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Ann Thorac Surg 2004;78:498-501
© 2004 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, Brisbane, Queensland, Australia
Accepted for publication February 6, 2004.
* Address reprint requests to Dr Saxena, Department of Cardiothoracic Surgery, The Prince Charles Hospital, Rode Rd, Chermside, Brisbane 4032, QLD, Australia
e-mail: drpankajsaxena{at}hotmail.com
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Abstract |
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METHODS: Six patients underwent combined OPCABG and lung resection during a 4-year period. Follow-up ranging from 9 months to 3 years is available for these patients.
RESULTS: Malignant pathology was the diagnosis in 5 patients and 1 patient was diagnosed with advanced chronic obstructive pulmonary disease. Right upper lobectomy was performed in 3 patients, left upper lobectomy was performed in 1 patient, right upper and middle bilobectomy was performed in 1 patient, and bilateral lung volume reduction was performed in one patient. Prolonged air leak occurred in 1 patient postoperatively and another patient experienced small right-sided residual pleural space that was resolved at 6 weeks follow-up. There were no operative deaths but there were 2 late deaths. Evidence of recurrence for angina or malignancy upon follow-up was not detected.
CONCLUSIONS: A combined procedure is a safe approach in patients diagnosed with concomitant coronary artery and pulmonary disease. Avoidance of CPB may decrease the incidence of postoperative complications.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Attention was now diverted to the lung. The involved lung was mobilized by dividing the inferior pulmonary ligament. LITA graft did not interfere lung resection as skeletonized grafts are longer. At times a pack was placed underneath the ipsilateral lung to bring the lung hilum forward into operative field. Branches of the pulmonary artery were ligated. The pulmonary veins were ligated and transfixed. Bronchial division was done with a TA-30 stapler (Auto Suture Co., Norwalk, CT). Lung fissures were divided with an ILA stapler (Auto Suture Co., Norwalk, CT). Hilar and mediastinal lymph nodes were dissected for staging. During lung volume reduction the staple lines were reinforced with Gore-Tex strips (W.L. Gore & Associates, Inc., Flagstaff, AZ). Bronchial stump was checked for the presence of an air leak. Apical and basal pleural chest tubes and mediastinal drains were positioned. The drains were placed on low suction.
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Results |
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There was no hospital mortality, however there were 2 late deaths. The mean hospital stay was 12.5 days (range 6–37 days). Two patients experienced postoperative complications. A 70-year-old female (patient 1) unfortunately died because of head injury after a fall. This happened 26 months postoperatively. Prolonged air leak after lung volume reduction surgery developed in a 58-year-old male (patient 2) with emphysema and end-stage lung disease. He also underwent a single vessel CABG with LITA to LAD. His preoperative forced expiratory volume in 1 second (FEV1) was 0.7 L (20% of predicted value) and he was categorized as New York Heart Association (NYHA) class IV. His recovery was also complicated by the development of pneumonia and hepatic dysfunction. His hospital stay was 37 days and he was discharged with a Heimlich valve attached to his chest drain. This was successfully removed at follow-up in an outpatient setting. This patient exhibited a satisfactory result postoperatively. He improved to NYHA class II and was free from angina. Thirty months later he was discovered at home in a collapsed state and could not be revived. An autopsy was not performed at the request of the family.
One patient experienced a small residual pleural space after removal of his chest drains. This was asymptomatic and he made a satisfactory postoperative recovery. He underwent a right upper lobectomy and CABG to three vessels. The patient was discharged on the ninth postoperative day. His right lung was fully expanded at the time of follow-up after 6 weeks.
Patients with malignant disease are followed clinically. Postoperatively chest x-rays and CT scans are performed every 3 months in the first year, every 6 months in the second year, and annually thereafter. The latest clinical status of these patients was checked by telephone follow-up with their general practitioners (GP). None of the patients in this study experienced the recurrence of angina or malignancy at the last follow-up.
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Comment |
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Median sternotomy is a less painful incision compared with posterolateral thoracotomy. Different authors have preferred the use of median sternotomy for lung resections. Median sternotomy causes decreased pulmonary dysfunction. Pulmonary procedure through this approach is better tolerated even in patients with poor pulmonary reserve [11, 12]. Urschel demonstrated that the operative time and hospital stay was reduced in patients undergoing pulmonary resection through median sternotomy compared with patients undergoing a conventional lateral thoracotomy incision. He favored the use of the median sternotomy approach for all lung resections routinely [13]. Early recovery of postoperative pulmonary function shortens convalescence.
Technical problems may be encountered regarding a malignant lesion through a median sternotomy. Left lower lobectomy is the most difficult lung resection to perform through a median sternotomy. Retraction of heart during this procedure may lead to hemodynamic compromise and arrhythmias. Opening the right pleura and pericardium widely and rotating the heart in an anticlockwise fashion can improve the exposure remarkably. Use of single lung ventilation, complete mobilization of the lung, and prior revascularization of the myocardium before pulmonary resection facilitated the completion of procedure. Recommendation for executing CPB when performing lobectomy or pneumonectomy on the left side has been illustrated in the patients undergoing cardiac surgery and pulmonary resection. This provides greater exposure of the left lung hilum while avoiding hemodynamic compromise. None of the patients presented to us with a lesion requiring left lower lobectomy or left pneumonectomy. Such patients can be managed in two stages with pulmonary resection through a lateral thoracotomy incision at a later stage. Alternatively they can have a separate thoracotomy incision after suitable positioning succeeding CABG surgery through median sternotomy. We believe that the contraindication for such a combined procedure would be in the form of advanced left lower lobe and superior sulcus tumors.
Another important issue in these patients is the adequacy of hilar and mediastinal lymph node dissection or sampling while performing lung resection through median sternotomy. Single lung anesthesia is helpful during the procedure. The collapsed lung was fully mobilized in the present series by dividing inferior pulmonary ligament and any intrapleural adhesions for the exposure of various groups of hilar and mediastinal lymph nodes. The dissection of subcarinal lymph nodes may be difficult through median sternotomy. We dissected hilar, interlobar, lobar, segmental, subsegmental, inferior pulmonary ligament lymph nodes on either side and subcarinal nodes on the left side. A CT scan was used for the assessment of mediastinal lymph nodes in these patients. Any patient exhibiting an abnormality of mediastinal lymph nodes underwent a preoperative mediastinoscopy. This was performed at the beginning of the procedure. We recommend the use of PET scan for staging these patients. These investigations are part of an effort to construct an accurate assessment of their stage preoperatively. None of our patients exhibited N2 disease. A posterior pericardial approach has been recommended for clearing the subcarinal and paratracheal lymph nodes. We agree with Izbicki and associates who, in a randomized trial, concluded the doubtful survival advantage of radical systematic mediastinal lymphadenectomy in comparison with lesser dissection of lymph nodes. In addition a radical lymph node dissection prolongs the operative time and increases postoperative morbidity [14]. On the other hand Miller and associates attributed a poor patient outcome after combined surgery to inadequate evaluation and clearance of lymph nodes [5].
CPB has been depicted as having an inhibitory effect on the different components of the immune system. NK cells are a type of lymphocyte that exhibit spontaneous cytotoxicity against tumor cells. It has been illustrated that the activity of these cells is inhibited by CPB and remains so in the immediate postoperative period [15]. Apart from the suppression of cell-mediated immunity there is depletion of complement system factors, lymphopenia, neutropenia, and pulmonary sequestration of polymorphonuclear cells. There is enough evidence to suggest that CPB exhibits an impact on many aspects of immunity, however there is no conclusive evidence to suggest that this has an effect on the tumor growth or the spread of malignancy in these patients. Cell-mediated immunity is involved in a protective role against chronic granulomatous infections such as tuberculosis and in the suppression of the activity of malignant cells. It is important to establish a tissue diagnosis of pulmonary nodules preoperatively. An infective pathology sustains a substantial risk of flare-up in the setting of immunosuppression. We believe that off-pump surgery eliminates the early phase of immunosuppression associated with CPB and reduces the incidence of postoperative complications in patients undergoing combined procedures.
OPCABG surgery has gained worldwide popularity. Various studies have indicated several advantages of avoiding the use of CPB including less pulmonary dysfunction, a decrease in the requirement of blood transfusion, a shorter hospital and/or intensive care unit (ICU) stay, a decreased incidence of postoperative atrial fibrillation, a decreased incidence of postoperative renal failure, a reduced need for perioperative use of an intraaortic balloon pump, a decreased incidence of neurologic complications, and the immunosuppressive effects of CPB and diminished risk of intrapulmonary hemorrhage after lung resection [4, 16–21]. Intrapulmonary hemorrhage superseded by respiratory failure has been reported with lung resection in patients undergoing cardiac surgery when CPB was used to facilitate pulmonary resection [4]. Off-pump surgery causes less derangement in coagulation profile. This would reduce the bleeding from additional areas of dissection related to pulmonary surgery. Attempts to resect pulmonary neoplasms using CPB may lead to the systemic seeding of the tumor cells inadvertently. In addition blood transfusion is associated with an increased risk of recurrence [6].
CPB is known to alter pulmonary physiology by increasing the pulmonary capillary permeability which promotes the accumulation of extravascular lung water. Moreover it has been illustrated that atelectasis causes ventilation perfusion mismatch and increases intrapulmonary shunt. This can be responsible for postoperative hypoxemia [21]. The chances of developing CPB-related pulmonary dysfunction are much higher in patients with underlying pulmonary disorders. OPCAB surgery avoids these pulmonary complications and hence also shortens the hospital and ICU stay. Güler and associates reported the results in patients with chronic obstructive airway disease undergoing on-pump, off-pump, and minimally invasive direct CABG surgery. They identified that the mean intubation time and ICU stay was substantially longer in patients undergoing on-pump surgery in comparison with patients undergoing off-pump surgery. Furthermore pulmonary complications were responsible for the prolonged ICU stay [18]. This was also observed in the present study as 2 of our patients were extubated in the OR at the end of procedure and the mean intubation time postoperatively in the remainder of the 4 patients was 6.6 hours. This should be considered despite the fact that 2 of these patients exhibited advanced pulmonary disease.
We conclude that combined OPCAB surgery and pulmonary resection can be performed safely in high-risk patients with minimal possibility of morbidity and mortality. Avoidance of CPB possesses a great advantage in this situation because of the diminished likelihood of causing systemic complications. CPB elicits notable changes in the immune system, however its role regarding the outcome of cancer surgery is not well established. Avoidance of CPB most likely shortens the convalescence time and reduces the incidence of postoperative morbidity and mortality in a patient undergoing an extensive procedure such as CABG and lung resection. A prospective randomized trial is required to assess the long-term benefit of off-pump surgery when treating patients undergoing combined CABG surgery and lung resection for malignancy. A relatively small number of such patients prohibits this type of analysis.
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This article has been cited by other articles:
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  P. Saxena and R. Tam COMBINED OFF-PUMP CORONARY ARTERY SURGERY AND LUNG RESECTION THROUGH THORACOTOMY Asian Cardiovasc Thorac Ann, December 1, 2006; 14(6): 537 - 538. [Full Text] [PDF]
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