Transdiaphragmatic excision of simultaneous lung and liver mets shows promise

By James E. Barone MD

NEW YORK (Reuters Health) - For selected patients with cancer, simultaneous resection of liver and peripheral lung metastases via a transdiaphragmatic approach achieves success rates comparable to staged procedures with significantly shorter hospital stays, according to researchers from the University of Texas M.D. Anderson Cancer Center.

Co-author Dr. Thomas A. Aloia, in an email to Reuters Health, said, "Noting no real morbidity from the diaphragm incision and the ability to get to even upper lung lesions, we are now routinely going with this approach."

After the liver resection is done using a standard laparotomy, the lung containing the metastatic lesions is exposed by a circumferential incision in the diaphragm sparing the central tendon. The lung is deflated, and the inferior pulmonary ligament is divided. The metastases are located using palpation and excised by wedge resection with staplers. The diaphragm is closed after placement of a chest tube.

Dr. Aloia explained that the liver does not hinder access to the right lung. He said, "By taking down the right triangular ligament and rotating the liver we have complete access to the right hemi diaphragm." He added that the diaphragmatic incision needs to be optimally placed, and its solid closure is critical to success.

Over a 12.5 year period, 23 patients underwent simultaneous resections of liver and lung metastases, with 16 performed via the transdiaphragmatic route.

Of the 16 patients who had transdiaphragmatic procedures, the primary was colorectal cancer in all but one patient, who had a granular cell carcinoma.

The center of the most distant tumor was 3 cm or less from the visceral pleura. The median number of resected metastases was 1 (range, 1 to 3) and the median tumor size was 10 mm (range, 5 to 30 mm).

All 16 patients survived at least 90 days. There was no difference in the estimated blood loss or duration of surgery whether the metastases were located in the upper, middle, or lower lung lobes.

The transdiaphragmatic patients were compared to 102 patients who had conventional staged liver and lung resections for metastases. The two groups were similar in age, sex, number and size of lesions, duration of surgery, and percentage of positive specimen margins.

The median estimated blood loss for the lung resections was 0 mL for the transdiaphragmatic cases vs. 50 mL for staged patients (p<0.001). No patient in either group required a blood transfusion. Total hospital length of stay was 6 days in the transdiaphragmatic cohort compared to 11 days in the conventional group (p<0.001).

One patient had a postoperative air leak which resolved within 48 hours, and another required reinsertion of the chest tube for a residual air leak. The incidence of lung-related complications in transdiaphragmatic patients (13%) did not differ significantly from that of the staged cohort.

Eight of the 16 patients in the series underwent repeat resections for recurrent liver metastases, which was not a contraindication for the transdiaphragmatic procedure.

In the paper, published online June 20 in Surgery, the authors suggested that the transdiaphragmatic procedure might also be useful for indeterminate lung lesions, which are difficult to definitively diagnose preoperatively.

Dr. Aloia stressed that the transdiaphragmatic approach may look simple, but it is technically demanding and requires hepatobiliary and thoracic expertise for both surgeons and anesthesiologists.

He said, "A discussion between the liver and lung teams and anesthesia is required after the liver resection is complete to confirm the patient is stable and optimized to proceed with the thoracic portion of the operation."

SOURCE: http://bit.ly/1muq7GS

Surgery 2014.