The use of cardiopulmonary bypass during extended resection of non-small cell lung cancer

Cardiopulmonary Bypass in Non-Cardiac Surgery

BACKGROUND

Cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) are used to facilitate circulatory support in standard cardiac surgery and emergency intervention, but CPB and ECMO are not used routinely in non-cardiac surgery involving the thorax and major vessels. The primary aim of this study was to identify the type of non-cardiac procedures and bypass used in our institution and review the patient outcomes including perioperative and bypass complications.

METHODS

A retrospective study was performed within the Royal Adelaide Hospital Cardiothoracic Surgery Unit (CTSU) that examined all operations between 2006 and 2014. There were 1,816 non-cardiac cases, of these nine used CPB or ECMO. Cases excluded from the study were those that required cardiac surgical management with the use of CPB or ECMO.

RESULTS

Twelve (12) non-cardiac surgery cases were reviewed, with three, and nine cases, respectively, using ECMO and CPB standby or support. The non-cardiac surgical procedures included eight thoracic cases, two renal cases and two tracheal cases. Of the thoracic cases, five were elective, two were bailout and one was an emergency. Both renal cases were bailout (with one as major vessel support and one as standby). Both tracheal cases were bailout (one as an emergency and one as standby). Intraoperative complications included severe haemorrhage in three cases. General postoperative complications included increased analgesia requirement, atelectasis, fever; and prolonged ECMO support and ICU stay which occurred in seven cases. No direct complications of CPB or ECMO are reported. Four of the 12 cases that encompassed thoracic, renal and tracheal surgery are discussed in detail.

CONCLUSIONS

Our review of 12 cases managed under the CTSU has shown that extracorporeal circulatory support can be used in a range of thoracic, renal and tracheal surgery. These surgical procedures have involved the management of haemodynamically unstable patients. Patient outcomes have been encouraging with few complications. With further research including the use of a larger sample size and control groups, more definitive conclusions could be made on the benefit of CPB and ECMO to patients in non-cardiac surgery.

[Cardiopulmonary bypass in thoracic surgery]

AIM

To analyze advisability of cardiopulmonary bypass in thoracic surgery.

MATERIAL AND METHODS

We estimated early and long-term results of CPB-assisted thoracic interventions in 31 patients with malignant and benign thoracic diseases and invasion into vital mediastinal structures or with concomitant cardiovascular pathology.

RESULTS

Acceptable rates of mortality and morbidity confirm safety of CPB in thoracic surgery while satisfactory long-term outcomes are arguments in favor of this direction of thoracic oncology.

Circulating Tumor Cell Count Can Be a Useful Prognostic Factor in Lung Resection via Cardiopulmonary Bypass

Tumor resection with cardiopulmonary bypass (CPB) remains controversial in the field of oncology. Here, we present a 57-year-old male patient with locally advanced squamous cell carcinoma. The tumor was located in the left hilum and invaded the left atrium. Complete resection, left pneumonectomy combined with partial left atrium resection, was achieved using CPB. We evaluated the circulating tumor cell (CTC) counts, as a surrogate for micrometastasis, in peripheral blood and the CPB circuit. Both CTC counts were 0, which could indicate local disease without micrometastasis. CTC count may be a useful indicator for tumor resection with CPB in lung cancer.

Cardiopulmonary Bypass and Extracorporeal Life Support for Emergent Intraoperative Thoracic Situations

Intraoperative thoracic surgical catastrophes may require extracorporeal circulation modes to support the patient while the appropriate repair is made. Teamwork is key and, given the evidence supporting better performance with the use of simulation and surgical-crisis checklists, their use should be encouraged. Anticipation is another important factor because the results of intrathoracic malignancy resection are clearly superior in the setting of planned cardiopulmonary support. In addition, familiarity with the different modes of support that are currently available can direct the decision-making process toward the best option to facilitate resolution of the intraoperative catastrophe with the least related morbidity.

Reconstruction of the pulmonary trunk via cardiopulmonary bypass in extended resection of locally advanced lung malignancies

BACKGROUND AND OBJECTIVES

The aim of this retrospective study is to summarize our improvement of surgical procedures for radical resection of left hilar tumors involving the pulmonary trunk and determine its clinical feasibility.

METHODS

From 2001 to 2008, four patients were selected for curative extended resection through multidisciplinary assessment and the pulmonary trunk was reconstructed via cardiopulmonary bypass (CPB). Surgical procedures were performed with posterolateral thoracotomy for two patients and anterolateral thoracotomy for the remaining two. CPB was performed via femoral artery-femoral vein cannulation on one patient and right atrial-aortic cannulation on the other three patients. Polytetrafluoroethylene patch or autologous pericardium was applied for reconstruction in different patients.

RESULTS

The duration of the operations ranged from 300 to 440 min and with CPB lasting 35-106 min. Three patients developed non-specific complications with no mortalities and discharged within 12-17 days. One patient had no evidence of recurrence during 50 months follow-up. Three patients died of metastasis 5, 14, and 35 months after surgery.

CONCLUSIONS

CPB-supported extended resection of lung malignancies involving the pulmonary trunk is feasible. Left anterolateral thoracotomy through the fourth intercostal space with right atrial-aortic cannulation would be the convenient approach. Survival may be prolonged in some selected patients.

Extracorporeal membrane oxygenation support for resection of locally advanced thoracic tumors

BACKGROUND

The international experience with resection of advanced thoracic malignancies performed with extracorporeal membrane oxygenation (ECMO) support is limited. We examined our results to assess the risks and benefits of this approach.

METHODS

We retrospectively analyzed all patients with thoracic malignancies who underwent tumor resection with ECMO support in our department between 2001 and 2010.

RESULTS

Nine patients (aged 21 to 71 years; mean, 54.8±7.5 years) underwent complex tracheobronchial resections (n=6) or resections of greater thoracic vessels (n=3) under venoarterial (VA) ECMO support. In 7 patients the underlying pathologic condition was non-small cell lung cancer, in 1 patient it was carcinoid tumor, and in 1 patient it was synovial sarcoma. The indication for extracorporeal support was complex tracheobronchial reconstruction (n=5), resection of the descending aorta (n=2), and resection of the inferior vena cava (n=1). ECMO cannulation was central (n=4), peripheral (n=4), or combined (n=1). Mean time on bypass was 110±19 minutes (range 40 to 135 minutes). A complete resection (R0) was achieved in 8 patients (89%). One patient died perioperatively as a result of hepatic necrosis. Eight patients were discharged from the hospital after 7 to 42 days (median, 10 days). Median time in the intensive care unit was 1 day (range, 0 to 36 days). The only complication related to the use of ECMO was a lymphatic fistula in the groin. Mean follow-up time was 38±42 months (range, 9 to 111 months). The actuarial 3-month survival was 88.9%, and the 1-year, 3-year, and 5-year survival was 76.7%.

CONCLUSIONS

Based on this experience, we consider VA ECMO support to be a safe alternative to cardiopulmonary bypass (CPB) for advanced general thoracic operations.