Thoracoscopic Pericardiectomy
Poster Presentation: International College of Chest Physicians, Amsterdam, Netherlands, June 1993.
Introduction:
Pericardial effusion in cancer patients is a common
and devastating problem. Metastatic tumor
obstructing the mediastinal lymph nodes draining the
pericardium is the common pathologic finding.
Consequently the tumors most frequently causing
pericardial effusion are lung and breast cancers, with
melanoma, lymphoma and leukemia as less common
causes.
If untreated, death usually results within a few
weeks from tamponade. Rapid recurrence is usual
after pericardiocentesis alone.
Surgical resection of
pericardium can provide relief from tamponade and
extend life, but survival is limited by the advanced
stage neoplasm. Accordingly, the goal of treatment
should be to provide adequate drainage and
prevention of recurrent effusion using a safe
technique that allows the patient to return to a normal
life style as quickly as possible.
Thoracoscopic Pericardiectomy
Patient Characteristics:
Nine consecutive patients underwent thoracoscopic
pericardiectomy between 12/91 and 4/93. There were no
intraoperative deaths. Eight patients with primary
cancers comprise the material for this study.
Males=4 ; Females=4
Primary tumor
Lung cancer=4
Breast cancer=2
Simultaneous uterus and kidney cancer=1
Acute myelogenous leukemia=1
Distant metastasis=4
Severe dyspnea=5
5 or more bronchial segments obstructed=5
Malignant pleural effusion=3
Positive pathology or cytology of pericardium=4
Technique:
Anesthesia:
- 1.Prep and drape awake in supine position.
- 2.Univent tube with endoscopic placement of blocker.
- 3.If unstable- then thoracoscopic pericardiocentesis.
- 4.If stable- then turn into right lateral decubitus.
- 5.Deflate left lung by inflating blocker balloon and
apply suction to catheter.
- 6.Monitor saturation and reinflate left lung prn.
Thoracoscopy:
- 1.First incision in seventh intercostal space under
direct vision and insert thoracoscope via trochar.
- 2.Explore hemithorax; visualize phrenic nerve and
plan resection.
- 3.Make two further incisions under thoracoscopic
vision (one usually anteriorly in fifth interspace and
one postero-inferiorly in fifth interspace.
- 4.Initial incision in pericardium anterior or posterior
to phrenic nerve with sharp tip, right angle scissors.
- 5.Grasp pericardium with long right angle clamp.
- 6.Resect pericardium as extensively as possible with
scissors and electrocautery.
- 7.Close the largest intercostal incision and place chest
tubes via the other two.
Results:
- Intraoperative mortality- 0%
- Intraoperative dysrhythmia-4- 50%
- Intraoperative desaturation-4- 50%
- Required intraoperative thoracoscopic
pericardiocentesis-3- 37.5%
- Required ventilator assistance >24 hours-1-12.5%
- Mean days in hospital-10-(4-21)
- 30 day mortality-2-25%
- Median survival-127 days
- Mean survival-147 days
- Patients still surviving-3-37.5% (128-323 days)
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