Lung Cancer Resection on Cardiopulmonary Bypass. Daniel J. Boffa, MD Yale University

Lung Cancer Resection on Cardiopulmonary Bypass Daniel J. Boffa, MD Yale University

None related to talk Disclosures

Disclaimers I love operating on CPB

Disclaimers I love operating on CPB I avoid it for lung CA

Disclaimers I love operating on CPB I avoid it for lung CA Pretty Average Practice

Mei J Surg Onc 2012

Could vs Should Mei J Surg Onc 2012

High Risk Surgery is Reasonable

High Risk Surgery is Reasonable Surgery of Unclear Benefit is Reasonable

High Risk Surgery is Reasonable Surgery of Unclear Benefit is Reasonable Don t do them in the same patient

Is tumor Driver of Demise

Is tumor Driver of Demise Tumor = lethal if not removed

Driver of Demise Tumor = lethal if not removed Nothing else more rapidly lethal Systemic disease Medical comorbidities

6 months after Metastasectomy

Patient Selection Complete Staging Metastatic Survey (PET and Brain MRI) Mediastinum (Invasive)* Local invasion (not very accurate)

Patient Selection Complete Staging Metastatic Survey (PET and Brain MRI) Mediastinum (Invasive)* Local invasion (not very accurate) Medical Evaluation Global Cardiac

Pump Effects

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

Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao 17 71 7 80 La Francesca 21 57 5 52 Brutel 79 66 6 42 Voets 24 83 21 25 Miller 30 77 7 35

Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao 17 71 7 80 La Francesca 21 57 5 52 Brutel 79 66 6 42 Voets 24 83 21 25 Miller 30 77 7 35 Average 71 8 44

Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao 17 71 7 80 La Francesca 21 57 5 52 Brutel 79 66 6 42 Voets 24 83 21 25 Miller 30 77 7 35 Average 71 8 44 Relatively Safe

Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao 17 71 7 80 La Francesca 21 57 5 52 Brutel 79 66 6 42 Voets 24 83 21 25 Miller 30 77 7 35 Average 71 8 44

Open Heart Surg and Lung CA N % Stage I % Op Mort % 5 Yr Survival Rao 17 71 7 80 La Francesca 21 57 5 52 Brutel 79 66 6 42 Voets 24 83 21 25 Miller 30 77 7 35 Average 71 8 44 Not Great.71% stage I

Pump Effect Cancer Dissemination? Sicker Patients?

Timing of CPB and Lobectomy Lobectomy then CPB Brutel de la Riviere EJCTS 1995

Stage I: Combined versus Staged Staged (N=6) Combined (N=23) Miller, ATS 1994

Toronto: 86% on CPB or After Rao et al Annals Thor Surg1996

Summary Open Heart and Lung Ca Reasonably Safe Suggestion of a compromise in survival with CPB Severely confounded by comorbidity

Cardiopulmonary Bypass for Lung resection Invasion of heart or great vessels Central Airway tumor

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

Mei J Surg Onc 2012

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

Bajwa Operative Tech Thor and CV Surg 2010

Outcomes of CPB for Lung CA Systematic Review 1990 2010 72 patients (20 manuscripts) 84% were stage IIIB (T4 status) Operative mortality 30 day = 0% 90 day = 1% Muralidaran JTCVS 2011

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

Outcomes 100 % Alive 80 60 40 20 Muralidaran JTCVS 2011 1 2 3 4 5 Years

Outcomes % Alive 100 80 60 40 20 37% survival at 5y Muralidaran JTCVS 2011 1 2 3 4 5 Years

Outcomes 100 % Alive 80 60 40 20 Survival for IIIB Muralidaran JTCVS 2011 1 2 3 4 5 Years

Multivariable Analysis Organ Resected (Ao vs other) HR [95% CI] P 1.11 [.034-3.67].86 Planned.28 [.09-.90].03 >2004.58 [.23 1.45].24 Muralidaran JTCVS 2011

Driver of Demise Slippery Slope

- Esophagectomy - Left atrial reconstruction - Left lower lobectomy - Decortication - Muscle flap or window

Intra-operative Misadventures

Opportunity for On Pump Surgery

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

Productive Reaction Damage Control Moves Communicate Issue Inform Anesthesiologist Second circulator and scrub Second surgeon Pump Cell saver Blood Bank Heparin

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

Exposure Open if VATS Add Sternotomy (convert to hemiclamshell) Enlarge thoracotomy

Outcomes Unplanned Muralidaran JTCVS 2011

Ways to avoid CPB Optimal incisions Intrapericardial mobilization Off pump retraction devices to elevate heart Ventilation strategies for tracheal resection

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

Cases done without SVC replacement Left atrial resection Right atrial resection Descending Aorta

Pericardium

VERY easy to encircle main Pulmonary Artery

VERY easy to encircle main Pulmonary Artery Clamp Trial before staple

Good case for pump standby

Prepare Access Prep groin Femoral Arterial Line Femoral cordis Do in pump-ready room Pump experienced scrub team

Jones, D Oper Tech Thor CV Surg 2009

Need to Plan for Arch of Azygous

Too much left atrial involvement

Banki Oper Tech Thor CV Surg 2007

- Vigilant Suctioning, blood aspiration - Fire Risk from 100% FiO2 Banki Oper Tech Thor CV Surg 2007

Banki Oper Tech Thor CV Surg 2007

Summary CPB and lung cancer surgery is safe Reasonable Survival in highly select patients driver of their demise Many ways to avoid pump