Lung Cancer Resection on Cardiopulmonary Bypass. Daniel J. Boffa, MD Yale University
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1 Lung Cancer Resection on Cardiopulmonary Bypass Daniel J. Boffa, MD Yale University
2 None related to talk Disclosures
3 Disclaimers I love operating on CPB
4 Disclaimers I love operating on CPB I avoid it for lung CA
5 Disclaimers I love operating on CPB I avoid it for lung CA Pretty Average Practice
6 Mei J Surg Onc 2012
7 Could vs Should Mei J Surg Onc 2012
8 High Risk Surgery is Reasonable
9 High Risk Surgery is Reasonable Surgery of Unclear Benefit is Reasonable
10 High Risk Surgery is Reasonable Surgery of Unclear Benefit is Reasonable Don t do them in the same patient
11 Is tumor Driver of Demise
12 Is tumor Driver of Demise Tumor = lethal if not removed
13 Driver of Demise Tumor = lethal if not removed Nothing else more rapidly lethal Systemic disease Medical comorbidities
14 6 months after Metastasectomy
15 Patient Selection Complete Staging Metastatic Survey (PET and Brain MRI) Mediastinum (Invasive)* Local invasion (not very accurate)
16 Patient Selection Complete Staging Metastatic Survey (PET and Brain MRI) Mediastinum (Invasive)* Local invasion (not very accurate) Medical Evaluation Global Cardiac
17 Pump Effects
18 Pump Effects
19 Heart Disease and Lung CA Retrospective case series of Coincidental Heart Disease and Lung Cancer (circa 1995) Median sternotomy Vast Majority Lobectomies 80-90% done on CPB or after CPB
20 Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao La Francesca Brutel Voets Miller
21 Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao La Francesca Brutel Voets Miller Average
22 Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao La Francesca Brutel Voets Miller Average
23 Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao La Francesca Brutel Voets Miller Average Relatively Safe
24 Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao La Francesca Brutel Voets Miller Average
25 Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao La Francesca Brutel Voets Miller Average Not Great.71% stage I
26 Pump Effect Cancer Dissemination? Sicker Patients?
27 Timing of CPB and Lobectomy Lobectomy then CPB Brutel de la Riviere EJCTS 1995
28 Stage I: Combined versus Staged Staged (N=6) Combined (N=23) Miller, ATS 1994
29 Toronto: 86% on CPB or After Rao et al Annals Thor Surg1996
30 Summary Open Heart and Lung Ca Reasonably Safe Suggestion of a compromise in survival with CPB Severely confounded by comorbidity
31 Cardiopulmonary Bypass for Lung resection Invasion of heart or great vessels Central Airway tumor
32 Position Optimize CPB and Lung resection Take advantage of CPB Don t lock into CPB Access Keep it out of the way Personnel Anesthesia Cardiac focused surgeon
33 Mei J Surg Onc 2012
34 Mei J Surg Onc 2012
35 CPB Access Arterial Right Chest Femoral Axillary Ascending Aorta Descending Aorta Venous Right Atrium Protection Arterial Left Chest Aorta Femoral Axillary Venous Femoral Vein Pulmonary Artery Protection
36 Bajwa Operative Tech Thor and CV Surg 2010
37 Bajwa Operative Tech Thor and CV Surg 2010
38 Outcomes of CPB for Lung CA Systematic Review patients (20 manuscripts) 84% were stage IIIB (T4 status) Operative mortality 30 day = 0% 90 day = 1% Muralidaran JTCVS 2011
39 Tissues Resected % of total Aorta 43 Left Atrium/pulm veins 25 Pulmonary Artery 11 SVC/IVC/Right Atrium 3 Trachea 3 Other Organs 4 Muralidaran JTCVS 2011
40 Outcomes 100 % Alive Muralidaran JTCVS Years
41 Outcomes % Alive % survival at 5y Muralidaran JTCVS Years
42 Outcomes 100 % Alive Survival for IIIB Muralidaran JTCVS Years
43 Multivariable Analysis Organ Resected (Ao vs other) HR [95% CI] P 1.11 [ ].86 Planned.28 [ ].03 > [ ].24 Muralidaran JTCVS 2011
44 Multivariable Analysis Organ Resected (Ao vs other) HR [95% CI] P 1.11 [ ].86 Planned.28 [ ].03 > [ ].24 Muralidaran JTCVS 2011
45 Driver of Demise Slippery Slope
46
47 - Esophagectomy - Left atrial reconstruction - Left lower lobectomy - Decortication - Muscle flap or window
48 Intra-operative Misadventures
49 Opportunity for On Pump Surgery
50 Surprises at Routine Resection Lymph nodes adherent to PA Stapler misfire (cut - no staples) Staple line or suture line deshiscence Disruption of patent IMA graft
51 Productive Reaction Damage Control Moves Communicate Issue Inform Anesthesiologist Second circulator and scrub Second surgeon Pump Cell saver Blood Bank Heparin
52 Crash On Arterial Right Chest Femoral (Aline)* Ascending Aorta Descending Aorta Venous Right Atrium Protection Arterial Left Chest Aorta Venous Femoral Vein (cordis)* Pulmonary Artery Sucker Bypass Protection
53 Exposure Open if VATS Add Sternotomy (convert to hemiclamshell) Enlarge thoracotomy
54 Outcomes Unplanned Muralidaran JTCVS 2011
55 Ways to avoid CPB Optimal incisions Intrapericardial mobilization Off pump retraction devices to elevate heart Ventilation strategies for tracheal resection
56 Ways to avoid CPB Optimal incisions Intrapericardial mobilization Off pump retraction devices to elevate heart Ventilation strategies for tracheal resection Preoperative cytoreduction? Should not change extent of resection, but may facilitate
57 Cases done without SVC replacement Left atrial resection Right atrial resection Descending Aorta
58 Pericardium
59 Pericardium
60 VERY easy to encircle main Pulmonary Artery
61 VERY easy to encircle main Pulmonary Artery Clamp Trial before staple
62 Good case for pump standby
63 Prepare Access Prep groin Femoral Arterial Line Femoral cordis Do in pump-ready room Pump experienced scrub team
64 Jones, D Oper Tech Thor CV Surg 2009
65
66
67
68 Jones, D Oper Tech Thor CV Surg 2009
69 Jones, D Oper Tech Thor CV Surg 2009
70 Need to Plan for Arch of Azygous
71 PA
72
73
74
75
76 Too much left atrial involvement
77 Banki Oper Tech Thor CV Surg 2007
78
79 Banki Oper Tech Thor CV Surg 2007
80 - Vigilant Suctioning, blood aspiration - Fire Risk from 100% FiO2 Banki Oper Tech Thor CV Surg 2007
81 Banki Oper Tech Thor CV Surg 2007
82 Summary CPB and lung cancer surgery is safe Reasonable Survival in highly select patients driver of their demise Many ways to avoid pump
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