Surgical management of carcinoma bronchus

Preoperative procedures for lung cancer

Comp history & physical exam Lung function tests –spirometry Radiograph of chest & suspicious bony

lesions Blood coagulation tests like BT/CT/PT CT scan of thorax, abdomen & brain Bronchoscopy Surgical evaluation of mediastinum at

mediastinoscopy or at thoracotomy PET-Positron emission tomography

Preoperative assessment of risky patients

Chronic bronchitis Excessive obesity Barrel shaped chest Bronchospasm

Criteria for surgical treatment

Fit patient No evidence of spread of tumour

outside the chest No clinical or investigatory evidence of

inoperability Tumour graded up to T2,N1,M0 are

indicated for surgical resection

Preparation of the patient

Reduction of bronchial infection Reduction of bronchospasm Deep breathing exercise instructed by

physiotherapist Arrangement 3-4pints of compatible

blood transfusion Consent-which also includes the

consent for death on table

Criteria for nonresectibility

Tumour inability to separate from aorta/sup vena cava

Inability to separate from lower end of trachea

Spread of tumour along the pulm vein to left atrium

Spread along the pulmonary artery Involvement of the oesophagial mucosa Contalateral/supraclavicular node

involvement Malignant pleural/pericardial effusion Phrenic nerve,recurrent laryngeal nerve

involvement

Approach for lung cancer surgery

Thoracotomy thoracoscopy

thoracotomyA thoractomy is performed

to diagnose lung cancer, remove lung cancer, and for other benign conditions. It is mainly performed in early stage non-small cell lung cancer patients.

A double lumen endotracheal tube is used to ventilate one lung keeping the other collapsed to facilitate surgery

Patient is turned on unaffected side in lateral position keeping upper arm supported in 90”flexion & lower limb flexed at hip & knee

Posterolateral incision is taken for best exposure allowing hilium to be approached both in front & behind

Rib spreader is inserted following the approximation of subcutaneous tissues & muscles

The anesthetist is now able to deflate the affected lung for better view of intrathoracic structures

Finally the appropriate surgical method for resection of tumour is performed

Surgeries 1. Pneumonectomy2. Lobectomy3. Wedge resection 4. Segmental

resection5. Sleeve lobectomy

Surgical treatment according to different stages

Surgical resection Surgical resection

with complete mediastinal lymph node dissection

En block resection of tumour with involved chest wall

Sleeve resection or pneumonectomy

Stage IA,IB,IIA,IIB & some IIIA

Stage IIIA• Tumours with chest

wall invasionT3• Sup sulcus tumours• Proximal airway

involvt

• Stage IIIA,IIIB,N2• Stage IIIB + carinal

invasion T4 Without N2 involt

Rt & chemotherapy Pneumonectomy

with tracheal sleeve resection with direct reanastomosis of contralat mainstem bronchus

LobectomySurgical removal of a

lobe of a lungIndication1. Peripheral growth

but confined to one lobe

2. Patient unfit for pneumonectomy for elderly age& impaired lung function

Following dissection of fissures & hilar structures in thoracotomy the branches of pulmonary artery & vein is isolated & ligated

The bronchus is later sewn or stapled After the completion of operation the

remaining lung is reinflated

Wedge resectionit is the surgical removal

of a small portion of the lung along with healthy tissue that surrounds the lung.

It is carried out by thoracoscopy or VATS

The newer methods are excision of portion of lobes using stapling devices,cautery or laser ablation

Sleeve lobectomySurgical removal of a

lobe along with some part of the involved bronchus

Indication-a tumor arising at the origin of a lobar bronchus precluding simple lobectomy, but not infiltrating as far as to require pneumonectomy.

It is a most valuable procedure in cases wherein the growth involves a part of bronchus

Here a sleeve of the main bronchus is removed with the lobe & the two ends of the main bronchus are re-anastomosed

SegmentectomyIt is the surgical removal of

one or more bronchopulmonary segments of an individual lobe through ligation & division of bronchopulmonary structures

Indication-localized peripheral tumour in an elderly patient with poor respiratory function

When a segment is to be resected the appropriate segmental artery & bronchus are divided at the hilium & clamp is then placed at the distal end of bronchus

The remaining lung is inflated by increasing endotracheal pressure

PneumonectomyIt is the surgical removal

of the whole lung Indication1. Tumours involving

many lobes but confined to the lung

2. Centrally tumours involving the main bronchus or those that straddle the fissures

Standard pneumonectomy Extended radical pneumonectomyHere the pulmonary artery is first

dissected , divide & sutured followed by superior or inferior pulmonary vein

Finally the main bronchus is divided keeping in mind no blind stump remains to prevent bronchoplueral fistula.

Mortality rate is 5-10%

VATS-video assisted thoracoscopic surgery

A type of minimally invasive surgery

it is used to detect stage, and/or remove lung cancer.

3 1/4-1/2” incisions are made between ribs &3 ports are inserted to hold instruments.

VATS here a camera is

attached to the thoracoscope with the image displayed on television screen

pneumonectomy , lobectomy & empyema drainage are possible

Advantages of thoracoscopy over thoracotomy

Mean blood loss is less No intraoperative death cases or any

major complications Shorter hospitalization Lesser post operative pain Lesser postoperative complication Less impairment of pulmonary

functions Better quality of life

Postoperative care

PrincipleAfter lobectomy/ segmental resection• Early expansion of remainder of lung• Prevent trachobronchial infection• Efficient physiotherapy • Fluid overload to be avoided• Mobilization in 2-3days• Breathing exercise

Post operative measures Expectoration-actively encouraged Analgesics-to relieve pain & increase

expectoration Postural draining Antibiotic cover Ambulation Chest tube management

Pain management

4 strategies1. Patient controlled analgesia with I V

bolus opiates2. Paravertebral,extraplueral catheter

delivered3. Oral analgesic& paracetamol4. Avoid rib fracture & entrapment of

intercostal nerves to prevent chronic unavoidable pain

Chest tube Drain Large calibre 24-28F

Intercostal drains inserted by making exit site thr 7th-8th intercostal space

Apical drain & Basal drain The intercostal tubes are

connected to underwater seal

The tube is clamped & released every hourly for 1min & draining is noted

Tube is removed after 24hrs

Suction should never be performed

Complications of surgeryEarly Sputum retention Atrial fibrillation Bronchospasm Surgical

emphysema Hemorrhage Persistent air leak

Late Empyema Bronchoplueral

fistula

Bronchoplueral fistula Serious complication Following

pneumonectomy the space left behind is initially filled with air which gradually gets filled with tissue fluid

Dehiscence of bronchial stump leads to fistula formation & the fluid is expectorated in large quantities

• In order to avoid bronchoplueral fistula the bronchus is divided close to the trachea or adjacent lobar bronchus

• The bronchial stump is usual stapled after pneumonectomy

• Postoperatively the patient is nursed sitting up turned to affected side to prevent infected fluid entering remaining lung & use of chest drain

Mortality according to cell types

Carcinoma 5-Years survival ratesSquamous cell carcinoma

35-50%

Adenocarcinoma 25-45%

Adenosquamous carcinoma

20-35%

Undifferentiated carcinoma

15-25%

Small cell carcinoma 0-5%

MortalityStage

Stage I

Stage II

Stage IIIa

Stage IIIb,IV

Treatment

Surgery followed by chemotherapy

Surgery followed by chemotherapy & radiation

Surgery followed by radiotherapy with/without chemotherapy before or after surgery

Surgery for lung tumour & brain tumour

5-year survival rates

60 to 70%

40 to 50%

15 to 30%

10 to 15%

SHUKRIYA