The Use of Cardiopulmonary Bypass During Resection of Locally Advanced Thoracic Malignancies

Is extended resection for locally advanced thoracic cancer with cardiopulmonary bypass justified?

BACKGROUND

Resection of intrathoracic tumor with cardiopulmonary bypass (CPB) remains a relatively under-reported intervention in literature, and its role in managing locally advanced mediastinal and lung cancers is a topic of ongoing debate. Our aim was to review our experience and assess the role of CPB for treating locally advanced mediastinal and lung cancers.

METHODS

Between 2015 and 2020, this study initially included 10 patients with primary locally advanced thoracic malignancies with apparent adjacent cardiovascular invasion demonstrated by thoracic imaging scans. Operation was performed based on a multidisciplinary tumor board consensus. Eventually, 8 patients (3 primary lung cancers and 5 mediastinal cancers) received either salvage or elective resection with CPB; two completed surgery without requiring CPB.

RESULTS

Regarding the extent of adjacent structure involvement, 4 patients presented with involvement of the superior vena cava (SVC), 1 involved the right atrium (RA), 2 involved the SVC and RA, and 1 involved the SVC, the origin of main pulmonary artery, and the ascending aorta. Thirty-day mortality occurred in two of three patients receiving salvage surgery due to respiratory insufficiency. With the long-term follow-up, one patient died of recurrence 25 months postoperatively, one survived with recurrence 30 months postoperatively, and four were alive without recurrence for 35, 36, 49, and 107 months after operations.

CONCLUSION

In certain patients, particularly for elective surgical candidates rather than salvage resection, CPB allows for extended resection of locally advanced thoracic cancers with acceptable perioperative safety and survival.

Simultaneous surgical management of malignancy and coronary heart disease

Coronary heart disease and cancer are the most common causes of mortality across the globe. It has been a dilemma for the surgical team to decide which surgical procedure should be done first when a patient needs surgery for both. This is a single-center retrospective observational study. Six patients who underwent simultaneous coronary artery bypass graft (CABG) and oncological surgeries between January 2018 and July 2021 were included in the study. One patient underwent lung bilobectomy via the same sternotomy incision; one underwent surgery for breast cancer, stomach cancer, and colon cancer; and one patient each of buccal mucosa carcinoma and tongue carcinoma. The median age was 65 years (59-70). Median blood loss was 550 ml (400-800). The median intensive care unit (ICU) stay was 60 h (46-130) and hospital stay was 7.5 days (6-14). The median follow-up of the present study was 31.5 months (6-38). One patient with lung carcinoma developed recurrence after 6 months and the patient is in remission after a follow-up of 32 months. Simultaneous CABG and oncological resection can be performed effectively and safely by an experienced team of cardiothoracic surgeons, surgical oncologists, and anesthetists after good patient selection.

Algorithm for airway management in benign intra-tracheal lesions

The authors have conducted a retrospective analysis based on two cases of patients with intra-tracheal pathologies who received treatment from the same surgeon at a tertiary referral center. The effective management of airways in patients with intra-tracheal lesions necessitates close collaboration between surgeons and anesthesiologists. Factors such as the size, location, rigidity of the tumor, and the remaining tracheal lumen space should be carefully considered. In situations where there is near complete obstruction of the trachea and a substantial risk of worsened respiratory function, resorting to cardiopulmonary bypass or extracorporeal membrane oxygenation is advisable. This pilot study aims at devising an algorithm for the airway management of intra-tracheal lesions, although a larger case cohort is needed to assess its applicability and effectiveness.

Extracorporeal membrane oxygenation support in oncological thoracic surgery

The use of extracorporeal lung support (ECLS) during thoracic surgery is a recent concept that has been gaining increasing approval. Firstly introduced for lung transplantation, this technique is now increasingly adopted also in oncological thoracic surgical procedures. In this review, we focus on the cutting-edge application of extracorporeal membrane oxygenation (ECMO) during oncological thoracic surgery. Therefore, we report the most common surgical procedures in oncological thoracic surgery that can benefit from the use of ECMO. They will be classified and discussed according to the aim of ECMO application. In particular, the use of ECMO is usually limited to certain lung surgery procedures that can be resumed such as in procedures in which an adequate ventilation is not possible such as in single lung patients, procedures where conventional ventilation can cause conflict with the surgical field such as tracheal or carinal surgery, and conventional procedures requiring both ventilators and hemodynamic support. So far, all available evidence comes from centers with large experience in ECMO and major thoracic surgery procedures.

Cardiopulmonary bypass does not consequentially contribute to postoperative distant metastasis of giant refractory thoracic tumors: A retrospective study with long-term follow-up

Background

Few clinical research studies with long‐term follow‐up have revealed whether cardiopulmonary bypass (CPB) increases the risk of postoperative distant metastasis in patients with giant refractory thoracic tumors. The present study evaluated the risk of distant metastasis after surgery utilizing CPB with long‐term follow‐up.

Methods

Clinical data for patients with giant refractory thoracic tumors who underwent resection with the use of CPB in the Second Affiliated Hospital of Soochow University during the past 11 years were retrospectively reviewed.

Results

Of the 14 patients with giant refractory thoracic tumors who had undergone surgery under CPB, 10 patients (71.4%) were completely resected. Twelve patients were followed up for 13–127 months with 10 patients were completely resected and two patients could not be completely resected due to severe tissue invasion. Three patients (25%) suffered from distant metastasis, and four patients (33.3%) experienced local recurrence. Only one patient (1/10) with complete resection suffered from distant metastasis, while two patients (2/10) experienced local recurrence. Two patients (2/2) with major resection suffered from both distant metastasis and local recurrence. Median overall survival for patients who have been regularly followed up was 50 months with 1‐, 5‐, and 10‐year survival of 100%, 75%, and 66.7%. No difference was found between the distant metastasis survival and the local recurrence survival. (p = 0.99).

Conclusions

CPB is an effective strategy for complete resection of the giant refractory thoracic tumors with an acceptable risk of postoperative distant metastasis for some patients.

Multivariate Analysis of Risk Factor for Mortality and Feasibility of Extracorporeal Membrane Oxygenation in High-Risk Thoracic Surgery

Background: Extracorporeal membrane oxygenation (ECMO) as intraoperative cardiorespiratory support during lung transplantation is well known, but use for other types of surgery are limited. To assess risk factor for mortality after high-risk thoracic surgery and feasibility of ECMO, we reviewed.

Methods: This study was an observational study. Between January 2011 and October 2018, 63 patients underwent thoracic surgery with ECMO for severe airway disease, pulmonary insufficiency requiring lung surgery, and other conditions.

Results: In all, 46 patients remained alive at 30 days after surgery. The mean patient age was 50.38 ± 16.16 years. ECMO was most commonly used to prevent a lethal event (34 [73.9%]) in the Survival (S) group and rescue intervention (13 [76.5%]) in the Non-survival (N) group. In all, 11 patients experienced arrest during surgery (S vs N: 2 [4.3%] vs 9 [52.9%], p ≤0.001). The multivariate analysis revealed that arrest during surgery (odds ratio [OR], 24.44; 95% confidence interval [CI], 1.82–327.60; p = 0.016) and age (OR, 7.47; 95% CI, 1.17–47.85; p = 0.034) were independently associated with mortality.

Conclusions: ECMO provides a safe environment during thoracic surgery, and its complication rate is acceptable except for extracorporeal cardiopulmonary resuscitation (ECPR).

Strategy for initial en bloc resection of a giant mediastinal solitary fibrous tumor: Judicious usage of cardiopulmonary bypass

A solitary fibrous tumor (SFT) is a rare mediastinal neoplasm associated with a high recurrence rate. Total excision on initial surgery is an established indicator of a positive outcome. Here, we report the case of a 52-year-old man who was admitted to our hospital with symptoms of cough, chest pain, and dyspnea for two months. Chest computed tomography (CT) scan revealed a middle mediastinal mass which infiltrated adjacent vital structures, and surgery was performed with the assistance of cardiopulmonary bypass (CPB) and median sternotomy. The mass was completely removed and histopathology confirmed the presence of a mesenchymal tumor. The patient had an uneventful recovery without any perioperative symptoms, hoarseness, or dysfunction of the diaphragm. Sixty-nine months after surgery, a CT scan confirmed that the patient remained disease-free without necessitating the introduction of chemotherapy or radiotherapy. Here, to the best of our knowledge, we report the first case of a giant invasive mediastinal SFT that was completely resected during initial surgery under CPB with a remarkable outcome.

Use of Extracorporeal Membrane Oxygenation for Major Cardiopulmonary Resections

BACKGROUND

In thoracic surgery, utilization of extracorporeal membrane oxygenation (ECMO) is mainly established for patients undergoing lung transplantation. The aim of our study was to summarize our single-center experience with intraoperative use of veno-venous- or veno-arterial-ECMO in patients undergoing complex lung surgery involving the main carina, or the left atrium or the descending aorta.

METHODS

A total of 24 patients underwent combined complex lung, carinal, aortal, or left atrial resections. In cases of carinal resection, percutaneous veno-venous, jugular-femoral cannulation was considered suitable. For combined resection of lung and descending aorta, a percutaneous femoral veno-arterial cannulation was used. In cases of extended left atrial resection, a percutaneous jugular-femoral veno-venous-arterial cannulation was favored.

RESULTS

Procedures were divided into three groups: carinal resections and reconstruction (n = 8), resections of the descending aorta and left lung (n = 7), resections of lung and left atrium (n = 9). No intraoperative complications occurred. Overall 30-day mortality was 25%. A complete resection was achieved in 18 patients. Median survival was 12 months. One- and 5-year survival were 48.1 and 22.7%, respectively.

CONCLUSION

The present study shows that intraoperative use of ECMO for extended carinal, aortic, or atrial resections is feasible with minimal intraoperative complications allowing surgeons increased operating-field safety. Perioperative mortality is high, but this is rather an attribute of local extended disease and patient comorbidities.

Extended resections for the treatment of patients with T4 stage IIIA non-small cell lung cancer (NSCLC) (T4N0-1M0) with or without cardiopulmonary bypass: a 15-year two-center experience

Background

Stage IIIA non-small cell lung cancer (NSCLC) is a heterogeneous group of patients, often requiring variable and individualized approaches. The dilemma to operate or not frequently arises, since more than 75% of the cases of NSCLC are diagnosed in advanced stages (IIIA). The main objective of this study was to assess whether the benefits outweigh surgical risks for the T₄N_0-1M₀ subgroup.

Methods

Data from 857 patients with locally advanced T4 NSCLC were retrospectively collected from two different institutions, between 2002 and 2017. Clinical data that were retrieved and analyzed, included demographics, comorbidities, surgical details, neoadjuvant or/and adjuvant therapy and postoperative complications.

Results

Twelve patients were in the cardiopulmonary bypass (CPB) group and thirty in the non-CPB. The most common types of lung cancer were squamous cell carcinoma (50.0%) and adenocarcinoma (35.7%). The most frequent invasion of the tumor was seen in main pulmonary artery and the superior vena cava. Significantly more patients of the CPB group underwent pneumonectomy as their primary lung resection (P=0.006). In all patients R0 resection was achieved according to histological reports. The overall 5-year survival was 60%, while the median overall survival was 22.5 months. Analysis revealed that patient age (P=0.027), preoperative chronic obstructive pulmonary disease (COPD) (P=0.001), tumor size (4.0 vs. 6.0 cm) (P=0.001), postoperative respiratory dysfunction (P=0.001) and postoperative atelectasis (P=0.036) are possible independent variables that are significantly correlated with patient outcome.

Conclusions

We suggest that in patients with stage IIIA/T4 NSCLC, complete resection of the T4 tumor, although challenging, can be performed in highly selected patients. Such an approach seems to result in improved long-term survival. More specific studies on this area of NSCLC probably will further enlighten this field, and may result in even better outcomes, as advanced systemic perioperative approaches such as modern chemotherapy, immunotherapy and improvements in radiation therapy have been incorporated in daily practice.

Combined one-stage minimally invasive surgery for primary pulmonary carcinoma and mitral regurgitation

Background

We report the first successful short-term outcome of one-stage minimally invasive surgery (MIS) mitral valve repair and video-assisted thoracoscopic surgery (VATS) lobectomy.

Case presentation

We report the first successful short-term outcome of combined one-stage video-assisted thoracoscopic surgery lobectomy and minimally invasive surgery in a patient with operable primary right upper lobe adenocarcinoma and mitral regurgitation. Post- operative recovery was uneventful, and follow-up at 6 weeks confirmed an excellent surgical and oncologic outcome.

Conclusions

We think one-stage minimally invasive surgery (MIS) cardiac surgery and video-assisted thoracoscopic surgery (VATS) lobectomy would benefit patients with satisfactory cardiac and pulmonary function.

Extracorporeal membrane oxygenation (ECMO) assisted mediastinal tumor resection and superior vena cava replacement are safe and feasible

Background

How to maximally improve the drainage of intracranial and upper body venous and to reduce neurological complications during thoracic tumor‐causedsuperior vena cava replacement are still clinical problems to be solved.

Methods

We have innovatively used the bilateral jugular vein‐left femoral vein ECMO shunting to perform mediastinal tumor resection and superior vena cava replacement in a 50‐year‐old woman.

Results

During the operation, this technique maintained the patient's hemodynamic stability, improved the cerebral oxygen saturation and reduced the cerebral ischemia, hypoxia as well as the neurological complications.

Conclusion

It is indicated for patients with superior vena cava replacement who are unable to perform venous bypass (such as innominate vein to right atrial bypass) or venous shunting (such as differential pressure drainage from internal jugular vein to femoral vein).

Effect of simultaneous surgical treatment of severe coronary artery disease and lung cancer

Objective

The co-incidence of lung cancer and coronary artery disease (CAD) is increasing in patients of advanced age. This study was performed to demonstrate the efficiency and safety of simultaneous coronary artery bypass grafting and lung cancer surgery in a selected group of older patients.

Methods

Twenty patients with severe CAD and coexisting lung cancer underwent simultaneous surgical interventions (Group A), and 20 patients with lung cancer underwent an isolated lung cancer operation (Group B). In Group A, the combined operations were carried out through 2 incisions in 3 patients, a single incision in 14 patients, and median sternotomy for heart surgery and thoracoscopic lobectomy for lung cancer in 3 patients. The single-incision approach was used in all patients in Group B.

Results

The operation time was longer and the blood loss volume was larger in Group A than B. No significant between-group differences were found in the 5-year relapse-free survival rate or 5-year survival rate.

Conclusions

The simultaneous performance of lung cancer surgery and cardiac surgery was effective and evidently safe in Group A. This treatment approach enabled earlier lung cancer resection and avoidance of the eventual complications associated with further surgical procedures.

Early and mid-term outcomes of simultaneous thoracic endovascular stent grafting and combined resection of thoracic malignancies and the aortic wall

Objectives

To aim of this study was to clarify the safety of simultaneous thoracic aortic endografting and combined resection of the aortic wall and thoracic malignancy in a one-stage procedure over the early and mid-term periods.

Methods

From March 2013 to December 2017, 6 patients underwent aortic endografting followed by one-stage en bloc resection of the tumor and aortic wall. Thoracic surgeons and cardiovascular surgeons discussed predicted tumor invasion range and resection site, stent placement position, stent length and size, and the surgical procedure, taking into account the safe margin.

Results

The proximal site of aortic endografting was the: aortic arch in 2 cases (subclavian artery (SCA) occlusion in one, and SCA fenestration in one); distal arch just beneath the SCA in 2; descending aorta in 2. Pulmonary resection involved lobectomy in 2 patients, pneumonectomy in 2, and completion pneumonectomy in 1. Aortic resection was limited to the adventitia in 2 cases, extended to the media in 3, and extended to the intima in 1. An endograft-related complication, external iliac artery intimal damage requiring vessel repair, was observed in one case. No complications associated with aortic resection were observed. Two postoperative complications of atrial fibrillation and chylothorax developed. There were no surgery-related deaths. During follow-up, no late endograft-related complications such as migration or endoleaks occurred.

Conclusions

Early and mid-term outcomes of stent graft-related complications are acceptable. Simultaneous thoracic aortic endografting and combined resection of the aortic wall and thoracic malignancies are feasible in one stage on the same day.

Largest known malignant solitary fibrous tumour of the pleura-extended resection warranting cardiopulmonary bypass support

This case reports the largest known malignant solitary fibrous tumour of the pleura treated with en bloc surgical resection warranting the use of cardiopulmonary bypass support. A 60-year-old male presented with dyspnoea and a dry cough. Following extensive investigations, a radiological and histologic diagnosis of malignant solitary fibrous tumour of the pleura was made. This 4.3 kg tumour occupied the entire left hemithorax, involved the left lung and infiltrated into the pericardial cavity. Although the postoperative course was uneventful with a 12-day length of stay, the patient opted not to undergo adjuvant radiotherapy to a single positive margin site and died 6 months later due to local recurrence.

Possibilities of Combined Surgical Treatment of Lung Tumours and Heart Diseases

The purpose of the study was a retrospective evaluation of the outcome of surgical therapy of lung cancer in patients where there was concomitant cardiac disease and who underwent a cardiac operation either because of ischemic heart disease or because of valvular disease. These patients were operated on at various time intervals (two to ten months) after their cardiac operation. Some patients had their lung cancer surgery after the cardiac operation because of the high risk of possible cardiac postoperative complications; in one patient the lung operation preceded the cardiac one.

Combined Coronary Artery Bypass Graft (CABG) Surgery and Lung Resection for Lung Cancer in Patients More than 50 Years-of-Age

Background

The co-existence of coronary heart disease (CHD) and lung cancer is increasing in an increasingly aging population. The aim of this study was to evaluate patient outcome from combined off-pump coronary artery bypass graft (CABG) surgery and lung resection in patients more than 50 years-of-age.

Material/Methods

A retrospective clinical study of 23 patients with a mean age of 70.2±8.4 years (range, 51–86 years) included 18 men and five women with CHD and lung cancer who underwent a single operation with combined off-pump CABG surgery and lung resection, for non-small cell lung cancer (NSCLC) (n=22) and small cell lung cancer (n=1). Surgical approaches included: median sternotomy in six patients; left lateral thoracotomy in nine patients; a median sternotomy in three patients; median sternotomy combined with thoracoscopic lobectomy in five patients.

Results

In the retrospective study of 23 patients, there were no deaths and no new cases of myocardial infarction (MI) in the immediate perioperative period. During the follow-up period, six patients died from lung cancer metastasis or recurrence; one patient died of acute renal failure; and one patient died from the effects of chemotherapy. The remaining 15 patients underwent postoperative follow-up for between 3–79 months with no deaths and no new cases of MI.

Conclusions

For patients who are more than 50 years-of-age and who have CHD and lung cancer, a single combined operation that includes off-pump CABG and lung resection can be safe and effective.

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.

Extended pneumonectomy for advanced lung cancer with cardiovascular structural invasions

Background

This study aims to investigate the predictive factors in relation to tumor stages, mediastinal involvements, perioperative adjuvant therapies and surgical techniques in advanced lung cancer patients who underwent extended pneumonectomy with cardiovascular structural resection.

Methods

A comprehensive literature review was performed for extended pneumonectomies with cardiovascular structural resections in the PubMed, Google Scholar and HighWire Press for the year range 2000-2016. Data were carefully extracted regarding details such as the study population, demographics, clinical features, types of lung cancer, pathologic stages, nodal involvement, extent of pneumonectomy, cardiovascular structural resections, use of cardiopulmonary bypass, completeness of resection, pre- and postoperative adjuvant therapies, 1-5-year survival, median survival duration, comorbidity and mortality.

Results

Patients undergoing extended pneumonectomy with cardiovascular structural resection were characterized more by squamous carcinomas, N0 or N1, T4, stage 3 and left atrial invasions. More patients received postoperative radiochemotherapy than radioor chemotherapy. The five-year survival rate was 30.5±11.5% and the median survival duration was 23.0±10.7 months. Level 1 left atrial, aortic adventitial, and partial superior vena cava resections could be performed without cardiopulmonary bypass, while levels 2 and 3 left atrial resections with aorta or superior/inferior vena cava replacement should be performed under cardiopulmonary bypass.

Conclusion

The advent of cardiopulmonary bypass facilitated complete resection of lung cancer, while leading to potential risks of metastasis and reoccurrence. Pathological status, surgical techniques and pre- and postoperative adjuvant therapies affect survival significantly. Surgical indications and negative predictive risk factors for patients' survival warrant further evaluations.

Principles and indications of extracorporeal life support in general thoracic surgery

The role of extracorporeal life support (ECLS) has expanded rapidly over the past 15 years to become an important tool in advanced general thoracic surgery practice. Intra-operative and in some cases continued post-operative ECLS is redefining the scope of complex surgical care. ECLS encompasses a spectrum of temporary mechanical support that may remove CO₂, oxygenate or provide hemodynamic support or a combination thereof. The most common modalities used in general thoracic surgery include extracorporeal membrane oxygenation (ECMO), interventional lung assist device (iLA^® Novalung^®, Heilbronn, Germany), and extracorporeal CO₂ removal (ECCO₂R). The ECMO and Novalung^® devices can be used in different modes for the short term or long-term support depending on the situation. In this review, the principles and current applications of ECLS in general thoracic surgery are presented.

Superior vena cava clamping during thoracic surgery: Implications for the anesthesiologist

Resection and reconstruction of the SVC is a challenging Intraoperative situation owing to the potential complications after clamping a patent vessel. Hemodynamic imbalance and neurological effects of SVC clamping can be life threatening. These complications can be prevented by careful intraoperative monitoring and management. Anaesthesiologist must be aware of different options to manage such challenging situations.

Care of the Postoperative Pulmonary Resection Patient

Patients undergoing pulmonary resection all exhibit, to some degree, a level of pulmonary dysfunction. This is due to the physiologic stress of the procedure performed, the patient’s comorbidities, and preexisting cardiopulmonary reserve. Although prognostic factors for intensive care requirement exist, to date, there is no consensus for postoperative admission. Institutional practices vary across the country, with patients often admitted to intensive care for surveillance. Guidelines published from the American Thoracic Society in 1999 emphasize that admission to the ICU be reserved for those patients requiring care and monitoring for severe physiologic instability. Admissions following pulmonary resection are typically due to respiratory complications and are an independent predictor of mortality. The following chapter will review the indications for admission to the ICU and common issues encountered following pulmonary resection and conclude with a discussion of the management of patients undergoing pulmonary transplantation.

Acute, unanticipated, and prolonged superior vena cava occlusion during pneumonectomy

Acute, unanticipated superior vena cava (SVC) occlusion during thoracic surgery can have profound hemodynamic consequences and lead to devastating neurologic injury. We describe the successful anesthetic management of a pneumonectomy complicated by prolonged intraoperative SVC occlusion lasting a total of 290 minutes. To our knowledge, this represents the longest reported SVC occlusion time with no subsequent neurologic sequelae. Based on our favorable outcome and a review of the relevant literature, we offer a discussion of strategies for anesthetic management.

Fiberoptic bronchoscopy-assisted endotracheal intubation in a patient with a large tracheal tumor

In the event of a high degree of airway obstruction, endotracheal intubation can be impossible and even dangerous, because it can cause complete airway obstruction, especially in patients with high tracheal lesions. However, a smaller endotracheal tube under the guidance of a bronchoscope can be insinuated past obstructive tumor in most noncircumferential cases. Here we report a case of successful fiberoptic bronchoscopy-assisted endotracheal intubation in a patient undergoing surgical resection of a large, high tracheal tumor causing severe tracheal stenosis. A 42-year-old Chinese man presented with dyspnea, intermittent irritable cough, and sleep deprivation for one and a half years. X-rays and computed tomography scan of the chest revealed an irregular pedunculated soft tissue mass within the tracheal lumen. The mass occupied over 90% of the lumen and caused severe tracheal stenosis. Endotracheal intubation was done to perform tracheal tumor resection under general anesthesia. After several failed conventional endotracheal intubation attempts, fiberoptic bronchoscopy-assisted intubation was successful. The patient received mechanical ventilation and then underwent tumor resection and a permanent tracheostomy. This case provides evidence of the usefulness of the fiberoptic bronchoscopy-assisted intubation technique in management of an anticipated difficult airway and suggests that tracheal intubation can be performed directly in patients with a tracheal tumor who can sleep in the supine position, even if they have occasional sleep deprivation and severe tracheal obstruction as revealed by imaging techniques.

Extension of Pulmonary Adenocarcinoma into the Left Atrium

A 62-year-old man presented with pulmonary adenocarcinoma that penetrated through the pulmonary vein into the left atrium. The tumor in the left atrium was removed via a right lower lobectomy under cardiopulmonary bypass. In selected cases, radical removal of a tumor in patients without mediastinal lymph node involvement may improve the prognosis. The use of cardiopulmonary bypass extends the possibilities of radical tumor removal.

Outcomes After Resection of T4 Non-Small Cell Lung Cancer Using Cardiopulmonary Bypass

BACKGROUND

Complete, en bloc resection offers the greatest chance of long-term survival in T4 non-small cell lung cancer (NSCLC). The use of cardiopulmonary bypass (CPB) to achieve an en bloc resection is controversial because of potentially increased bleeding, lung dysfunction, and tumor dissemination. We reviewed our institutional experience to assess CPB's effect on survival.

METHODS

All patients who underwent resection for T4 NSCLC at our institution between 1980 and 2013 were retrospectively reviewed and stratified according to whether they did (CPB group, n = 20) or did not (No CPB group, n = 355) undergo CPB. Primary outcomes of interest were overall and disease-free survival and perioperative complications.

RESULTS

Baseline characteristics and medical therapy were similar between the groups. Median overall survival for all patients was 31 months, with 1-, 3-, 5-, and 10-year survival of 73%, 47%, 40%, and 26%, respectively. Median disease-free survival for all patients was 19 months, with 1-, 3-, 5-, and 10-year disease-free survival of 61%, 40%, 33%, and 21%, respectively. No difference was found in overall or disease-free survival at 1, 3, 5, and 10 years between the No CPB and CPB groups (p = 0.89 and p = 0.88). In addition, no differences were found in the rates of major perioperative complications.

CONCLUSIONS

The use of CPB allows for complete, en bloc resection in otherwise inoperable patients with T4 NSCLC and offers similar overall and disease-free survival to patients resected without CPB. All thoracic surgeons who manage T4 NSCLC should consider the use of CPB if it is necessary to achieve a complete, en bloc resection.

Lung cancer mimicking aortic dissecting aneurysm in a patient with situs inversus totalis

Lung cancer and situs inversus totalis are two completely irrelevant conditions. The likelihood of both conditions occurring simultaneously in one person is very rare. We report here a case of a 50‐year‐old man who presented with intermittent chest pain. Enhanced computed tomography of the chest showed situs inversus totalis and a round mediastinal mass embracing the thoracic aorta. The primary diagnosis was suggested as pseudo aortic dissecting aneurysm. However, a tumor in the right lower lung was discovered during surgery, which enclosed and invaded the thoracic aorta. Finally, the patient successfully underwent right lower lobectomy accompanied by lymph node excision and partial replacement of the thoracic aorta with an artificial vascular graft under cardio‐pulmonary bypass.

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.

Extracorporeal support for pulmonary resection: current indications and results

Extracorporeal assistances are exponentially used for patients, with acute severe but reversible heart or lung failure, to provide more prolonged support to bridge patients to heart and/or lung transplantation. However, experience of use of extracorporeal assistance for pulmonary resection is limited outside lung transplantation. Airways management with standard mechanical ventilation system may be challenging particularly in case of anatomical reasons (single lung), presence of respiratory failure (ARDS), or complex tracheo-bronchial resection and reconstruction. Based on the growing experience during lung transplantation, more and more surgeons are now using such devices to achieve good oxygenation and hemodynamic support during such challenging cases. We review the different extracorporeal device and attempt to clarify the current practice and indications of extracorporeal support during pulmonary resection.

Resection of thoracic malignancies infiltrating cardiac structures with use of cardiopulmonary bypass

Background

Only few reports exist on malignant thoracic neoplasms that require cardiopulmonary bypass during resection. We aimed to investigate the early and late clinical outcome of these patients.

Methods

Patients with thoracic malignancies that underwent surgery between 2002 and 2014 were analyzed. All patients had cardiopulomonary bypass support during resection. Clinical and perioperative data was retrospectively reviewed for outcome and overall survival.

Results

Fifteen patients (12 female, mean age of 55 ± 15 years, range 24 to 80 years) were identified. Eleven (8 female) were diagnosed with primary thoracic malignomas and four with metastases. Three patients died early postoperatively. Patients diagnosed with sarcoma had a significantly worse outcome than non-sarcoma patients (83.3 ± 15.2 % after 1 year, 31.3 ± 24.5 % after 5 years vs. 83.3 ± 15.2 % after 1 year, 0 ± 0 % after 5 years, p = 0.005).

Conclusions

Malignancies with extension into cardiac structures or infiltration of great vessels can be resected with cardiopulmonary bypass support and tolerable risk. Carefully selected patients can undergo advanced operative procedures with an acceptable 1-year-survival, but only few patients achieved good long-term outcome.

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.

Cryopreserved arterial allograft reconstruction after excision of thoracic malignancies

BACKGROUND

The purpose of this study was to evaluate the long-term clinical and immunologic outcome of cryopreserved arterial allograft (CAA) revascularization of intrathoracic vessels invaded by malignancies.

METHODS

Since January 2002, consecutive patients whose intrathoracic vessels were invaded by malignancies were operated on and revascularizion made using human lymphocyte antigen (HLA)- and ABO-mismatched CAAs. Immunologic studies were performed preoperatively, and 1, 3, 6, 12, and 24 months postoperatively. Postoperative oral anticoagulation therapy was not given.

RESULTS

Twenty-six patients aged 53.1 +/- 15 years with a nonsmall-cell lung cancer (n = 10), invasive mediastinal tumors (n = 7), pulmonary artery sarcoma (n = 3), laryngeal (n = 2), or other rare lung neoplasms (n = 4) underwent operation. Cardiopulmonary bypass was used in 10 cases (38%), and all resections were pathologically complete. Revascularization was either for venous (n = 12) or arterial (n = 14) vessels, and a total of 30 allografts revascularized the superior vena cava (n = 6), pulmonary artery (n = 7), innominate vein (n = 3) or artery (n = 2), ascendent (n = 4) or descending (n = 1) aorta, and subclavian vein (n = 3) or artery (n = 4). Hospital morbidity and mortality were 50% (n = 13) and 3.8% (n = 1), respectively, all CAA unrelated. With a median follow-up of 18 months (range, 3 to 60+), 5-year survival and allograft patency were 84% and 95%, respectively. Preoperative anti-HLA antibodies were detected in 2 patients (7.7%) and a postoperative anti-HLA antibody response, clinically irrelevant, in 1 of 24 patients (4%).

CONCLUSIONS

Revascularization of intrathoracic venous and arterial vessels in patients with malignancies using HLA- and ABO-mismatched CAA is technically feasible and clinically attractive because of no infection risk and postoperative anticoagulation, and excellent long-term survival, patency, and nonimmunogeneicity.

Cardiopulmonary bypass as an adjunct for the noncardiac surgeon

The use of cardiopulmonary bypass (CPB) in noncardiac surgical settings has been increasingly developed and has greatly benefited noncardiac surgeon. A few years after the advent of CPB as well as profound hypothermic circulatory arrest in the early years, it was employed by neurosurgeons in cerebrovascular surgery and by general thoracic surgeons in carinal tumor resection. Indications for CPB were extended and modified year after year. It has facilitated not only the surgical management by surgeons of lesions that cannot be managed safely and effectively by conventional techniques, or conventional techniques carry significant risks to the patient, but also the preservation of the viability of multiple organ procurement, the practice of isolated limb perfusion for the treatment of malignancies of the extremities, and emergent cardiopulmonary resuscitation. Owing to the complications arising from CPB and profound hypothermic circulatory arrest, such as postoperative bleeding, coagulopathy, and neurologic deficits, efforts have been made to avoid these common hazards. Thus, innovative techniques including extracorporeal membrane oxygenation, percutaneous cardiopulmonary support, venovenous bypass, normothermic CPB, and minimally invasive approaches have emerged and played an important role as alternatives of standard CPB in decreasing morbidity and mortality and improving survival.

Cardiopulmonary bypass to facilitate excision of a giant pleural tumour

A 55-year-old female developed dyspnoea following an elective hysteroscopy. A chest radiograph demonstrated a tissue density opacity occupying the right hemithorax. A CT scan suggested this was a tumour arising from the postero-lateral chest wall. Surgical resection was attempted; however, mobilisation of the tumour caused significant airway compromise. Cardiopulmonary bypass was used to facilitate oxygenation while the tumour was dissected and removed. Although cardiopulmonary bypass has been used as an adjunct to aid resection of tumours invading major vascular or upper airway structures, in this case CPB was used to aid mobilisation of a giant pleural tumour.

Management of difficult airway in intratracheal tumor surgery

BACKGROUND

Tracheal malignancies are usual victim of delay in diagnosis by virtue of their symptoms resembling asthma. Sometimes delayed diagnosis may lead to almost total airway obstruction. For difficult airways, not leaving any possibility of manipulation into neck region or endoscopic intervention, femorofemoral cardiopulmonary bypass can be a promising approach.

CASE PRESENTATION

We are presenting a case of tracheal adenoid cystic carcinoma (cylindroma) occupying about 90% of the tracheal lumen. It was successfully managed by surgical excision of mass by sternotomy and tracheotomy under femorofemoral cardiopulmonary bypass (CPB).

CONCLUSION

Any patient with recurrent respiratory symptoms should be evaluated by radiological and endoscopic means earlier to avoid delay in diagnosis of such conditions. Femorofemoral cardiopulmonary bypass is a relatively safe way of managing certain airway obstructions.

Resection of Locally Advanced (T4) Non-Small Cell Lung Cancer With Cardiopulmonary Bypass

BACKGROUND

Resection of T4 non-small cell lung cancer (NSCLC) on cardiopulmonary bypass (CPB) has rarely been reported in the literature. Hence, we have reviewed our experience in the role of CPB for the surgical treatment of locally advanced NSCLC.

METHODS

All patients undergoing lung resection for bronchogenic carcinoma on CPB in our institution between January 1998 and June 2004 were reviewed.

RESULTS

Seven patients underwent lung resections on CPB for bronchogenic carcinoma during the study period. Cardiopulmonary bypass was performed for tumors invading the subclavian artery down to the aortic arch (n = 2), the descending aorta (n = 1), or the origin of the left pulmonary artery with the left atrium (n = 2). All patients were discharged home after 9 to 21 days (median, 15 days). In the long term, 2 patients are alive without recurrence 17 and 25 months after their operations, and 3 are alive with recurrence 8, 13, and 54 months postoperatively. Two additional patients required CPB while undergoing carinal resection for difficulty ventilating the left lung. Both patients had a difficult postoperative course, but were eventually discharged from hospital. One patient died without recurrence 6 months later, and the other is alive without recurrence after 72 months.

CONCLUSIONS

This study confirms the safety of CPB for NSCLC invading the great vessels and/or the left atrium in well-selected patients, and its utility when pulmonary edema develops during carinal resection. Further studies, however, are required to confirm long-term survival.