Quel avenir pour la chirurgie thoracique et ... - Siz Nursingchirurgie colo-rectale… • î 30 %...

Quelavenirpourlachirurgiethoraciqueetdela

transplanta4onpulmonaire

PrBRondelet,MD,PhD

«Laminimalinvasivec’estnouveauetc’estl’avenirdela

chirurgiethoracique… »

VATS:unenouveauté?

DelMedJ.1992Apr;64(4):267-72.Video-assistedthoracicsurgery:ourfirst20cases.DaviesAL,PanasukDB.Video-assistedthoracicsurgeryhasbeenperformedin20pa4entsattheMedicalCenterofDelaware.Opera4onsincludedsevenpulmonarywedgeresec4ons,onemedias4nalprocedure,and12pleuralprocedures.Inallcases,adefini4vediagnosiswasmadeorthelesionwasremoved.Onepostopera4veatypicalpneumoniaoccurred.Onepa4entwhosewedgeresec4onprovedtobesquamouscellcarcinomaonfrozensec4onunderwentaformalthoracotomyandlobectomy.Es4matedsavingsintheeightpa4entswhoformerlywouldhaveundergoneathoracotomyincisionises4matedat$30,000forroomcostalone.Weforeseeamarkedlyexpandedroleforthistechniqueinmajorpulmonaryresec4ons,esophagealprocedures,andcardiacsurgeryinthenearfuture

ChestSurgClinNAm.1994Feb;4(1):185-94.Thymoma.Theuseofminimallyinvasiveresec<ontechniques.KaiserLR.Surgeryremainsthecornerstoneoftherapyforthymomawhetherthelesionisencapsulatedorinvasive.Video-assistedthoracicsurgicaltechniquesmaybeapplicableinanumberofpa4entswithencapsulatedthymomafordefini4vetherapy,especiallywhencombinedwithatranscervicalapproachtoachievetotalthymectomy.Ini4alexperiencewithaminimallyinvasiveapproachforresec4onofthymomasisdescribed.Thedevelopmentofnewinstrumenta4onfacilitatestheperformanceoftheseprocedures.

VATS:unenouveauté?

JThoracCardiovascSurg.1992Dec;104(6):1679-85;discussion1685-7.Video-assistedthoracicsurgicalresec<onofmalignantlungtumors.LewisRJ,CaccavaleRJ,SislerGE,MackenzieJW.Fortypa4entswithmalignantpulmonarydiseaseunderwentevalua4on,staging,andabiopsyorresec4onbymeansofvideo-assistedthoracicsurgery.Therewere20menand20womenwhoseagesrangedfrom27to82years.Eightpa4entshadawedgeresec4onformetasta4ccarcinoma,threealobectomyforprimarycarcinoma,sixexplora4onofthethorax,fivebiopsyoftheaortopulmonarywindow,andeighteenasublobarresec4onforprimarycarcinomaofthelung.Therewasnomortality.Threepa4entshadairleaksthatlastedanaverageof8days.Video-assistedthoracicsurgeryseemstobeusefulformoreprecisestagingofcarcinomaofthelung,and,insomepa4ents,resec4onalopera4onscanbeperformed.

VATS:unenouveauté?

Thorax.1993Sep;48(9):921-4.Thoracoscopyassistedpulmonarylobectomy.WalkerWS1,CarnochanFM,TinM.Thisreportdescribesapreliminaryexperiencewithsixpa4entsundergoingvideoimagedthoracoscopicpulmonarylobectomy.Threelegupperlobectomies,andoneeachofrightupper,rightlowerandleglowerlobectomywereundertaken.Theresec4onswereperformedasorthodoxdissec4onallobectomyproceduresbutwerecarriedoutundervideothoracoscopicimagingwithinstrumentsintroducedthroughtwostabincisions.Theen4reresectedlobewasdeliveredthrougha7cmsubmammaryintercostalincision.Therewerenoopera4vedeathsorcomplica4onsahributabletothetechnique.Inthreeotherpa4entsconversiontoanopenthoracotomywasrequiredbecauseofbleeding(twocases)orobscureanatomy(onecase).Post-opera4vepaininthoseundergoingthoracoscopicresec4onwaslessthanthatencounteredwithstandardthoracotomyandearlyclinicreviewshowedthepa4entstobepainfreewithexcellentshouldermovement.Majorpulmonaryresec<onaccordingtostandardcancerprac<cesisfeasiblewithvideothoracoscopictechniques.Thisapproachislikelytoofferconsiderablefunc<onalbenefittopa<ents.Specimendeliverythroughthesubmammaryincisionimposesa5cmprimarylesionsizelimita4on.Detailedmedias4nalassessmentisnecessarytoexcludeN2statusbeforeundertakingthoracoscopicsurgery.

VATS:unenouveauté?

JThoracCardiovascSurg.2003Jul;126(1):292-3.Robot-assistedlobectomy.AshtonRCJr,ConneryCP,SwistelDG,DeRoseJJJr.Video-assistedthoracoscopicsurgery(VATS)forana-tomicpulmonaryresec4onscon4nuestodevelopsinceitsapplica4onintheearly1990s.1-5UsingthedaVinciSurgicalSystem(Intui4veSurgical,Inc.,MountainView,Calif),weperformedananatomicrightlowerlobectomyforstageIanon–smallcelllungcancer.

Robo4clobectomy:unenouveauté?

Laminimalinvasiven’estpasunedémarchenouvelle…

Ques4ons…

•  Y-a-t-ilunintérêtautrequelaperformancemanuelleàfairedelachirurgiemoinsinvasive?

•  Quellessontlesrépercussionssurlasociété?

•  Commentladémarchepeutelleêtreefficiente?

Fast-TrackChirurgie

•  Récupéra:onrapidedespa:entsaprèschirurgie Réhabilita:onprécoce Fast-track-surgery EnhancedrecoveryaBersurgery

•  Viselareprised'uneautonomieac4veetcomplètedupa4ent,leplusrapidementpossibleaprèssachirurgie.

•  C’estunemédecinefondéesurlesfaits,validéepardespublica4onsscien4fiques.

=

Fast-TrackChirurgie

•  Méta-analysed'essaisrandomiséscontrôléspourlachirurgiecolo-rectale…•  î30%laduréedeséjour,•  î50%lescomplica4onspéri-opératoires.

•  Chaqueétape,chaquesoinyestop4miséetorganiséautourdel’opéré.

•  Elleaétéini4alementdéveloppéeparlePrHKehletauDanemarken1995pourlachirurgiecolique.

•  Larécupéra4onrapideaprèschirurgiesecombineidéalementaveclestechniqueschirurgicalesmini-invasivestellesquelacœlioscopie.

Cafait20ansqu’onfaitça…

•  Kehletaeul'intui4onquedenombreusesétapesdelapriseenchargeclassiqueenchirurgiereposaientplussurlepoidsdeshabitudesetsurlestradi4onsquesuruneanalysesystéma4quedesbénéficesapportésauxpa4ents.

•  Iladoncanalyséchacunedecesétapesetderechercherquelétaitleniveaudepreuvescien4fiquementpubliéjus4fiantlaprésenceoul'absenced'uneétapedonnéedanslesprotocolesu4lisés.

•  Ilapuprouverquedenombreuxactesréalisésétaientnonseulementinu4lesmaisdélétèrespourlaplupartdespa4entsopérésducôlon.

Unpa4entacteur…

•  L'autrepilierdelaréflexiondeKehletestl'associa4ondupa4entàsessoins.

•  Dansleschémaclassique,lepa4entauneposturepassive.Lesdécisionssontprisesparlespra4ciens;lepa4entestinformé.

•  Danslarécupéra4onrapideaprèschirurgie,lepa4entreçoituneinforma4ontrèsapprofondiesurlesdifférentstempsdutraitement.Lapa4entestinscritdansunpartenariat.

•  Lepa4entestdoncréellementunmoteurdesapropreréhabilita4onetpeutinfluencerlesdécisionsenfonc4ondesespropressensa4onsetduretourd'informa4onqu'ildonneauxprofessionnelsdesanté.

Touspourunmalade…Unmaladepourtous!

•  Pluridisciplinaritédelapriseencharge…•  Audelàdubinômehabituelchirurgie-anesthésiste,il

associelepersonnelinfirmier,leskinésithérapeutes,lesdiété4ciens,lesassistantssociaux,lescoordinateursdesoins,etc…

•  Chacunvaapportersonexper4sedefaçoncoordonnéepouraheindrelesobjec4fsfixésetcommuniquerpourajusterlapriseenchargesibesoin.

•  Cehepluridisciplinaritésetrouveformaliséesousformedeprotocoles/parcourtsdesoinsrigoureuxdontl'exécu4onestrégulièrementévaluée.

Desprincipes…

•  Réduirelestressphysiqueetpsychiqueliéàl'interven4on.

•  Prévenirlesdysfonc4onsorganiquessecondairesdelachirurgie•  Nausées,•  Somnolence,•  Vomissements,•  Dyspepsieetiléusparaly4quepostopératoire,•  Douleur...

Desprincipes…

•  Combinaisondemesures:jeûnepré-opératoirelimité,u4lisa4ondedrogued’anesthésieàcourteduréed’ac4on,préven4ondel’hypothermie,analgésiemul4modaleauplusprochedelasource,ges4onindividualiséedesapportsliquidiens,u4lisa4onlimitéededrains,u4lisa4onlimitédesondageurinaire,réalimenta4onprécoce,mobilisa4onrapide…

•  C’estl’ensembledecesmesuresetlacoordina4ondel’équipedepriseenchargequipermetaupa4entderetrouverplusvitesonautonomie.

Desprincipes…

•  Leretouràl'autonomiedupa4entluipermetnonseulementderentrerplusrapidementàlamaison,maisaussidepouvoirmieuxgérerceretouràdomicilehorsducoconprotecteurdel'hôpitaloudelaclinique.

•  L'ensembledel'organisa4onestformalisésousformedeprocéduresetprotocolesstandardisés.Ilssuiventlatrajectoiredupa4entetprennentsouventlenomdei4nérairecliniquequicomprendparexemplelesdocumentsd'informa4onquiserontremisaupa4entetlesscoresquipermehentd'évaluersonétatetdedéciderdesasor4e.

Desretombéesimportantes…

•  Lespublica4onsscien4fiquesmontrentquelasa4sfac4ondespa4entsestexcellenteetquelestauxdecomplica4onsetréadmissionssontiden4ques(voiremeilleurs)qu’avecunepriseenchargetradi4onnelle.

•  Lepa4entretrouveunconfortplusrapidementetladuréed’hospitalisa4onestlimitéeainsilescoûtsdiminuent.

•  Danslespaysoùelleestlargementdiffusée,elleréduitlenombredelitsdechirurgienécessairespourfairefaceàlademandedelapopula4ondufaitdelabaissedeladuréemoyennedeséjour,sansquelesdépensessoientreportéessurlamédecinedevilleoulescentresderééduca4on.Lesressourcesainsilibéréespeuventdoncêtreconsacréesàd'autresbesoinssanitaires.

Desretombéesimportantes…

•  Ceheapprocheestplébiscitéeaujourd’huiparleNa4onalHealthservice(NHS)etestdevenuelanormeenGrandeBretagne.

•  Depuislafin2011,larécupéra4onrapideaprèschirurgiepourlaprothèsetotaledehancheetlaprothèsedugenoubénéficieainsid'unetarifica4onspécialeenGrandeBretagnedanslecadredes"bestprac4cetarifs».

•  Unnombrecroissantdecentresadopteégalementlarécupéra4onrapideaprèschirurgieàtraverslemondemaiselleresteconfiden4elleenBelgiquemalgrélespreuvesdesonefficience.

Etlachirurgiethoracique?

Anesthésie&Ges4ondela

douleur

Servicesocial

Nursing

Revalida4on

Soinsintensifs

Chirurgie

Diété4que

Tabacologie

Démarche(s)…

•  Toutdoitêtresystéma4quementremisencause…•  Etablirunelistedesétapeduprocessuspourchaque

spécialité.•  Pourchaqueétape,faireunerevuedelalihérature

exhaus4vepourdégagerlesméthodesquidonnentlemoinsdedysfonc4onsorganiquessecondaires.Abandonnerlestradi4ons,implémenterdesa�tudesbaséessurl’evidencebasedmedicine.

•  Etablirdesprotocolespourchaqueen4téimpliquée.•  Etablirunparcourtdesoinsquiar4culechaquespécialité

aveclesautres.•  Etablirunparcourtde«communica4on»dansl’équipeet

aveclepa4ent.

•  Laqualitédelarésec4on:R0,R1…

•  Laqualitéducurageganglionnaireetdustaging…

Pourlachirurgie…Lasurvieestcondi4onnéepar…

Stagingmédias4nalpré-op?EUS/EBUScombinésenpremièreinten4onChest.2014Aug;146(2):389-97.Endosonographicmedias<nallymphnodestagingoflungcancer.LibermanM,SampalisJ,DuranceauA,ThiffaultV,HadjeresR,FerraroP.Itisunclearwhetherendoscopicmedias4nallymphnode(LN)stagingtechniquesareequivalenttosurgicalmedias4nalstaging(SMS)techniquesinpa4entswithpoten4allyoperablenon-smallcelllungcancer(NSCLC).Atotalof166pa4entswithconfirmedorsuspectedNSCLCwhorequiredSMSbasedoncurrentguidelineswereenrolledinthisprospec4vecontrolledtrialcomparingendosonographicmedias4nalLNstagingwithSMS.Eachpa4entservedashisorherowncontrol.Allpa4entsunderwentendobronchialultrasound(EBUS),endoscopicultrasound(EUS),andSMSduringasingleprocedure.ResultsofEBUS,EUS,andcombinedEBUS/EUSwerecomparedwithSMS(goldstandard)andinpa4entswithnega4veLNstagingresults,withLNsamplingatpulmonaryresec4on.

ThecombinedEBUS/EUSprocedurecanreplacesurgicalmedias<nalstaginginpa<entswithpoten<allyresectableNSCLC.Addi<onally,endosonographyleadstoimprovedstagingcomparedwithSMSbecauseitallowsthebiopsyofLNsandmetastasesunaPainablewithSMStechniques.

Stagingmédias4nalpré-op?Uneplacepourlamédias4noscopie?

InteractCardiovascThoracSurg.2013Nov;17(5):823-8.Medias<nalstagingindailyprac<ce:endosonography,followedbycervicalmedias<noscopy.Dowereallyneedboth?VerhagenAF,SchuurbiersOC,Looijen-SalamonMG,vanderHeideSM,vanSwietenHA,vanderHeijdenEH.Inpa4entswithlungcancer,endosonographyhasemergedasaminimallyinvasivemethodtoobtaincytologicalproofofmedias4nallymphnodes,suspiciousformetastasesonimaging.Incaseofanega4veresult,itiscurrentlyrecommendedthatacervicalmedias4noscopybeperformedaddi4onally.However,indailyprac4ce,asecondprocedureisogenregardedsuperfluous.Thegoalofourstudywastoassesstheaddi4onalvalueofacervicalmedias4noscopy,ageranega4veresultofendosonography,inrou4neclinicalprac4ce.Inaretrospec4vecohortstudy,therecordsof147consecu4vepa4entswithanindica4onformedias4nallymphnodestagingandanega4veresultofendosonographywereanalysed.Asasubsequentprocedure,124pa4entsunderwentacervicalmedias4noscopyand23pa4entswerescheduledforanintendedcura4veresec4ondirectly.Thenega4vepredic4vevalue(NPV)forbothdiagnos4cprocedureswasdetermined,aswellasthenumberofpa4entswhoneededtoundergoamedias4noscopytofindonefalse-nega4veresultofendosonography(numberneededtotreat(NNT)).Clinicaldataofpa4entswithafalse-nega4veendosonographywereanalysed.

Inpa<entswithahighprobabilityofmedias<nalmetastases,basedonimaging,andnega<veendosonography,cervicalmedias<noscopyshouldnotbeomiPed,notevenwhentheaspirateseemsrepresenta4ve.

Stagingmédias4nalpré-op?Quelletechniquedemédias4noscopie?

JThoracCardiovascSurg.2013Oct;146(4):774-80.Video-assistedmedias<noscopiclymphadenectomyisassociatedwithbePersurvivalthanmedias<noscopyinpa<entswithresectednon-smallcelllungcancer.TurnaA,DemirkayaA,OzkulS,OzB,GursesA,KaynakK.Weaimedtoanalyzetheaccuracyofvideo-assistedmedias4noscopiclymphadenectomy(VAMLA)asatoolforpreopera4vestagingandtheimpactofthetechniqueonsurvivalinpa4entswithnon-smallcelllungcancer(NSCLC)undergoingpulmonaryresec4on.BetweenMay2006andDecember2010,433pa4entsunderwentpulmonaryresec4onforNSCLC,89(21%)hadVAMLAbeforeresec4onand344(79%)hadstandardmedias4noscopy.Thepa4entswhohadnega4veVAMLA/medias4noscopyresultsunderwentanatomicpulmonaryresec4onandsystema4clymphnodedissec4on.Themedianandmeannumbersofresectedlymphnodesta4onswere5and4.9intheVAMLAgroupand4

Video-assistedmedias<noscopiclymphadenectomywasassociatedwithbePersurvival(oddsra<o,1.34;95%VAMLAwasassociatedwithimprovedsurvivalinNSCLCpa<entswhohadresec<onalsurgery.

Stagingmédias4nalpré-op?Quelle(s)technique(s)?Quand?Comment?

EurJCardiothoracSurg.2014May;45(5):787-98.RevisedESTSguidelinesforpreopera<vemedias<nallymphnodestagingfornon-small-celllungcancer.DeLeynP,DoomsC,KuzdzalJ,LardinoisD,PasslickB,Rami-PortaR,TurnaA,VanSchilP,VenutaF,WallerD,WederW,ZielinskiM.1.Incaseofcomputedtomography(CT)-enlargedorpositronemissiontomography(PET)-posi4vemedias4nallymphnodes,4ssueconfirma4onisindicated.

a.Endosonography[endobronchialultrasonography(EBUS)/esophagealultrasonography(EUS)]withfine-needleaspira4on(FNA)isthefirstchoice(whenavailable),sinceitisminimallyinvasiveandhasahighsensi4vitytoruleinmedias4nalnodaldisease.b.Ifnega4ve,surgicalstagingwithnodaldissec4onorbiopsyisindicated.Video-assistedmedias4noscopyispreferredtomedias4noscopy.Thecombineduseofendoscopicstagingandsurgicalstagingresultsinthehighestaccuracy.

2.WhentherearenoenlargedlymphnodesonCTandwhenthereisnouptakeinlymphnodesonPETorPET-CT,directsurgicalresec4onwithsystema4cnodaldissec4onisindicatedfortumours≤3cmlocatedintheouterthirdofthelung.3.IncentraltumoursorN1nodes,preopera4vemedias4nalstagingisindicated.ThechoicebetweenendoscopicstagingwithEBUS/EUSandFNAorvideo-assistedmedias4noscopydependsonlocalexper4setoadheretominimalrequirementsforstaging.4.Fortumours>3cm,preopera4vemedias4nalstagingisadvised,mainlyinadenocarcinomawithhighstandardizeduptakevalue.5.Forrestaging,invasivetechniquesprovidinghistologicalinforma4onareadvisable.Bothendoscopictechniquesandsurgicalproceduresareavailable,buttheirnega4vepredic4vevalueislowercomparedwiththeresultsobtainedinbaselinestaging.Anintegratedstrategyusingendoscopicstagingtechniquestoprovemedias4nalnodaldiseaseandmedias4noscopytoassessnodalresponseagerinduc4ontherapyneedsfurtherstudy.

Résec4onpulmonaireVATSlobectomy:Techniquesûreetefficace?

ZhonghuaYiXueZaZhi.2013Oct8;93(37):2972-5.[Acompara<vestudyofcompletevideo-assistedthoracoscopiclobectomyandvideo-assistedmini-thoracotomyintreatmentoflungcancer].ZhangY,LiYB,LiuBD,ChenDH,WangRT,LiuL,QianK,ZhiXY.Toexploretheclinicalapplica4onvalueofcompletevideo-assistedthoracoscopic(cVATS)lobectomyinthemini-invasivetreatmentoflungcancer.90pa4entswithnon-smallcelllungcancer(NSCLC)whohadundergonelobectomywerereviewed.Accordingtosurgicalapproach,completevideo-assistedthoracoscopiclobectomygroup(cVATS,n=47)andvideo-assistedmini-thoracotomygroup(VAMT,n=43)werestudied.Numbersofdissectedlymphnodes,opera4ondura4on,volumesofintraopera4vebleeding,dura4onofpostopera4vecatheterdrainage,lengthofpostopera4vehospitalstay,incidenceratesofpostopera4vecomplica4ons,postopera4vepainscoresofpa4entswerecomparedbetweenthetwogroupsretrospec4vely.

Completevideo-assistedthoracoscopiclobectomyissafeandeffec<vesurgicalstrategyforlungcancerpa<entswithadvantageofrapidrecovery.

Résec4onpulmonaireRobo4clobectomy:Techniquesûreetefficace?

AnnSurg.2017Feb;265(2):431-437.Long-termSurvivalBasedontheSurgicalApproachtoLobectomyForClinicalStageINonsmallCellLungCancer:ComparisonofRobo<c,Video-assistedThoracicSurgery,andThoracotomyLobectomy.YangHX1,WooKM,SimaCS,BainsMS,AdusumilliPS,HuangJ,FinleyDJ,RizkNP,RuschVW,JonesDR,ParkBJ.Tocomparethelong-termoutcomesamongrobo4c,video-assistedthoracicsurgery(VATS),andopenlobectomyinstageInonsmallcelllungcancer(NSCLC).Survivalcomparisonsbetweenrobo4c,VATS,andopenlobectomyinNSCLChavenotyetbeenreported.SomestudieshavesuggestedthatsurvivalagerVATSissuperior,forunclearreasons.Threecohorts(robo4c,VATS,andopen)ofclinicalstageINSCLCpa4entswerematchedbypropensityscoreandcomparedtoassessoverallsurvival(OS)anddisease-freesurvival(DFS).Univariateandmul4variateanalyseswereperformedtoiden4fyfactorsassociatedwiththeoutcomes.

MinimallyinvasiveapproachestolobectomyforclinicalstageINSCLCresultinsimilarlong-termsurvivalasthoracotomy.UseofVATSandrobo<csisassociatedwithshorterlengthofstay,andtherobo4capproachresultedingreaterlymphnodeassessment.

Résec4onpulmonaireVATS,Est-ceefficaced’unpointdevueoncologique?

AnnThoracSurg.2014Jul;98(1):197-202.Thoracoscopicapproachtolobectomyforlungcancerdoesnotcompromiseoncologicefficacy.BerryMF,D'AmicoTA,Onai4sMW,KelseyCR.Wecomparedsurvivalbetweenvideo-assistedthoracoscopicsurgery(VATS)andthoracotomyapproachestolobectomyfornon-smallcelllungcancer.Overallsurvivalofpa4entswhohadlobectomyforanystagenon-smallcelllungcancerwithoutpreviouschemotherapyorradia4onfrom1996to2008wasevaluatedusingtheKaplan-Meiermethodandmul4variateCoxanalysis.Propensityscoringwasusedtoassesstheimpactofselec4onbias.

Thethoracoscopicapproachtolobectomyfornon-smallcelllungcancerdoesnotresultinworselong-termsurvivalcomparedwiththoracotomy.

Résec4onpulmonaireYa-t-ilunealterna4veefficaceauVATSsiconversion?

EurJCardiothoracSurg.2014Oct;46(4):614-9.doi:10.1093/ejcts/ezu050.Epub2014Feb26.Thecomparisonofcomplica<on,pain,qualityoflifeandperformancea`erlungresec<onswiththoracoscopyandaxillarythoracotomy.ErusS,TanjuS,KapdağlıM,ÖzkanB,DilegeŞ,TokerA.Theaimofthisprospec4vestudywastocomparetheeffectsofaxillarythoracotomy(AT)andvideo-assistedthoracoscopicsurgery(VATS)onacute-phaseresponses,performancestatusandqualityoflifeinpa4entsundergoingpulmonaryresec4on.Figy-fivepa4entswithperipherallylocatedlunglesionswereenrolledintothisstudy.SurgerywasdonebyVATSorAT.Forcedexpiratoryvolume,smokinghabits,complica4ons,Charlsoncomorbidityindex,sex,age,lengthofincision,lengthofopera4on,lengthofhospitalstay,lengthofdrainage,lengthofairleakage,preopera4veandpostopera4veC-reac4veprotein(CRP)values,visualanaloguescale,qualityoflifeandperformancestatusofthepa4entsweremeasuredandcompared.

AxillarythoracotomyisatechniqueequivalenttoVATSintermsofearlycomplica<ons,,performancestatusandqualityoflife;VATSprovidedashorterpostopera<vestay.

Résec4onpulmonaireVATSvsMini-thoracotomied’unpointdevuedouleur….

EurJEurJCardiothoracSurg.2014Nov;46(5):907-12.doi:10.1093/ejcts/ezu092.Epub2014Mar18.Postopera<vepaincontrol:videothoracoscopicversusconserva<vemini-thoracotomicapproach.Andree�C,MennaC,IbrahimM,CicconeAM,D'AndrilliA,VenutaF,RendinaEA.Themanagementofpostopera4vepaininthoracicsurgeryisanopenissue.Theaimofthisstudywastocomparepostopera4vepainageravideothoracoscopiclobectomyversusamini-thoracotomyapproach.BetweenApril2011andJanuary2013weenrolledinaprospec4ve,non-randomizedstudy145pa4entsundergoingpulmonarylobectomywithlymphadenectomyforStageIlungcancer.In75cases(GroupA),surgerywasperformedthroughavideothoracoscopicapproach.In70cases(GroupB),surgerywasundertakenthroughaconserva4vemini-thoracotomy.Painwasassessedbyvisualanaloguescaleandlungfunc4onbyspirometryandsix-minutewalkingtest(6MWT)beforesurgery,at48hand1monthagersurgery.

ThevideothoracoscopicapproachinthetreatmentofStageIlungcancerreducespostopera<vepain,whichseemstoallowarapidfunc<onalrecoveryofpa<ents.

Résec4onpulmonaireVATSvsthoracotomie:Résultats…

PLoSOne.2013Dec31;8(12):e82366.ThoracoscopiclobectomyversusopenlobectomyinstageInon-smallcelllungcancer:ameta-analysis.CaiYX,FuXN,XuQZ,SunW,ZhangN.Theobjec4veofthepresentmeta-analysiswastoevaluatethesurvival,recurrencerate,andcomplica4onsinpa4entswithstageInon-smallcelllungcancer(NSCLC)whoreceivedvideo-assistedthoracoscopicsurgery(VATS)oropenlobectomy.

Pa<entswithstageINSCLCundergoingVATSlobectomyhadlongersurvivalandfewercomplica<onsthanthosewhoreceivedopenlobectomy.

Résec4onpulmonaireVATSvsthoracotomie:Coûts…

AnnThoracSurg.2014Jul;98(1):191-6.Ninety-daycostsofvideo-assistedthoracicsurgeryversusopenlobectomyforlungcancer.FarjahF,BackhusLM,VargheseTK,MulliganMS,ChengAM,Alfonso-CristanchoR,FlumDR,WoodDE.Complica4onsagerpulmonaryresec4onleadtohighercostsofcare.Video-assistedthoracoscopicsurgery(VATS)forlobectomyisassociatedwithfewercomplica4ons,butlowerinpa4entcostsforVATShavenotbeenuniformlydemonstrated.Becausesomecomplica4onsoccuragerdischarge,wecompared90-daycostsofVATSlobectomyversusopenlobectomyandexploredwhetherdifferen4alhealthcareuseagerdischargemightaccountforanyobserveddifferencesincosts.Acohortstudy(2007-2011)ofpa4entswithlungcancerwhohadundergoneresec4onwasconductedusing

VATSlobectomyisassociatedwithlower90-daycosts--arela4onshipthatappearstobemediatedbylowerratesofPLOS.AlthoughVATSmayleadtolowerratesofPLOSamongpa4entsundergoinglobectomy,observa4onalstudiescannotverifythisasser4on.StrategiesthatreducePLOSwilllikelyresultincost-savingsthatcanincreasethevalueofthoracicsurgicalcare.

Résec4onpulmonaireVATS/Robo4c:L’épargnepulmonaire,camarche?

JThoracOncol.2017Jan20ComparisonofSegmentectomyandLobectomyinStageIAAdenocarcinomas.ZhaoZR1,SituDR2,LauRW1,MokTS3,ChenGG1,UnderwoodMJ1,NgCS4Recentstudieshavesuggestedthatsegmentectomymaybeanacceptablealterna4vetreatmenttolobectomyforsurgicalmanagementofsmallerlungadenocarcinomas.Theobjec4veofthisstudywastocomparesurvivalagerlobectomyandsegmentectomyamongpa4entswithpathologicalstageIAadenocarcinomacategorizedasstageT1b(>0to≤20mm)accordingtotheneweighthedi4onoftheTNMsystem.

Pa<entswhounderwentsegmentectomymayhavesurvivaloutcomesnodifferentthanthoseofsomepa<entswhoreceivedlobectomyforpathologicalstageIAadenocarcinomasatleast10butnolargerthan20mminsize.Theseresultsshouldbefurtherconfirmedthroughprospec4verandomizedtrials.

Résec4onpulmonaireVATS/Robo4c:L’épargnepulmonaire,camarche?

EurJCardiothoracSurg.2017Apr11.StageInon-small-celllungcancer:long-termresultsoflobectomyversussublobarresec<onfromthePolishNa<onalLungCancerRegistry†.DziedzicR1,ZurekW1,MarjanskiT1,RudzinskiP2,OrlowskiTM2,SawickaW3,MarczykM4,PolanskaJ4,RzymanW1.Anatomicallobarresec4onandmedias4nallymphadenectomyremainthestandardforthetreatmentofearlystagenon-small-celllungcancer(NSCLC)andarepreferredoverproceduressuchassegmentectomyorwedgeresec4on.However,thereisanongoingdebateconcerningtheinfluenceoftheextentoftheresec4ononoverallsurvival.Theaimofthisar4clewastoassesstheoverallsurvivalfordifferenttypesofresec4onforStageINSCLC.Weperformedaretrospec4veanalysisoftheresultsofthesurgicaltreatmentofStageINSCLC.Between1January2007and31December2013,thedatafrom6905pa4entswhounderwentStageINSCLCopera4onswerecollectedinthePolishNa4onalLungCancerRegistry(PNLCR)andoverallsurvivalwasassessed.Apropensityscore-matchedanalysiswasusedtocompare3groupsofpa4ents,eachconsis4ngof231pa4ents

Wedgeresec<onwasassociatedwithsignificantlylower3-yearand5-yearsurvivalratescomparedtotheothermethodsofresec<on.Therewasnosignificantdifferencein3-yearor5-yearsurvivalratesbetweenlobectomyandsegmentectomy.Segmentectomy,butnotwedgeresec<on,couldbeconsideredanalterna<vetolobectomyinthetreatmentofpa<entswithStageINSCLC.

Résec4onpulmonaireVATSvsrobo4c:Coûts…Effetduvolumeopératoire.

Chest.2017Feb;151(2):329-339.HospitalVolumeandOutcomesofRobot-AssistedLobectomies.TchoutaLN1,ParkHS2,BoffaDJ1,BlasbergJD1,DeherbeckFC1,KimAW3..Theposi4veimpactofhospitalopera4vevolumeonoutcomesfollowingvideo-assistedthoracoscopicsurgeryhasbeenestablished.Thegoalofthisstudywastodeterminewhetherornotthisvolume/outcomerela4onshiptranslatestorobot-assistedthoracoscopicsurgery(RobATS)lobectomy.Pa4entswhounderwentRobATSlobectomywereiden4fiedbetween2008and2013intheHealthcareCostandU4liza4onProjectNa4onalInpa4entSampledatabase.Hospitalvolume,aswellasdemographic,clinical,andhealth-caresystem-relatedfactorswereselectedaspoten4alpredictorsofoutcomes.Outcomevariablesincludedlengthofstay(LOS),inpa4entmortality,andcomplica4ons.Hospitalsweredesignatedbyquar4lesaccordingtoannualcasevolume,withverylow-volumedefinedasthefirstquar4leandhigh-volumedefinedasthefourthquar4le.Regressionanalyseswereusedtoiden4fyindependentpredictorsoftheoutcomesofinterest.

Undergoinglobectomyathigh-volumeRobATScentersconfersfavorablemortalityandLOSoutcomescomparedwithverylow-volumecenters.However,thebeneficialeffectofvolumeonmortalitysuggestsaneedforthecarefuladop<onofthispromisingtechnology.

Stagingper-opVATSvsthoracotomie:Curageganglionnaire…

JThoracDis.2014Jan;6(1):45-51.Compara<vestudyofsystema<cthoracoscopiclymphadenectomyandconven<onalthoracotomyinresectablenon-smallcelllungcancer.WangW,YinW,ShaoW,JiangG,WangQ,LiuL,LiuD,WangZ,ZhuZ,ChenH,HeJ.Toassessthefeasibilityandsafetyofthevideo-assistedthoracoscopysurgery(VATS)systema4clymphnodedissec4oninresectablenon-smallcelllungcancer(NSCLC).Theclinicaldataofpa4entswithNSCLCwhounderwentVATSorthoracotomycombinedwithlobectomyandsystema4clymphadenectomyfromJanuary2001toJanuary2008wereretrospec4velyanalyzedtoiden4fytheirdemographicparameters,numberofdissectedlymphnodesandpostopera4vecomplica4ons.Forpa<entswithresectableNSCLC,VATSsystema<clymphnodedissec<onissafeandeffec<vewithfewerpostopera<vecomplica<ons,andsignificantlyfasterpostopera<verecoverycomparedwithtradi<onalopenchestsurgery.

Stagingper-opVATSvsthoracotomievsrobo4c:Curageganglionnaire…?

AnnSurg.2017Feb;265(2):431-437.Long-termSurvivalBasedontheSurgicalApproachtoLobectomyForClinicalStageINonsmallCellLungCancer:ComparisonofRobo<c,Video-assistedThoracicSurgery,andThoracotomyLobectomy.YangHX1,WooKM,SimaCS,BainsMS,AdusumilliPS,HuangJ,FinleyDJ,RizkNP,RuschVW,JonesDR,ParkBJ.Tocomparethelong-termoutcomesamongrobo4c,video-assistedthoracicsurgery(VATS),andopenlobectomyinstageInonsmallcelllungcancer(NSCLC).Survivalcomparisonsbetweenrobo4c,VATS,andopenlobectomyinNSCLChavenotyetbeenreported.SomestudieshavesuggestedthatsurvivalagerVATSissuperior,forunclearreasons.Threecohorts(robo4c,VATS,andopen)ofclinicalstageINSCLCpa4entswerematchedbypropensityscoreandcomparedtoassessoverallsurvival(OS)anddisease-freesurvival(DFS).Univariateandmul4variateanalyseswereperformedtoiden4fyfactorsassociatedwiththeoutcomes.

MinimallyinvasiveapproachestolobectomyforclinicalstageINSCLCresultinsimilarlong-termsurvivalasthoracotomy.UseofVATSandrobo4csisassociatedwithshorterlengthofstay,andtherobo4capproachresultedingreaterlymphnodeassessment.

Stagingper-opPeutonencoreêtremoinsinvasif?

JThoracCardiovascSurg.2017Feb10Anoveltechniquefortumorlocaliza<onandtargetedlympha<cmappinginearly-stagelungcancer.HacheyKJ1,DigesuCS1,ArmstrongKW1,GilmoreDM2,KhullarOV3,WhangB1,TsukadaH1,ColsonYL4.Toinves4gatesafetyandfeasibilityofnaviga4onalbronchoscopy(NB)-guidednear-infrared(NIR)localiza4onofsmall,ill-definedlunglesionsandsen4nellymphnodes(SLN)foraccuratestaginginpa4entswithnon-smallcelllungcancer(NSCLC).Pa4entswithknownorsuspectedstageINSCLCwereenrolledinaprospec4vepilottrialforlesionlocaliza4onandSLNmappingviaNB-guidedNIRmarking.Successfullocaliza4on,SLNdetec4onrates,histopathologicstatusofSLNversusoverallnodes,andconcordancetoini4alclinicalstageweremeasured.Exvivoconfirma4onofNIR+SLNsandadverseeventswererecorded.

NB-guidedNIRlesionlocaliza<onandSLNiden<fica<onwassafeandfeasible.Thisminimallyinvasiveimage-guidedtechniquemaypermittheaccuratelocaliza<onandnodalstagingofearlystagelungcancers.

Therefore, 2 separate groups used the strategy of combin-ing both blue dye and radioisotopes to aid in the detection ofthe SLN in patients with lung cancer. Schmidt and col-leagues18 used intraoperative injection of both blue dyeand technetium-99m to identify the mediastinal lymph no-des. However, again, the rate of SLN identification wasonly 81%.18 The second group, Tiffet and colleagues,19

studied intraoperative injection of both markers, identifyingSLN in only 13 (54%) of 24 patients, with some patients ex-hibiting only blue dye or technetium-99mmigration and notboth markers.19 These previous approaches have demon-strated the technical difficulty of visualizing blue dyewithinthe anthracotic nodes and the differences in anatomy thatmake use of Geiger counters to identify radioisotopes diffi-cult. In addition, the use of radioactivity poses a biologicrisk to the surgeon, operating room personnel, patient, andpathologist and is limited by the ‘‘shine through’’ to nearbystructures. As a standard approach to the thousands of pa-tients with lung cancer, this is not an ideal solution. Thepoor reliability negates the clinical utility of these ap-proaches and new innovations are needed.

NIR IMAGINGRecent success with ICG in lymph node mapping in pre-

clinical trials involving animal models and clinical trials ofbreast cancer have renewed the interest in SLN biopsy inNSCLC.20,21 NIR fluorescence uses safe NIR excitation toprovide simultaneous intraoperative imaging of visiblereflected light and the NIR fluorescence emitted from ICG(Figure 1). ICG can quickly and reliably migrate to draininglymph node basins, permitting rapid and accurate SLN iden-tification in a real-time intraoperative setting. Invisible NIRlight penetrates into tissue, detecting fluorescent objects ata depth of 1 cm in solid tissue. By maintaining separationof the visible and NIR fluorescent light, it is possible to si-multaneously acquire color and NIR fluorescence imagesand to overlay the 2 images. Thus, a single, intraoperativeprocedure is available to visualize SLNs, in which the surgi-cal field remains unaltered, without additional radiation riskto the patient or operating staff. To date, NIR-guided SLNdetection in nonthoracic systems has been characterizedby the identification of the SLN using NIR technology and

concurrent real-time videoscopic images of the necessaryanatomic landmarks required for safe and accurate surgicaldissection, low background signal from biologic tissue,a nearly 100% sensitivity owing to the high signal/noise ra-tio in the node, and successful identification of a single SLNstation in more than 90% of cases.

TECHNIQUEIn our phase I clinical trial, we assessed the safety and

feasibility of NIR imaging using ICG for SLN identificationin NSCLC in 29 patients. From the results of large animalstudies, our initial technique consisted of peritumoral sub-pleural injection of low-dose ICG (3.8 mg) coupled withfresh frozen plasma under direct visualization using theopen-platform fluorescence-assisted resection and explora-tion camera. After injection, the surgeon proceeded with theplanned operation, avoiding excision of the tumor or manip-ulation of the lymphatic drainage system while the ICG wasmigrating within the lymphatic channels to the SLN for atleast 5 minutes and for up to 20 minutes. Inconsistent visu-alization of migration and/or SLN identification led to thefollowing alterations of our initial technique.

Imaging PlatformAt the onset of our trial, most lung resections were per-

formed through a thoracotomy, making the open FLARE

TABLE 1. Initial sentinel lymph node biopsy mapping studies in

non–small cell lung cancer

Group Year Technique Success rate (%)

Little et al14 1999 Blue dye 47

Liptay et al15 2000 Radioisotope 81

Liptay et al16 2009 Radioisotope 51

Noromi et al17 2007 Preoperative radioisotope 81

Schmidt et al18 2002 Intraoperative blue

dye/radioisotope

81

Tiffet et al19 2005 Intraoperative blue

dye/radioisotope

54

FIGURE 1. Near-infrared imaging. The light source of normal white light

and near-infrared fluorescence is reflected off the surgical field and col-

lected by the camera, producing a real-time merged image.

Session VIII: Innovation and the Future Gilmore et al

S82 The Journal of Thoracic and Cardiovascular Surgery c September 2012

Sen4nellymphnodewithnear-infraredfluorescentinNSCLC–Bostongroupstudy

Sen4nellymphnodeNear-infraredfluorescentinNSCLC

lower lobe in the residual three injections and from theleft lower lobe in 2 animals (Table 3). This highlights thevariability of lymphatic mapping in the lung, with asignificant number of SLN being located within the N2mediastinal stations and skipping traditional N1 nodes“nearest” the tumor.

Comment

In this preclinical study, we demonstrate feasibility ofNIR fluorescence-guided SLN mapping using the clin-ically available fluorophore ICG. Previously, we haveshown the utility of NIR quantum dots for intraopera-tive SLN mapping of the lung and pleura in swine [21,22]. Unfortunately, quantum dot fluorophores are cur-rently not approved for human use and, given the

concern of heavy metal content, will not be approvedin the near future. Direct identification of SLN withICG alone requires a large dose of ICG that carries arisk of anaphylaxis and may lead to diffuse greenstaining and distortion of the surgical field [19, 20]. Lowdoses of ICG bound to plasma proteins enhance fluo-rescence intensity of ICG, and allow NIR detectionwith light-emitting diode– based excitation light in asafe environment without the use of lasers, withoutradiation risk, and without distortion of the surgicalfield. Using a large-animal model, the current studydemonstrates that NIR fluorescence imaging with ICGis an effective, simple, and rapid method for SLNmapping in the lung. Furthermore, a dramatic en-hancement of ICG fluorescence is seen when boundwith plasma proteins, resulting in protein concentra-

Color NIR Fluorescence Color-NIR Merge

3 m

in

post

-inje

c!on

D

isse

cted

SLN

1 cm Inj

*

0.5 cm

Fig 4. In vivo and ex vivo identification of the sentinel lymph node (SLN) using 250 !M indocyanine green (ICG):porcine plasma (PL). Thetop row demonstrates in vivo near-infrared (NIR) imaging of the injection site, lymphatic migration, and SLN identification. After resection ofthe SLN, bottom row, ex vivo NIR fluorescence imaging confirms uptake of ICG within the lymph nodes. Arrow indicates primary SLN; ar-rowhead indicates bronchus, and asterisk (*) indicates secondary lymph node.

Fig 5. Dose-dependent increase in signal-to-background (SBR) and signal-to-bronchus ra-tio (SBrR): After in vivo injection of 200 !L of125 !M or 250 !M bound to porcine plasma,the SBR and SBrR were calculated. There is adose-dependent increase in both (A) SBR and(B) SBrR when compared with the 10 !Mdose.

316 KHULLAR ET AL Ann Thorac SurgSENTINEL LYMPH NODE MAPPING IN PORCINE LUNG 2013;95:312–8

GEN

ERA

LT

HO

RA

CIC

Sen4nellymphnodewithnear-infraredfluorescentinNSCLC–Bostongroupstudy

DrainagepleuralCombiendedrain?…1

TohokuJExpMed.2014;232(1):55-61.Postopera<vedrainagewithonechesttubeisappropriateforpulmonarylobectomy:arandomizedtrial.TanakaM,SagawaM,UsudaK,MachidaY,UenoM,MotonoN,SakumaT.Toexpandpostopera4veresiduallungsagerpulmonarylobectomy,thoracicdrainagewithtwochesttubeshasbeenrecommended.Severalstudiesrecentlydemonstratedthatpostopera4vedrainagewithonechesttube(PD1)wasassafeasthatwithtwochesttubes(PD2).However,mostofthepa4entsinthosestudiesunderwentlobectomybystandardthoracotomy.Althoughthenumberofpulmonarylobectomiesbyvideo-assistedthoracicsurgery(VATS)hasbeenincreasinginrecentyears,therehavebeennoreportsthatcomparedPD1withPD2agerpulmonarylobectomy,includingthatbyVATS.Toelucidatewhetherpostopera4vemanagementwithPD1isassafeasthatwithPD2,weconductedarandomizedcontrolledtrial.

Inconclusion,sincePD1hasadvantagesinsavingcostand<meandinlowriskoftranscutaneousinfec<on,PD1isappropriatea`erpulmonarylobectomybyVATSandbyopenthoracotomy.

DrainagepleuralOnl’enlèvequand?EurJCardiothoracSurg.2014Feb;45(2):241-6.Earlychesttuberemovala`ervideo-assistedthoracicsurgerylobectomywithserousfluidproduc<onupto500ml/day.BjerregaardLS,JensenK,PetersenRH,HansenHJ.Infast-trackpulmonaryresec4ons,weremovedchesttubesagervideo-assistedthoracicsurgery(VATS)lobectomywithserousfluidproduc4onupto500ml/day.Subsequently,weevaluatedthefrequencyofrecurrentpleuraleffusionsrequiringreinterven4on.Datafrom622consecu4vepa4entsundergoingVATSlobectomyfromJanuary2009toDecember2011wereregisteredprospec4velyinanins4tu4onaldatabase.Dataincludedage,gender,lobe(s)resected,bleedinganddura4onofsurgery.Follow-upwas30daysfromdischarge.Allcomplica4onsrequiringpleurocentesisorreinser4onofachesttube,andallreadmissionswereregistered.Twenty-threepa4entswereexcludedduetomissingdata,in-hospitalmortalityandlosstofollow-up,leaving599forfinalanalysis.Ourprimaryoutcomewasthenumberofpa4entsrequiringreinterven4onduetorecurrentpleuraleffusion.Secondaryoutcomesincluded4meofchesttuberemovaland4metodischarge.Theincidenceofrecurrentpleuraleffusionsrequiringreinterven4onwascomparedbetweenthreegroupsaccordingtothepostopera4veday(POD)ofchesttuberemoval(Day0-1,2-3and≥4,respec4vely)usingFisher'sexacttest.

Ourfindingssuggestthatchesttuberemovala`erVATSlobectomyissafedespitevolumesofserousfluidproduc<onupto500ml/day.Thepropor4onofpa4entswhodevelopedpleuraleffusionnecessita4ngreinterven4onwaslow(2.8%),andacomplica4onofthereinterven4onwasseeninonly1pa4ent.

DrainagepleuralCombiendedrain?…ZERO

EurJCardiothoracSurg.2013Aug;44(2):225-9;discussion229.Omiingchesttubedrainagea`erthoracoscopicmajorlungresec<on.UedaK,HayashiM,TanakaT,HamanoK.Absorbablemeshandfibringlueappliedtopreventalveolarairleakagecontributetoreducingthelengthofchesttubedrainage,lengthofhospitaliza4onandtherateofpulmonarycomplica4ons.Thisstudyinves4gatedthefeasibilityofomi�ngchesttubedrainageinselectedpa4entsundergoingthoracoscopicmajorlungresec4on.Intraopera4veairleakagesweresealedwithfibringlueandabsorbablemeshinpa4entsundergoingthoracoscopicmajorlungresec4on.Thechesttubewasremovedjustagertrachealextuba4onifnoairleakagesweredetectedinasuc4on-inducedairleakagetest,whichisanoriginaltechniquetoconfirmpneumostasis.Pa4entswithbleedingtendencyorextensivethoracicadhesionswereexcluded.

Therefinedstrategyforpneumostasisallowedtheomissionofchesttubedrainageinthemajorityofpa<entsundergoingthoracoscopicmajorlungresec<onwithoutincreasingtheriskofadverseevents,whichmaycontributetoafast-tracksurgery.

AnesthésiePériduraleoublocparavertébral,c’estu4le?

JCardiothoracVascAnesth.2012Feb;26(1):78-82.Thoracicepiduralorparavertebralcatheterforanalgesiaa`erlungresec<on:istheoutcomedifferent?ElsayedH,McKevithJ,McShaneJ,ScawnN.Theaimofthisstudywastodeterminewhetherthoracicepiduralanalgesia(TEA)oraparavertebralcatheterblock(PVB)withmorphinepa4ent-controlledanalgesiainfluencedoutcomeinpa4entsundergoingthoracotomyforlungresec4on.Thestudypopula4onconsistedof1,592pa4entswhohadundergonethoracotomyforlungresec4onbetweenMay2000andApril2008.

Paravertebralcatheteranalgesiawithmorphinepa<ent-controlledanalgesiaseemsaseffec<veasthoracicepiduralforreducingtheriskofpostopera<vecomplica<ons.Theauthorsaddi<onallyfoundthatparavertebralcatheteruseisassociatedwithashorterhospitalstayandmaybeabePerformofanalgesiaforfast-trackthoracicsurgery.

FasttrackinthoracicsurgeryRapportd’expérience…EurJCardiothoracSurg.2009Aug;36(2):383-91;discussion391-2.Fast-trackrehabilita<onforlungcancerlobectomy:afive-yearexperience.Das-Neves-PereiraJC,BaganP,Coimbra-IsraelAP,Grimaillof-JuniorA,Cesar-LopezG,Milanez-de-CamposJR,RiquetM,Biscegli-JateneF.Fast-trackrehabilita4onisagroupofsimplemeasuresthatreducesmorbidity,postopera4vecomplica4onandacceleratespostopera4verehabilita4onreducinghospitalstay.Itcanbeappliedtolungcancerlobectomy.Fast-trackrehabilita4oncornerstonesare:minimallyinvasivesurgicaltechniquesusingvideo-assistedandmusclesparringincisions,normovolemia,normothermia,goodoxygena4on,euglicemia,nounnecessaryan4bio4cs,epiduralpa4ent-controlledanalgesia,systemicopiods-freeanalgesia,earlyambula4onandoralfeeding.Ourobjec4veistodescribeafive-yearexperiencewithfast-trackrehabilita4onAretrospec4venon-controlledstudyincluding109consecu4vepa4entssubmihedtofast-trackrehabilita4oninthepostopera4vecareoflungcancerlobectomywasperformed.Onlycollabora4vepa4entswhocouldreceivedouble-lumenintuba4on,epiduralcatheterswithpa4ent-controlledanalgesia,whohadKarnofskyindexof100,previousnormalfeedingandambula4on,absenceofmorbidobesity,diabetesorasthma,wereeligible.Postopera4veoralfeedingandaggressiveambula4onstartedassoonaspossible.

Fast-trackrehabilita<onforlungcancerlobectomiescanbesafelyperformedinaselectedgroupofpa<entsifamo<vatedmul<disciplinarygroupofprofessionalsisavailableandseemstoreducepostopera<vecomplica<onandhospitalstay.

I4néraireUnpa4entdansunmouvementdèslepremiercontact…

CMOinterven4onchirurgicale

Bilanpréopératoire

Interven4onchirurgicale

Objec4fs

QUALITÉ&SÉCURITÉ

PERSONNEL

PATIENTS

GESTIONFINANCIÈRE

•  Lepa4entpartenairedesonrétablissement•  Lepa4entpréparéàsoninterven4on•  L’anxiétépriseencharge•  Lepa4entpluri-consulterapidement•  Lasor4edupa4entestan4cipée

•  Ledélaicourtentrelechoixthérapeu4queetl’interven4on

•  Lespa4entscondi4onnésphysiquementàl’interven4on(dénutrironsdétectée,évalua4onanesthésiste)

•  Réconcilia4onmédicamenteuse•  Ges4ondeladouleurefficaceetprécoce•  Larééduca4onimmédiate

•  Chaquemé4ersaitcequ’ildoitfaireetquand•  Touslespa4entsconnusparl’équipe•  Transmissionsdesinforma4onsclairesbaséesur

lesobjec4fsaaheindre

•  Diminuerladuréemoyennedeséjour

Consulta4onmédico-chirurgicale/Ruth

Check-list,planifica4onexamenscompl.SNetRDVparamédicaux

Décisioninterven4onchirurgicaleenCMO

Vendredi

Programma4on

ExamenscomplémentairesRDVkiné13hÉvalua4onrespiratoiredupa4ent

Remisedel’insen4vepourkinédomicile

Valida4ondeladateopératoire

DimPM14h

hospitalisa4on

Consulta4on:médico-chirurgicaleAnesthésiePrévenir:KinésithérapeuteetA.Social

Remisebrochureinforma4ve

CMODécisionchirurgie

Programma4onjournéeconsulta4ons:Ruth

Co-programma4onQO:SecrchirthoraciqueetRuth+info

pa<enttél.

Consulta4onanesthésiste

PsychologueSNtabaccoSN

mardi

Mercredi11h/11h30

PassageAS

BonECG

Consulta4onpneumologie

Informa4onpa4entchoixthérapeu4queetdateopératoireÉvalua4onnutri4onnelle

omnimail

OrdremédicauxPMI

Évalua4oninterven4on

ok?

omnimail

0

2

4

6

8

10

Na4onale Historiquetomie HistoriqueVATS Fast-trackVATSRobo4c

I4néraireNosrésultats…

Conclusions

•  Lefastrackestunesurlacons4tu4ondeparcourtdesoinsbaséssurl’evidencebasemedicinequiréduitlestressphysiqueetpsychiqueliéàl'interven4on.

•  C’estunevisionintégréeetinterdisciplinairedelapriseenchargedupa4ent.

•  Cehedémarchediminueladuréeduséjourhospitalier,lescoûtsgénérauxetpourraitraisonnablementavoirunimpactsurlamorbi-mortalité(cfchirurgiediges4veetcardiaque).

Conclusions

•  L’avenirdelaChirurgieThoraciqueestdoncl’intégra4ondesdifférentsmé4ersdansdesmissionscommunesdéfiniesautouretaveclepa4entpourchaquepathologie.

•  L’organisa4ondeshôpitauxdoitêtrerevuefondamentalementetorganiséeen“trajetsdesoins”plutôtqu’enservicesmédicauxetparamédicaux.

Entransplanta4onpulmonaire,onpeutencoreavancer?

Theshortageofdonorlungs

•  AccordingtotheThir:ethAdultLungandHeart-LungTransplantReport2013,fromtheRegistryoftheInterna4onalSocietyforHeartandLungTransplanta4on,lungtransplanta4on(LTx)isatherapythatisbeingperformedworldwide,withnumbersincreasingeveryyear.

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4000

1985

1986

1987

1988

1989

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Belgium, 2013



•  Nevertheless,theamountoflungssuitablefortransplanta4onhasnotfollowedthistrendandthisequa4ongeneratesconsiderablewaitlistmortality(15,4per100wait-listyearsintheUSform2010to2012).


0

20

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1988

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1994

1995

1996

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2003

2004

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Patie

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Valapour,AmJTransplant,2013

0%

20%

40%

60%

80%

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1987

1988

1989

1990

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1994

1995

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0

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0-11 12-17 18-34 35-49 50-59 60+ Donor mean age

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•  Themeanageoflungdonorincreaseswithdecreasinginrela4veorganquality(ET:From21in1989to39in2009).


•  Donor lungs are subjected to several injurious mechanisms during the brain death/organ donation process (such as ventilator-acquired pneumonia, neurogenic and hydrostatic pulmonary edema, barotrauma). Thus, it is not surprising that the majority of donor lungs are not utilized for transplantation (39% ET 2012, 22% in the US 2012).


StrategiesforlungdonorpoolexpansionIdealdonor

•  Idealdonor:•  <55year-old,•  <20pack-yearsmokinghistory,•  nochesttrauma,•  clearchestX-ray,•  centralP/F>300,•  absenceofpurulentsecre4onsandorganismsongramstainofrespiratory

samples.

•  Thisscenarioisknowntocorrespondtolessthanhalfofthedonorsu4lizedfortransplanta4on.

Pierre,JThoracCardiovascSurg,2002

StrategiesforlungdonorpoolexpansionExtendedcriteriadonor

•  Severalstudiesaddressingtheuseofextendedcriteriadonors•  Areviewstudysummarizedthefindingsof10studiesrangingfrom1993

to2010,bringingthebestevidenceuptodate.•  Althoughnocleardifferencesinmidorlong-termsurvivalwereobserved,4of

thesestudiesrevealedworseearlyoutcomes(suchas30-and90-daymortality,ICUandhospitalstayandgasexchangeatICUarrival).

•  Recently,theHannovergrouphasshownaninteres4ngalgorithmproposingalloca4onofextendedcriteriadonorlungstolower-riskrecipients.Resultswereencouraginganddeservefurtheranalysis.

Schiavon,InteractCardiovascThoracSurg,2012

Sommer,JHeartLungTransplant,2013

StrategiesforlungdonorpoolexpansionControlledDCDdonor

•  The first successful LTx was performed from DCD (Hardy - 1963) •  the concept of using controlled DCD lungs has been clinically

revisited by D’Alessandro in 1995.

•  Series of studies have followed, reporting an increasing international experience and highlighting the potential of DCD to partially address the shortage of donor lungs… But…

•  Nevertheless, caution is still observed in the transplant community as there are a series of specific injuries that the DCD lung is prone to, specially during the interval from withdrawal of life sustaining therapies to pulmonary artery flush.

D’Alessandro,Transplanta<on,1995

Cypel,JHeartLungTransplant,2009Erasmus,Transplanta<on,2010LoveRB,AmJTransplant,2012Mason,AnnThoracSurg2012

DeOliveira,JThoracCardiovascSurg,2010Levvey,AmJTransplant,2012

Puri,AnnThoracSurg,2009

StrategiesforlungdonorpoolexpansionUncontrolledDCDdonor

•  Anotherpoten4alsourceoflungscomesfromtheuseofuncontrolledDCDs(MaastrichtcategoriesIandII).

•  ThegroupofMadridhasexploredthispeculiarpool,repor4ngtheexperiencewith29cases.Ninety-dayand1-yearmortalitywere22%and32%respec4vely,withhigherratesofprimarygragdysfunc4on(PGD)2-3thanexpected.

deAntonio,JHeartLungTransplant,2007

StrategiesforlungdonorpoolexpansionExvivolungperfusion

•  ClinicalEVLPwasshowntosafelyincreasethedonorpoolbypreservinghigh-riskdonorlungswithsimilaroutcomestostandardcriteriadonorlungs.

CypelM,NEnglJMed,2011

EVLP – Philosophies…

•  Evaluation – Extending donor pool •  Improving quality – Reconditionning •  Prolong perfusion and/or transport time •  Research

EVLP Evaluation – Extending donor pool

•  Evaluation of poor prognostic donor… •  DCD donor •  Circulatory death •  Extending criteria donor •  Hanging victim •  Infected or suspicion of infection

•  Evaluation of in vivo inevaluable donor… •  Maastricht 2 •  High-pressure pneumoplegia •  ECMO

•  Evaluation for prognosing… •  Perfusate protein expression during EVLP can differentiate lungs with good

outcome from lungs PGD3 after transplantation.

Elgharably,ThoracSurgClin,2015

Bozso,CanRespirJ,2014

Machuca,AnnSurg.2014

Bozso,TransplInt,2014

BenneP,AnnThoracSurg,2014

Suzuki,AmJTransplant,2014

Boffini,TransplInt,2014

Pa<l,JThoracCardiovascSurg,2014

GarcíaSáez,EurJCardiothoracSurg,2014


Transplant Proc. 2013 Sep;45(7):2624-6.

Ex vivo lung perfusion increases the pool of lung grafts: analysis of its potential and real impact on a lung transplant program. Boffini, Ricci, Barbero, Bonato, Ribezzo, Mancuso, Attisani, Simonato, Magistroni, Mansouri, Solidoro, Baldi, Pasero, Amoroso, Rinaldi.

BACKGROUND: Among the strategies to increase the number of lung transplants, ex vivo lung perfusion (EVLP) represents a novel technique to expand the donor pool. METHODS: Data from donors referred to our center were retrospectively analyzed to identify grafts that could potentially be potentially reconditioned by EVLP and for comparison with those obtained by clinical application of EVLP program in our center. RESULTS: Among 75 rejected lungs, 23 organs have been identified as potentially treatable with EVLP with a hypothetic increase of lung transplant activity of 53%. After the introduction of the EVLP program in our center, lung transplantation with reconditioned grafts was performed in 7 (23%) patients with a 30% increase in transplant procedures. CONCLUSION: Although less than expected, EVLP increased the number of lungs suitable for transplantation.

EVLP Improving quality – Reconditioning

•  Improve function… •  EVLP alone •  Plasmin administration •  Hydrogen preconditioning

•  Treating… •  Aspiration with intrabronchial surfactant instillation •  Acute pulmonary embolism with urokinase •  Reducing microbial load by high-dose empirical AB •  Inflammation by mechanical removal of dendritic cell-generating non-classical monocytes

•  Surgical act… •  LVRS - Lobectomy

Cypel,ThoracSurgClin,2015

Motoyama,JHeartLungTransplant,2014

Noda,Transplanta<on,2014

Inci,JSurgRes,2013

Inci,AnnThoracSurg,2014

Andreasson,JHeartLungTransplant,2014

Stone,JHeartLungTransplant,2014

Nosoi,TransplantProc,2014

WorldwideexperiencewithclinicalEVLPResults

•  Toronto conducted a nonrandomized clinical trial to assess the feasibility of EVLP selecting high-risk donor lungs for this modality of preservation.

•  23 donor lungs were submitted to EVLP, •  20 being ultimately transplanted (15 bilateral/5 unilateral), •  PGD grade 2 or 3 at 72 hours: 15% of the EVLP group and 30% of the

contemporary no EVLP controls (116 cases), with no significant difference, •  Time on mechanical ventilation, ECLS requirement, ICU stay, hospital stay and

30-day mortality were not different.

•  This experience was recently updated… •  with a total of 50 lung transplants from 58 EVLPs (86% yield), •  PGD 3 at 72 hours was recorded in 2% EVLP vs. 8.5% control (P=0.14), •  Again, time on mechanical ventilation, ECLS requirement, ICU stay, hospital stay

and 30-day mortality were not different, •  1-year survivals: 87% for EVLP group vs. 86% for the standard group.


Cypel,JThoracCardiovascSurg,2012


•  Vienna reported their experience… •  13 clinical EVLPs which rendered 9 double-lung transplants (69% yield), •  Early outcomes - days on mechanical ventilation, ICU stay, hospital stay and 30-

day mortality were comparable to 119 contemporary conventional preservation transplants,

•  Interestingly, all the four declined cases developed massive pulmonary edema and were recovered from donors with trauma history.

•  The groups from Toronto, Vienna and Paris presented their clinical EVLP experience at the 2013 ISHLT meeting.

•  A total of 125 clinical EVLPs were performed with an 82.5% yield, •  Incidence of PGD3 at 72 hours was 5% and the 12-month mortality was 12%.

Aigner,AmJTransplant,2012

Cypel,JournalofHeartandLungTransplanta<on2013


•  TheNOVELLungtrialisanFDAmandatedmul4centerclinicaltrial(NOVELLungTrial)studyingEVLPformarginaldonors.

•  Theini4alreportincluded31pa4entsthatreceivedEVLPlungs.EarlyoutcomessuchasPGD,lengthonmechanicalven4la4on,ICUstay,hospitalstayand30-daymortalityweresimilarto31non-EVLPcontrols.

•  Atthe2014ISHLTmee4ng,thetrialresultswereupdatedto76EVLPsrendering42lungtransplants(55%conversionrate).Incomparisonwith42contemporarycontrols,earlyoutcomesand1-yearsurvivalwerenotdifferent.

Sanchez,JHeartLungTransplant,2014


EVLPProlongperfusionand/ortransport4me

Am J Transplant. 2014 Oct;14(10):2412-6.

Combined liver and lung transplantation with extended normothermic lung preservation in a patient with end-stage emphysema complicated by drug-induced acute liver failure. Ceulemans, Monbaliu, Verslype, van der Merwe , Laleman , Vos , Neyrinck, Van Veer, De Leyn , Nevens , Pirenne , Verleden , Van Raemdonck . Isolated lung transplantation (LuTx) and liver transplantation are established treatments for irreversible lung and liver failure. Combined liver and lung transplantation (cLiLuTx) is a less common, but approved therapy of combined organ failure, mostly applied in patients suffering from progressive cystic fibrosis and advanced liver disease. We report a patient who was listed for LuTx due to end-stage chronic obstructive pulmonary disease and who developed drug-induced acute hepatic failure. The only therapeutic option was hyper-urgent cLiLuTx. To correct the poor coagulation in order to reduce the per-operative risk of bleeding, the liver was transplanted first. In anticipation of the longer lung preservation time, cold flushed lungs were preserved on a portable lung perfusion device for ex vivo normothermic perfusion for 11 h 15 min, transplanted sequentially off-pump, and reperfused after a total ex vivo time of 13 h 32 min and 16 h for the first and second lung, respectively. Ten months later, the patient is doing well and no rejection occurred. Normothermic ex vivo lung perfusion may help to prolong preservation time, facilitating long-distance transport and combined organ transplantation..


Eur J Cardiothorac Surg. 2014 Mar;45(3):e54-60.

Successful prolonged ex vivo lung perfusion for graft preservation in rats. Noda, Shigemura, Tanaka, Bhama, D'Cunha, Luketich, Bermudez.

Ex vivo lung perfusion (EVLP) strategies represent a new frontier in lung transplantation technology, and there have been many clinical studies of EVLP in lung transplantation. The establishment of a reliable EVLP model in small animals is crucial to facilitating translational research using an EVLP strategy. The main objective of this study was to develop a reproducible rat EVLP (R-EVLP) model that enables prolonged evaluation of the explanted lung during EVLP and successful transplantation after EVLP. The donor heart-lung blocks were procured with cold low-potassium dextran solution and immersed in the solution for 1 h at 4 °C. And then, the heart-lung blocks were flushed retrogradely and warmed up to 37 °C in a circuit perfused antegradely with acellular perfusate. The perfusate was deoxygenated with a gas mixture (6% O2, 8% CO2, 86% N2). The perfusion flow was maintained at 20% of the entire cardiac output. At 37 °C, the lungs were mechanically ventilated and perfusion continued for 4 h. Every hour, the perfused lung was evaluated for gas exchange, dynamic lung compliance (Cdyn) and pulmonary vascular resistance (PVR). R-EVLP was performed for 4 h. Pulmonary oxygenation ability (pO2/pCO2) was stable for 4 h during EVLP. It was noted that Cdyn and PVR were also stable. After 4 h of EVLP,

EVLPResearch

World J Exp Med. 2014 May 20;4(2):7-15.

Animal models of ex vivo lung perfusion as a platform for transplantation research. Nelson, Bobba, Ghadiali, Hayes, Black, Whitson. Ex vivo lung perfusion (EVLP) is a powerful experimental model for isolated lung research. EVLP allows for the lungs to be manipulated and characterized in an external environment so that the effect of specific ventilation/perfusion variables can be studied independent of other confounding physiologic contributions. At the same time, EVLP allows for normal organ level function and real-time monitoring of pulmonary physiology and mechanics. As a result, this technique provides unique advantages over in vivo and in vitro models. Small and large animal models of EVLP have been developed and each of these models has their strengths and weaknesses. In this manuscript, we provide insight into the relative strengths of each model and describe how the development of advanced EVLP protocols is leading to a novel experimental platform that can be used to answer critical questions in pulmonary physiology and transplant medicine.

•  The use of EVLP… •  allows an objective assessment of high-risk donor lungs. •  autorize treatment, reconditionning of suposed non-transplantable

lungs. •  permits when these lungs are transplanted, acceptable rates of primary

graft dysfunction, with an early and mid-term outcomes similar to those with conventionally selected and transplanted lungs.

•  permits to explore new source of donors (DCD donor, circulatory death, extending criteria donor, hanging victim, infected organs, ECMO…).

•  help to prolong preservation time, facilitating long-distance transport and combined organ transplantation.

•  leads to experimental platform that can be used to answer questions in pulmonary physiology and transplant medicine.

Conclusions



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3500

4000

1985

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1987

1988

1989

1990

1991

1992

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1994

1995

1996

1997

1998

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2002

2003

2004

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2010

Num

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Bilateral/DoubleLung

SingleLung


KUL53

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Belgium, 2013



•  Nevertheless,theamountoflungssuitablefortransplanta4onhasnotfollowedthistrendandthisequa4ongeneratesconsiderablewaitlistmortality(15,4per100wait-listyearsintheUSform2010to2012).


0

20

40

60

80

100

120

140

160

180

200

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

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2002

2003

2004

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2008

Patie

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En attente(n)Transplantés (n)

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Valapour,AmJTransplant,2013

0%

20%

40%

60%

80%

100%

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

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2004

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2006

2007

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)

•  Themeanageoflungdonorincreaseswithdecreasinginrela4veorganquality(ET:From21in1989to39in2009).


•  Donor lungs are subjected to several injurious mechanisms during the brain death/organ donation process (such as ventilator-acquired pneumonia, neurogenic and hydrostatic pulmonary edema, barotrauma). Thus, it is not surprising that the majority of donor lungs are not utilized for transplantation (39% ET 2012, 22% in the US 2012).


StrategiesforlungdonorpoolexpansionIdealdonor

•  Idealdonor:•  <55year-old,•  <20pack-yearsmokinghistory,•  nochesttrauma,•  clearchestX-ray,•  centralP/F>300,•  absenceofpurulentsecre4onsandorganismsongramstainofrespiratory

samples.

•  Thisscenarioisknowntocorrespondtolessthanhalfofthedonorsu4lizedfortransplanta4on.

Pierre,JThoracCardiovascSurg,2002

StrategiesforlungdonorpoolexpansionExtendedcriteriadonor

•  Severalstudiesaddressingtheuseofextendedcriteriadonors•  Areviewstudysummarizedthefindingsof10studiesrangingfrom1993

to2010,bringingthebestevidenceuptodate.•  Althoughnocleardifferencesinmidorlong-termsurvivalwereobserved,4of

thesestudiesrevealedworseearlyoutcomes(suchas30-and90-daymortality,ICUandhospitalstayandgasexchangeatICUarrival).

•  Recently,theHannovergrouphasshownaninteres4ngalgorithmproposingalloca4onofextendedcriteriadonorlungstolower-riskrecipients.Resultswereencouraginganddeservefurtheranalysis.

Schiavon,InteractCardiovascThoracSurg,2012

Sommer,JHeartLungTransplant,2013

StrategiesforlungdonorpoolexpansionControlledDCDdonor

•  The first successful LTx was performed from DCD (Hardy - 1963) •  the concept of using controlled DCD lungs has been clinically

revisited by D’Alessandro in 1995.

•  Series of studies have followed, reporting an increasing international experience and highlighting the potential of DCD to partially address the shortage of donor lungs… But…

•  Nevertheless, caution is still observed in the transplant community as there are a series of specific injuries that the DCD lung is prone to, specially during the interval from withdrawal of life sustaining therapies to pulmonary artery flush.

D’Alessandro,Transplanta<on,1995

Cypel,JHeartLungTransplant,2009Erasmus,Transplanta<on,2010LoveRB,AmJTransplant,2012Mason,AnnThoracSurg2012

DeOliveira,JThoracCardiovascSurg,2010Levvey,AmJTransplant,2012

Puri,AnnThoracSurg,2009

StrategiesforlungdonorpoolexpansionUncontrolledDCDdonor

•  Anotherpoten4alsourceoflungscomesfromtheuseofuncontrolledDCDs(MaastrichtcategoriesIandII).

•  ThegroupofMadridhasexploredthispeculiarpool,repor4ngtheexperiencewith29cases.Ninety-dayand1-yearmortalitywere22%and32%respec4vely,withhigherratesofprimarygragdysfunc4on(PGD)2-3thanexpected.

deAntonio,JHeartLungTransplant,2007

StrategiesforlungdonorpoolexpansionExvivolungperfusion

•  ClinicalEVLPwasshowntosafelyincreasethedonorpoolbypreservinghigh-riskdonorlungswithsimilaroutcomestostandardcriteriadonorlungs.



•  Evaluation of poor prognostic donor… •  DCD donor •  Circulatory death •  Extending criteria donor •  Hanging victim •  Infected or suspicion of infection

•  Evaluation of in vivo inevaluable donor… •  Maastricht 2 •  High-pressure pneumoplegia •  ECMO

•  Evaluation for prognosing… •  Perfusate protein expression during EVLP can differentiate lungs with good

outcome from lungs PGD3 after transplantation.

Elgharably,ThoracSurgClin,2015

Bozso,CanRespirJ,2014

Machuca,AnnSurg.2014

Bozso,TransplInt,2014

BenneP,AnnThoracSurg,2014

Suzuki,AmJTransplant,2014

Boffini,TransplInt,2014

Pa<l,JThoracCardiovascSurg,2014

GarcíaSáez,EurJCardiothoracSurg,2014


Transplant Proc. 2013 Sep;45(7):2624-6.

Ex vivo lung perfusion increases the pool of lung grafts: analysis of its potential and real impact on a lung transplant program. Boffini, Ricci, Barbero, Bonato, Ribezzo, Mancuso, Attisani, Simonato, Magistroni, Mansouri, Solidoro, Baldi, Pasero, Amoroso, Rinaldi.

BACKGROUND: Among the strategies to increase the number of lung transplants, ex vivo lung perfusion (EVLP) represents a novel technique to expand the donor pool. METHODS: Data from donors referred to our center were retrospectively analyzed to identify grafts that could potentially be potentially reconditioned by EVLP and for comparison with those obtained by clinical application of EVLP program in our center. RESULTS: Among 75 rejected lungs, 23 organs have been identified as potentially treatable with EVLP with a hypothetic increase of lung transplant activity of 53%. After the introduction of the EVLP program in our center, lung transplantation with reconditioned grafts was performed in 7 (23%) patients with a 30% increase in transplant procedures. CONCLUSION: Although less than expected, EVLP increased the number of lungs suitable for transplantation.

EVLP Improving quality – Reconditioning

•  Improve function… •  EVLP alone •  Plasmin administration •  Hydrogen preconditioning

•  Treating… •  Aspiration with intrabronchial surfactant instillation •  Acute pulmonary embolism with urokinase •  Reducing microbial load by high-dose empirical AB •  Inflammation by mechanical removal of dendritic cell-generating non-classical monocytes

•  Surgical act… •  LVRS - Lobectomy

Cypel,ThoracSurgClin,2015

Motoyama,JHeartLungTransplant,2014

Noda,Transplanta<on,2014

Inci,JSurgRes,2013

Inci,AnnThoracSurg,2014

Andreasson,JHeartLungTransplant,2014

Stone,JHeartLungTransplant,2014

Nosoi,TransplantProc,2014


•  Toronto conducted a nonrandomized clinical trial to assess the feasibility of EVLP selecting high-risk donor lungs for this modality of preservation.

•  23 donor lungs were submitted to EVLP, •  20 being ultimately transplanted (15 bilateral/5 unilateral), •  PGD grade 2 or 3 at 72 hours: 15% of the EVLP group and 30% of the

contemporary no EVLP controls (116 cases), with no significant difference, •  Time on mechanical ventilation, ECLS requirement, ICU stay, hospital stay and

30-day mortality were not different.

•  This experience was recently updated… •  with a total of 50 lung transplants from 58 EVLPs (86% yield), •  PGD 3 at 72 hours was recorded in 2% EVLP vs. 8.5% control (P=0.14), •  Again, time on mechanical ventilation, ECLS requirement, ICU stay, hospital stay

and 30-day mortality were not different, •  1-year survivals: 87% for EVLP group vs. 86% for the standard group.


Cypel,JThoracCardiovascSurg,2012


•  Vienna reported their experience… •  13 clinical EVLPs which rendered 9 double-lung transplants (69% yield), •  Early outcomes - days on mechanical ventilation, ICU stay, hospital stay and 30-

day mortality were comparable to 119 contemporary conventional preservation transplants,

•  Interestingly, all the four declined cases developed massive pulmonary edema and were recovered from donors with trauma history.

•  The groups from Toronto, Vienna and Paris presented their clinical EVLP experience at the 2013 ISHLT meeting.

•  A total of 125 clinical EVLPs were performed with an 82.5% yield, •  Incidence of PGD3 at 72 hours was 5% and the 12-month mortality was 12%.

Aigner,AmJTransplant,2012

Cypel,JournalofHeartandLungTransplanta<on2013


•  TheNOVELLungtrialisanFDAmandatedmul4centerclinicaltrial(NOVELLungTrial)studyingEVLPformarginaldonors.

•  Theini4alreportincluded31pa4entsthatreceivedEVLPlungs.EarlyoutcomessuchasPGD,lengthonmechanicalven4la4on,ICUstay,hospitalstayand30-daymortalityweresimilarto31non-EVLPcontrols.

•  Atthe2014ISHLTmee4ng,thetrialresultswereupdatedto76EVLPsrendering42lungtransplants(55%conversionrate).Incomparisonwith42contemporarycontrols,earlyoutcomesand1-yearsurvivalwerenotdifferent.




Am J Transplant. 2014 Oct;14(10):2412-6.

Combined liver and lung transplantation with extended normothermic lung preservation in a patient with end-stage emphysema complicated by drug-induced acute liver failure. Ceulemans, Monbaliu, Verslype, van der Merwe , Laleman , Vos , Neyrinck, Van Veer, De Leyn , Nevens , Pirenne , Verleden , Van Raemdonck . Isolated lung transplantation (LuTx) and liver transplantation are established treatments for irreversible lung and liver failure. Combined liver and lung transplantation (cLiLuTx) is a less common, but approved therapy of combined organ failure, mostly applied in patients suffering from progressive cystic fibrosis and advanced liver disease. We report a patient who was listed for LuTx due to end-stage chronic obstructive pulmonary disease and who developed drug-induced acute hepatic failure. The only therapeutic option was hyper-urgent cLiLuTx. To correct the poor coagulation in order to reduce the per-operative risk of bleeding, the liver was transplanted first. In anticipation of the longer lung preservation time, cold flushed lungs were preserved on a portable lung perfusion device for ex vivo normothermic perfusion for 11 h 15 min, transplanted sequentially off-pump, and reperfused after a total ex vivo time of 13 h 32 min and 16 h for the first and second lung, respectively. Ten months later, the patient is doing well and no rejection occurred. Normothermic ex vivo lung perfusion may help to prolong preservation time, facilitating long-distance transport and combined organ transplantation..


Eur J Cardiothorac Surg. 2014 Mar;45(3):e54-60.

Successful prolonged ex vivo lung perfusion for graft preservation in rats. Noda, Shigemura, Tanaka, Bhama, D'Cunha, Luketich, Bermudez.

Ex vivo lung perfusion (EVLP) strategies represent a new frontier in lung transplantation technology, and there have been many clinical studies of EVLP in lung transplantation. The establishment of a reliable EVLP model in small animals is crucial to facilitating translational research using an EVLP strategy. The main objective of this study was to develop a reproducible rat EVLP (R-EVLP) model that enables prolonged evaluation of the explanted lung during EVLP and successful transplantation after EVLP. The donor heart-lung blocks were procured with cold low-potassium dextran solution and immersed in the solution for 1 h at 4 °C. And then, the heart-lung blocks were flushed retrogradely and warmed up to 37 °C in a circuit perfused antegradely with acellular perfusate. The perfusate was deoxygenated with a gas mixture (6% O2, 8% CO2, 86% N2). The perfusion flow was maintained at 20% of the entire cardiac output. At 37 °C, the lungs were mechanically ventilated and perfusion continued for 4 h. Every hour, the perfused lung was evaluated for gas exchange, dynamic lung compliance (Cdyn) and pulmonary vascular resistance (PVR). R-EVLP was performed for 4 h. Pulmonary oxygenation ability (pO2/pCO2) was stable for 4 h during EVLP. It was noted that Cdyn and PVR were also stable. After 4 h of EVLP,

EVLPResearch

World J Exp Med. 2014 May 20;4(2):7-15.

Animal models of ex vivo lung perfusion as a platform for transplantation research. Nelson, Bobba, Ghadiali, Hayes, Black, Whitson. Ex vivo lung perfusion (EVLP) is a powerful experimental model for isolated lung research. EVLP allows for the lungs to be manipulated and characterized in an external environment so that the effect of specific ventilation/perfusion variables can be studied independent of other confounding physiologic contributions. At the same time, EVLP allows for normal organ level function and real-time monitoring of pulmonary physiology and mechanics. As a result, this technique provides unique advantages over in vivo and in vitro models. Small and large animal models of EVLP have been developed and each of these models has their strengths and weaknesses. In this manuscript, we provide insight into the relative strengths of each model and describe how the development of advanced EVLP protocols is leading to a novel experimental platform that can be used to answer critical questions in pulmonary physiology and transplant medicine.

•  The use of EVLP… •  allows an objective assessment of high-risk donor lungs. •  autorize treatment, reconditionning of suposed non-transplantable

lungs. •  permits when these lungs are transplanted, acceptable rates of primary

graft dysfunction, with an early and mid-term outcomes similar to those with conventionally selected and transplanted lungs.

•  permits to explore new source of donors (DCD donor, circulatory death, extending criteria donor, hanging victim, infected organs, ECMO…).

•  help to prolong preservation time, facilitating long-distance transport and combined organ transplantation.

•  leads to experimental platform that can be used to answer questions in pulmonary physiology and transplant medicine.

Conclusions

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