Transdiaphragmatic excision of simultaneous lung and liver mets shows promise
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.
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