vats for thoracic diseases.ppt - bges€¦ · vats for thoracic diseases starters package ‐13 th...

Dr Sokolow Y.Dpt of Thoracic Surgery

Hôpital Académique ErasmeBruxelles

VATS for Thoracic Diseases

Starters Package ‐ 13 th edition ‐ Strasbourg18 th & 19 th February 2013

VATS INDICATIONS Mediastinal indications

Thymic Surgery Posterior neurogenic tumor Intra thoracic Parathyroid surgery VATS Staging in NSCLC (station L5 – L6)

Lung indications Wedge excision (biopsy, bullectomy, metastasectomy) VATS Lobectomy LVRS

Pleural indications Empyema Pleural biopsy

Others Thoracic Sympatectomy (palmar hyperhydrosis) Pectus excavatum (NUSS Technique) Diaphragmatic rupture

ADVANTAGES OF VATS

Reduction of chest wall trauma Reduction of post operative pain Reduction of impairment of pulmonary function Reduction of length of hospital stay Reduction of the time to return to work The overall cost of a VATS mediastinal mass

excision may be less than an open procedure(much of the expensive disposableinstrumentation is not needed for thesesoperations)

Lin, Surg Oncol. 2003; 12: 195-200Demmy, Ann Thorac Surg. 1998; 66: 187-92

VATS for Mediastinal Lesions

ANATOMY

Sukumar. Laryngoscope. 2006; 116: 482-87

VATS INDACTIONS

Posterior Neurogenic Tumors

Mediastinal cysts

Thymic hyperplasia

Thymoma

Intrathoracic parathyroid adenoma

POSTERIOR NEUROGENIC TUMORS

The majority of posterior mediastinal neurogenic tumors are Schwannoma followed by ganglioneuroma and neurofibroma

The frequency of malignant lesions has been reported to be between 4 % and 13 %

VATS is recommended if the tumor is smaller than 7 cm and if there is no radiological signs of malignancy

Cansever. Thorac Cardiov Surg. 2010: 58; 473-5

POSTERIOR NEUROGENIC TUMORS

VATS is the treatment of choice for posterior neurogenic tumors that show no preoperative signs of malignancy and do not involve the medulla spinalis

Cansever. Thorac Cardiov Surg. 2010: 58; 473-5

VATS RESECTIONOF POSTERIORNEUROGENIC

LESION

MEDIASTINAL CYSTS

Types Bronchogenic Cysts (50-60 % of mediastinal cysts)

Pericardic Cysts (30 % of mediastinal cysts)

Thymic Cysts (10-15 % of mediastinal cysts)

Resection is indicated for All symptomatic cysts

Large-sized even asymptomatic (excepted PC)

In case of non-formal diagnosis

Le Pimpec Barthes. Rev Pneumol Clin. 2010; 66:52-62

MEDIASTINAL CYSTS

The only radical and definitive treatment is complete surgical resection of the cyst

VATS is considered as the gold standard approach for mediastinal cysts but : VATS may not always be technically possible,

especially in case of dense pericystic adhesions of the cyst with adjacent structures

a bronchogenic cyst's central location, (ex: aortico pulmonary window) would have made VATS resection hazardous

Le Pimpec Barthes. Rev Pneumol Clin. 2010; 66:52-62Hazelrigg. Ann Thorac Surg. 1993; 56:659.

Ribet. Ann Thorac Surg. 1996; 61:1636

THYMUS – MYASTHENIA GRAVIS

Thymectomy is an effectivetreatment in patients withmyasthenia gravis withequivalent clinical outcomesobtained by VATS or openapproach.

Meyer. Ann Thorac Surg. 2009; 87: 385-91

Independently of the surgical approach,extracapsular resection of the thymus must beperformed, including the mediastinal fattytissue.

THYMUS – MYASTHENIA GRAVIS

VATS was found to be superior with regard to improvement ofmyasthenia gravis associated symptoms. The hospital stay wasshorter, and the patients felt less disturbed by direct effects ofthe operation. Therefore, VATS thymectomy can be regarded asthe treatment of choice for patients undergoing surgery formyasthenia gravis.

Bachmann. Surg Endosc. 2008; 22: 2470-77

THYMUS - THYMOMA

For early stage thymoma (stage I and II), the most significant prognostic factor is completeness of resection

VATS of early stage thymoma appears safe and feasible and is associated with a shorter hospital stay. The oncologic outcomes are comparable in the VATS and open surgery groups.

Davenport. Ann Thorac Surg. 2008; 86: 673-84Pennathur. J Thorac Cardiovasc Surg 2011; 141: 694-701

VATS THYMECTOMYFOR THYMIC HYPERPLASIA

IN CASE OF MYASTHENIA GRAVIS

VATS TECHNICAL ASPECTS

Position of trocars

ECTOPIC MEDIASTINAL PARATHYROID ADENOMAS

Ectopic mediastinal parathyroid adenomas can be found in up to 25 % of patients with primary hyperparathyroidism.

Most of these adenomas are located adjacent to the upper thymus and can be resected by cervical incision.

Less than 2% of these adenomas require a thoracic approach (12,5 % in case of re-operative cases)

Cupisti. Langenbeck’s Arch Surg. 2002; 386: 488-93

Russell. Ann Surg. 1981; 193: 805-9Callender. J Am Coll Surg. 2009; 208: 887-93


Localisation


Tcherveniakov. JCTS. 2007; 2: 41

Videomediastinoscopy


Alesina. World J Surg. 2008;32: 224-31


VATS is actually the gold standard approach for intrathoracic parathyroid adenoma.

(Sternotomy) and thoracotomy should only be used only in case of VATS failure.

VATS is should not be an exploratory procedure. Accurate preoperative anatomic localization of the parathyroid is essential (SPECT/Semstamibi)

Cupisti. Langenbeck’s Arch Surg. 2002; 386: 488-93Alesina. World J Surg. 2008; 32: 224-31

SUMMARY

VATS is considered as the gold standard approach for Mediastinal cysts excepted for some cases of

central or adherent bronchogenic cysts Intrathoracic parathyroid adenoma. Posterior neurogenic tumors that show no

preoperative signs of malignancy and do not involve the medulla spinalis

Thymectomy for Myasthenia Gravis Thymectomy for Stage I (and II) Thymoma

VATS LOBECTOMY

TYPE OF INCISIONS

Koizumi. Ann Thorac Cardiovasc Surg. 2007; 13: 228-35

VATS LOBECTOMY

Earliest reports of VATS lobectomy were

published in the early 1990

Definition of VATS lobectomy is ambiguous

The technique varies in the number of

incisions, degree of rib spreading, and type

of hilar dissection

Flores. Ann Thorac Surg. 2008; 85:S710-15

VATS LOBECTOMYINDICATIONS

Benign disease

Benign tumor

Bronchiectasis

Malignant disease

NSCLC Stage I or II (Intra Lobar)

Metastasis

Carcinoid Tumor

VATS LOBECTOMYTECHNIQUES

Simultaneously stapled (SIS) Lobectomy Endoscopic procedure

Stapled division of fissures

Mass stapled division of lobar hilar structures

Lewis. Ann Thorac Surg. 1993; 56: 762-8


Minithoracotomy Lobectomy Procedure through mini thoracotomy

Thoracoscope used as accessory light source Rib retraction Conventional hilar dissection


Endoscopic hilar dissection

Full endoscopic procedure No rib retraction Individual dissection and stapling of the hilar

structures

VATS SURGERY LOBECTOMY REPORT OF CALGB 39802 : A PROSPECTIVE MULTI INSTITUTION FEASIBILITY STUDY

Swanson. J Clin Oncol. 2007; 25: 4993-7

Within 30 days, 3 (2,7%) of 111patients death occurred

7 (7,4 %) of 95 patients hadgrade 3 or greater complications,with only one case of bleeding

Conclusion : A standardizedapproach to VATS Lobectomywith avoidance of rib spreadingis feasible

NSCLCMANAGEMENT OF MEDIASTINAL LYMPH NODES

Mediastinal lymph node dissection shouldbe performed for all NSCLC patients

At Least 10 Mediastinal lymph nodes fromthree or more stations should be examined

Whitson. ATS. 2007; 84: 1059-65

A PROSPECTIVE TRIAL OF SYSTEMATIC NODAL DISSECTION FOR LUNG CANCER BY VATS: CAN IT BE PERFECT ?

Sagawa. Ann Thorac Surg. 2002; 73: 900-4

SYSTEMATIC NODE DISSECTION BY VATS IS NOT INFERIOR TO THAT THROUGH AN OT : A COMPARATIVE CLINICO PATHOLOGIC RETROSPECTIVE STUDY

Watanabe. Surgery. 2005; 135: 510-7

VATS LOBECTOMYINTRAOPERATIVE COMPLICATIONS


VATS LOBECTOMYCONVERSION TO OPEN THORACOTOMY

Conversion is not a failure Conversion rate = 1-21 % Conversion Criteria

Inability to find lesion Loss of view

Inability to achieve good lung deflation

Inflammatory disease loss of pulmonary arterial sheath

Uncertain anatomy Major bleeding Unexpected advanced oncologic status

LONG TERM SURVIVAL AFTER VATS VS OPEN THORACOTOMY LOBECTOMY FOR STAGE I NSCLC


VATS VS OPEN THORACOTOMYADVANTAGES OF VATS

Whitson. Ann Thorac Surg. 2008; 86: 2008-18

SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED AND NONRANDOMIZED TRIALS ON SAFETY AND EFFICACY OF VATS FOR EARLY-STAGE NSCLC

Yan. J Clin Oncol. 2009; 27: 2553-62

IMPACT OF MAJOR LUNG RESECTION ON IMMUNE FUNCTIONVATS VS OPEN THORACOTOMY

Ng. Asian Cardiovasc Thorac Ann. 2009. 17; 426-32

VATS LOBECTOMY FACILITATES THE DELIVERY OF CHEMOTHERAPY AFTER RESECTION FOR LUNG CANCER

Petersen. Ann Thorac Surg. 2007. 83; 1245-50

VATS VS OPEN THORACOTOMYCOSTS

Nakajima. Cancer. 2000; 89: 2498-2501Casali. EJCTS. 2009; 35: 423-8

VATS LOBECTOMYCAN IT BE TAUGHT ?

Fergusson. EJCTS. 2006; 29: 806-9

VATS LOBECTOMY - WHO WILL DO IT ?

Major Thoracic interest

Good open thoracic surgical experience High volume thoracic surgeons (>20 resections/year)

Familiarity with hilum dissection

Familiarity with endoscopic surgery

Aptitude (spatial awareness)

Patience

Walker. 2005. 13th meeting of ESTS. Barcelona.

VATSLEFT UPPER LOBECTOMY

VATS LEFTRADICAL

LYMPHADENECTOMY

CONCLUSIONS

VATS Lobectomy is safe and feasible in themanagement of Stage I and II NSCLC

VATS Lymphadenectomy is feasible and aseffective as OT Lymphadenectomy in term of Number of lymph nodes retrieved Number of stations assessed Therefore, concerns about the efficacy of VATS

Lymphadenectomy should not limit the adoptionof VATS Lobectomy

CONCLUSIONS

Oncological principles are preserved Complete lymph nodes dissection could be

achieved There is no difference in term of local

reccurence VATS lobectomy seems to have a beneficial

impact in term of systemic reccurence and long term survival

vats for thoracic diseases.ppt - bges€¦ · vats for thoracic diseases starters package ‐13 th...

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