gore and Associates, Flagstaff, AZ), the omentum is brought through a slit in the diaphragmatic patch and sutured in place with interrupted 3-0 Vicryl sutures. If the omentum is not suitable for use as a patch, either periesophageal tissues, an intercostal muscle, or pericardial fat pad may be used to cover the right main bronchial stump.
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr11
      Figure 11(A) A “dynamic” patch is created for the diaphragm using 2 pieces of 2-mm-thick Gore-Tex Dual Mesh, 20 cm × 30 cm in diameter (W.L. Gore and Associates). The pieces are stapled laterally but deliberately left unstapled at the center to permit movement during forceful respiration and/or Valsalva maneuver. (B) The patch is contoured to the hemithorax with stitches in the center part. This creates a dynamic seam in the diaphragmatic patch. The dynamic nature of this patch prevents subsequent forceful tearing of the patch off the chest wall. The diaphragmatic patch is sutured posteriorly, laterally, and anteriorly to the chest wall with 9 Ethibond sutures placed through the patch and intercostal space. (Inset) Each suture is passed through a 14-mm Gore-Tex button and secured in place to the chest wall using a Ti-knot device (LSI Solutions, Victor, NY).
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr12
      Figure 12(A) Next, the pericardium is reconstructed using a 0.2 mm-thick Gore-Tex (W.L. Gore and Associates) patch. The pericardial patch is fenestrated to prevent fluid accumulation and/or cardiac tamponade before it is placed over the heart. (B) The patch is sutured to the cut edge of the pericardium circumferentially using nine 0-Ethibond sutures. The patch is tied to the pericardium using the same Ti-knot device shown in the inset of .
      (Reprinted with permission from Lee JM, Sugarbaker DJ. Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma and other diffuse pleural malignancies, in: Sugarbaker DJ, Bueno R, Krasna MJ, et al. (eds): Adult Chest Surgery. New York, NY, McGraw-Hill, 2009.)
      Figure thumbnail gr13
      Figure 13Our method for managing the pneumonectomy space has been previously described.
      • Wolf A.S.
      • Jacobson F.L.
      • Tilleman T.R.
      • et al.
      Managing the pneumonectomy space after extrapleural pneumonectomy: Postoperative intrathoracic pressure monitoring.
      Before closing the chest, a 14-Fr Rob-Nel catheter is placed in the pneumonectomy space. The catheter exits the chest and is connected to an arterial line monitor setup via a 3-way stopcock. On completion of the operation, approximately 1000 mL of air is removed from the right side and 750 mL from the left side in men, and 750 mL of air is removed from the right side and 500 mL from the left side in women to balance the mediastinum. The Rob-Nel catheter is then connected to a pressure transducer and the intrathoracic pressures are monitored continuously for 48 hours. Rapid fluid accumulation can cause contralateral mediastinal shift with compression of the remaining lung and respiratory insufficiency. We manage this problem by aspirating fluid from the pneumonectomy space intermittently as needed, whenever there is an increase in intrathoracic pressure, refractory hypotension, mediastinal shift on chest radiograph, or clinical decline. (A) Normal midline mediastinum. (B) Severe ipsilateral mediastinal shift. (C) Severe contralateral mediastinal shift.
      (Reprinted with permission from Wolf AS, Jacobson FL, Tilleman TR, et al. Managing the pneumonectomy space after extrapleural pneumonectomy: Postoperative intrathoracic pressure monitoring. Eur J Cardiothorac Surg 37:770-775, 2010.)

      Left EPP Key Differences in Technique

      The operation is similar to the procedure done on the right with a few important differences because of the more prominent presence of the aorta, esophageal hiatus, and long extrapericardial course of the pulmonary artery. First, when the pleura is dissected off the aorta, it is easy to inadvertently start dissecting behind the aorta and thereby injure the intercostal branches. Beginning this part of the dissection on the arch can prevent this problem. Second, the left main pulmonary artery is divided extrapericardially while the pulmonary veins are divided intrapericardially. Caution must be exercised around the thoracic duct and recurrent laryngeal nerve while dissecting the area between the aortopulmonary window and the takeoff of the subclavian vessel. During diaphragmatic resection, leave a 1- to 2-cm rim of left diaphragmatic crus over the gastric incisura. Sutures placed here during patch reconstruction prevent gastric herniation.

      Conclusions

      The perioperative management of patients undergoing EPP is critical and has been previously described.
      • Sugarbaker D.J.
      • Jaklitsch M.T.
      • Bueno R.
      • et al.
      Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies.
      With aggressive management and appropriate preventative measures, this operation can be safely performed by an experienced team of surgeons and anesthesiologists with acceptable morbidity and mortality.

      References

        • Butchart E.G.
        • Ashcroft T.
        • Barnsley W.C.
        • et al.
        Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura.
        Thorax. 1976; 31: 15-24
        • Jemal A.
        • Siegel R.
        • Xu J.
        • et al.
        Cancer statistics, 2010.
        CA Cancer J Clin. 2010; 60: 277-300
        • Sugarbaker D.J.
        • Flores R.M.
        • Jaklitsch M.T.
        • et al.
        Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: Results in 183 patients.
        J Thorac Cardiovasc Surg. 1999; 117 (discussion 55): 54-63
        • Sugarbaker D.J.
        Macroscopic complete resection: The goal of primary surgery in multimodality therapy for pleural mesothelioma.
        J Thorac Oncol. 2006; 1: 175-176
        • Mujoomdar A.A.
        • Sugarbaker D.J.
        Hyperthermic chemoperfusion for the treatment of malignant pleural mesothelioma.
        Semin Thorac Cardiovasc Surg. 2008; 20: 298-304
        • Wolf A.S.
        • Jacobson F.L.
        • Tilleman T.R.
        • et al.
        Managing the pneumonectomy space after extrapleural pneumonectomy: Postoperative intrathoracic pressure monitoring.
        Eur J Cardiothorac Surg. 2010; 37: 770-775
        • Sugarbaker D.J.
        • Jaklitsch M.T.
        • Bueno R.
        • et al.
        Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies.
        J Thorac Cardiovasc Surg. 2004; 128: 138-146