TECHNIQUE OF PLEURAL PNEUMONECTOMY IN DIFFUSE MESOTHELIOMA

TECHNIQUE OF PLEURAL PNEUMONECTOMY IN DIFFUSE MESOTHELIOMA GENERAL THORACIC SURGERY CHAPTER 66 Extrapleural pneumonectomy • Improvement in operative mortality since 1970（30% to 6%）. • Patient selection, preoperative preparation, intraoperative management, postoperative care with this extremely complex disease. Staging • Use the Butchart staging system— Surgical resection only appropriate for stage I disease. • Brigham stage I and II as potentially respectable. Table 66-2. Patient selection • Karnofsky performance status higher than 70. • Normal liver and liver function, • ABG – Room air PCO2 less than 45 mmHg, PO2 more than 65 mmHg. • Lung function and ventilation–perfusion scan normal. • Echocardiography, CT and MRI– For determine the presence of transdiaphragmatic extention or mediastinal invasion. Technique of right side extrapleural pneumonectomy • Before thoracotomy, limited subcostal incision– Explore the possible transdiaphragmatic involvement. (May laparoscopic exploration). If peritoneal invasion, the thoracotomy should be terminated. • Left lateral decubitus position, extended right posterolateral thoracotomy, • N.G. tube. Technique of right side extrapleural pneumonectomy • Sixth ribs is excised. • Widely based extrapleural blunt and sharp dissection. • Superiorly toward the apex and anterior component. • Posterior latterly after adequate exposure of anterior side which can provide safe view of mediastinal structure. Technique of right side extrapleural pneumonectomy • Brachial triangle is exposed carefully– To avoid avulsion of subclavian artery and vein • Protected internal mammary artery. • Open pericardium with resection posterior to hilum. • Diaphragm is dissected off the peritoneum by blunt dissection using sponge stick. Technique of right side extrapleural pneumonectomy • Ligated the right main pulmonary artery, superior and interior pulmonary vein, right main stem bronchus. • Pericardial fat-pad– Cover the cutting end of bronchus. • Radical lymph node dissection. • Right side pericardium is reconstructed by prothetic patch to prevent cardiac herniation. • Diaphragm reconstructed by prosthetic impermeable patch. Technique of left side extrapleural pneumonectomy • Dissection is less difficult. • Dissection the posteromedial aspect – Should entering correct plane in preaortic region – To prevent avulsion intercostals vessels. • Assessment of aorta is critical step on left side pleuropneumonectomy. • Protect esophagus. • Pericardium is NOT routinely reconstructed– Because of risk of cardiac herniation is low. Technique of extrapleural pneumonectomy • Hemostasis— Intra-operative blood loss 750 for right side and 500 for left side. • Use argon beam coagulator and electrocautery for the numerous small vessels in extrapleural plane. Postoperative management • Control pain. • Minimize intravascular volume change（1L, 24hour fluid restriction for 3-5 days）. • DVT prophylaxis. • Bed rest 48 hours– To facilitate mediastinal stability. Result • Mortality 3.8% （1999）. • 2-year survival – 38%. • 5-year survival – 15%.