Multiple Pulmonary Nodules Clinical Trial
Official title:
Combined Liver and Right Lung Resection for Colorectal Metastases by Means of J-shaped Thoracophrenolaparotomy
The purpose of this study is to determine whether J-shaped thoracophrenolaparotomy is effective in the surgical treatment of simultaneous liver and right lung metastases from colorectal cancer
Right-sided lung metastases are resected synchronously with liver metastases by means of a
thoracophrenolaparotomy.
The pre-operative staging includes for all patients colonoscopy, thoracic and abdominal
contrast enhanced computed tomography (CT), contrast enhanced magnetic resonance (MRI) of
the upper abdomen, and 18-fluorodeoxyglucose PET scan.
Laboratory examinations including liver function tests, spirometry, cardiologic and
anesthesiological evaluation are also performed in alla patients.
Surgical Procedures The patient is placed in supine position with the arms extended
laterally. The anaesthesiologist for selective lung insufflation positions the double lumen
endotracheal tube. The J-shaped abdominal incision conventionally adopted for liver surgery
is performed. In case of tumors involving segment 1 or cranial segment portion of segments 4
superior, 7 and 8 close to the caval confluence, the incision is prolonged along the 9th
right intercostal space allowing the access to thoracic cavity. The incision of the skin and
the external oblique muscle reaches the anterior axillary line. A small portion, about 2
centimetres, of the cartilaginous costal arch is removed, and then the diaphragm is divided
in a radial direction. The inner parietal incision, involving parietal pleura and
intercostal muscles is prolonged up to the posterior axillary line preserving the
intercostal neurovascular bundle.
Intraoperative ultrasound (IOUS) is performed in all patients to stage the liver involvement
as well as to assess the relation between tumors and vascular structures and guidance in the
dissection of hepatic parenchyma. If nodules are isoechoic in comparison to the surrounding
tissue, the staging is completed with contrast-enhanced IOUS (CEIOUS); the contrast agent
consists of 4.8 mL of microbubbles filled with sulfur hexafluoride (SonoVue®; Bracco
Imaging, Italy), which is injected intravenously.
Once surgical strategy is defined, the liver mobilization is completed by dividing the right
and/or left triangular and coronary ligaments as needed. For combining the abdominal and
thoracic procedures the right liver has to be mobilized at least up to the exposure of the
inferior vena cava allowing larger radial incision of the diaphragm and enlarged view field
to the thoracic cavity.
At first the thoracic surgeon performs the pulmonary part. The bed is tilted to the left
side and exposure of right thoracic cavity is gained to the entire lung and the lateral
mediastinum. With deflation and gentle retraction of the ipsilateral lung, the mediastinum
and pericardium are exposed. Pulmonary ligament and lobar fissures are divided as needed.
Manual palpation of the lung to detect the metastatic lesion is carried out. Then, wedge
resection of the lung metastases is performed by using disposable stapler. Allowing the lung
to collapse facilitates application of the stapling device and achievement of an adequate
margin. Absorbable monofilament sutures are used, if necessary, to ensure haemostasis and/or
small air leaks.
The hepatic resection is then started. Briefly, definition of the resection area with the
main purpose of surrounding the tumor at its deepest portion combining the minimal
parenchymal sacrifice and the flattest cut surface is performed under IOUS guidance. The
hilar pedicle is then encircled with a tourniquet if dissection is not intended. Otherwise,
in case of major hepatectomy, hilar dissection is performed. For all patients, parenchymal
transection is obtained under intermittent clamping by Pringle maneuver continued for 15
minutes followed by 5 minutes of reperfusion without preconditioning. After 4 clamping
cycles, reperfusion time is prolonged for 10 minutes. Liver dissection is accomplished using
crush clamping technique, ligating with sutures all the vessels but those thinner which are
coagulated using bipolar electrocautery . Before abdominal closure, the cut surface of the
liver is sealed with haemostatic agent.
Closed suction abdominal drains are inserted in every patient around the liver, in variable
number depending to the number and the size of liver cut surfaces. They are removed on the
7th postoperative day (POD) if the bilirubin level in the drain discharge sampled routinely
on the 3rd, 5th, and 7th POD showed a decrement, and in any case was below 10 mg/ml.
One or two chest tube are placed in the pleural cavity, being removed from the 3rd POD, in
absence of air leak within the bottle and if the serous output is below 200 mL/24h.
The ribs are approximated with pericostal sutures using braided absorbable sutures size 2.
The diaphragm is closed with a single layer running suture. Peritoneum and fasciae of the
chest and abdominal wall are closed in an anatomic pattern. Subcutaneous layer and skin are
finally closed in the routine manner.
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Observational Model: Cohort, Time Perspective: Retrospective
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