Surgical techniques Video-Mediastinoscopy Thoracoscopy (VATS) Gunda Leschber Department of Thoracic Surgery ELK Berlin Chest Hospital, Berlin, Germany Teaching Hospital of Charité Universitätsmedizin Berlin
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Alternative staging methods for the mediastinum PET-CT (+): non-invasive (-): lack of sensitivity in BAC, Adeno-Ca or inflammatory diseases EBUS-FNA/EUS-FNA (+): less invasive (-): observer dependend (experience), small tissue samples Mediastinoscopy (+): large tissue samples (-): invasive VATS (+): large tissue samples, evaluation of intrathoracic tumor extent (-): invasive Schrager JB, Ann Thorcic Surg 2010; 89:S2084-9
Indication for Mediastinoscopy Enlarged lymph nodes on CT scan (N2/3) PET-positive lymph nodes Suspicion of mediastinal invasion Question: which kind of mediastinoscopy? Conventional Video VAMLA
Mediastinoscopy - history 1959 Carlens: Mediastinoscopy 1987 Ginsberg: extended mediastinoscopy 1994 Sortini (I), Lerut (B): Video-mediastinoscopy 2002 Hürtgen: VAMLA (video-assisted mediastinal lymphadenectomy)
Conventional versus Video-Mediastinoscopy (n = 366) Complications n Recurrent laryngeal nerve palsy Bleeding (mediastinal enlargment on postop. chest X-ray) Others * Total Video- Mediastinoscopy Conventional mediastinoscopy 234 5 (2.1%) 2 (0.9%) 3 (1.3%) 10 (4.3%) 132 4 (3.0%) 3 (2.3%) 0 (0.0%) 7 (5.3%) All 366 9 (2.5%) 5 (1.4%) 3 (0.8%) 17 (4.6%) * pneumonia (1), laceration of pleura (1), laceration of main bronchus (1) No perioperative death or hemorrhage Leschber G et al. Eur J Cardiothorac Surg 2008; 33:289
Conventional versus Video-Mediastinoscopy Negativ predictive value Video-Mediastinoscopy 0,83 Conventional Mediastinoscopy 0,81 Accuracy Video-Mediastinoscopy 87,9% Conventional Mediastinoscopy 83,8% Conclusion: Advantage of Video-Mediastinoscopy Standardisation of the technique Leschber G et al. Eur J Cardiothorac Surg 2008; 33:289
Video-Mediastinoscopy VAMLA
VAMLA by Hürtgen Video-assisted mediastinal lymphadenectomy Dissection of all mediastinal structures trachea, main bronchi, pulmonary artery, vena azygos, superior vena cava, esophagus Complete lymphadenectomy en bloc resection of station 7, 4 R+L, 3, (station 8) Hürtgen M et al. Eur J Cardiothorac Surg 2002;21:348-51
VAMLA - Indication Exact mediastinal staging Prior to VATS lobectomy (two-step-procedure: no frozen section of lymph nodes in Germany) Advantage: Complete resection of stat. 7 is easy by VAMLA En-bloc resection of stat. 4 R and 7 by VAMLA saves time during VATSlobectomy
VAMLA - Results n = 226 staging: 144 diagnostic: 82 Operative time: 54 min Complication: 4.0% (beginning 5.3%, later 2.6%) False-negative rate: 0.9%, Sensitivity: 93.8% VAMLA replaces conventional mediastinoscopy because of better pretherapeutic staging Witte B et al. Ann Thorac Surg 2006;82: 1821
Thoracoscopy (VATS) Tissue confirmation Biopsy of tumor (or resection) Biopsy of lymph nodes (hilar, mediastinal) T-status (chest wall/mediastinal infiltration) N-status M-status (pleural involvement) Resectability Intervention Howington JA. Semin Thorac Cardiovasc Surg 2007; 19:212-16
Thoracoscopy (VATS) Routine VATS as first step of the planned resection for lung cancer N = 1306 (1991-2007) 4.4% unsuspected causes of inoperability (pleural carcinosis, mediastinal infiltration, infiltration of artery in the fissure) 34.4% Thoracoscopic resections (lobectomy, pneumonectomy, wedge) 61.2% Conventional resections (lobectomy, pneumonectomy, wedge) Result: 38.4% spared thoracotomies Vergani C et al. J Thorac Cardiovasc Surg 2009; 138:1206-12
Thoracoscopy (VATS) Intervention: Resection Pleurodesis Pericardial window
Conclusion (Video-)Mediastinoscopy remains Goldstandard for staging of the mediastinum Standardisation of lymphadenectomy by Video-Mediastinoscopy VAMLA is a further devellopment of Video-Mediastinoscopy VAMLA as a precondition for VATS-lobectomy Thoracoscopy for TNM-Status Thoracoscopy for staging AND intervention