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Ann Thorac Surg 2005;80:1143-1145
© 2005 The Society of Thoracic Surgeons

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How to do it

A Median Sternotomy Approach to Right Extrapleural Pneumonectomy for Mesothelioma

Department of Thoracic Surgery, Glenfield Hospital, Leicester, United Kingdom

Accepted for publication April 1, 2004.

^_* Address reprint requests to Dr Waller, Department of Thoracic Surgery, Glenfield Hospital, Groby Rd, Leicester LE3 9QP, UK. (Email: david.waller{at}uhl-tr.nhs.uk).

	Abstract

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Although pulmonary resections have been performed through median sternotomy, this approach for extrapleural pneumonectomy in the management of malignant pleural mesothelioma has not been described. We assessed the feasibility of a median sternotomy approach as an alternative to thoracotomy in right-sided resections. Over a 15-month period, this approach was attempted in 10 cases. In 7 of them, the entire procedure was completed without additional thoracotomy access. There were no postoperative deaths in this group. At median follow-up of 8 months, we have not encountered tumor progression in the scars.

	Introduction

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Standard techniques for right extrapleural pneumonectomy in the radical management of malignant pleural mesothelioma have been described using a right thoracotomy with rib excision as the surgical approach [1, 2]. Pulmonary resections have been described through median sternotomy [3], but the feasibility of performing extended surgery such as extrapleural pneumonectomy with this approach has not been explored.

We report the perioperative course of an initial cohort of 10 patients who have undergone right extrapleural pneumonectomy for malignant pleural mesothelioma through sternotomy. Owing to the position of heart and pulmonary veins, we have not attempted median sternotomy for left-sided resections.

Our patient selection criteria for extrapleural pneumonectomy in malignant pleural mesothelioma follow standard protocols [1, 2]. Computed tomography (CT) and contrast-enhanced magnetic resonance imaging (MRI) scans are used to determine resectability [4], and we now advocate routine cervical mediastinoscopy for staging [5]. Initially, we did exclusively employ the standard exposure through thoracotomy for right-sided resections; over the last 15 months, we have approached selected cases through median sternotomy (10 of 14 patients).

	Technique

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With the patient under general anesthesia, double-lumen endotracheal intubation and analgesia administered through a thoracic epidural, median sternotomy is performed in a standard fashion. The right extrapleural plane is developed from the sternal border, and blunt dissection is carried out toward the apex to separate the parietal pleura from the endothoracic fascia. Apical attachments are divided with electrocautery. The internal thoracic vessels are electively divided at their cranial origin and excised en-bloc with the main specimen together with internal thoracic lymph nodes. In the posterior dissection, preoperative insertion of an esophageal bougie aids in the identification of the esophagus, thus minimizing the risk of injury during the dissection. The extrapleural dissection continues inferiorly until the diaphragm is reached. An intrapericardial pneumonectomy is performed with stapled division of right pulmonary artery, right pulmonary veins, and right main bronchus. At this point, the incision in the pericardium is extended to excise all pericardium in contact with right parietal pleura. The final part of the resection includes en-bloc excision of the diaphragm unless the peritoneum can be preserved in very early tumors, preserving a peripheral rim of muscle for attachment of the prosthetic diaphragmatic patch. The specimen is removed en bloc from the hemithorax through the sternotomy. Extrapleural lymphadenectomy of the paratracheal, subcarinal, and paraoesophageal regions is performed.

We favor the use of a Gore-Tex patch (W. L. Gore & Associates, Inc) to replace the diaphragm. The patch is sutured to the preserved edge of the diaphragm with continuous and interrupted sutures of nonabsorbable monofilament Prolene (Ethicon, Somerville, NJ). To facilitate this part of the procedure, we have modified the standard technique by placing four or five interrupted sutures in the most lateral diaphragmatic rim initially that remain untied until all are placed. The anteromedial border of the patch is inserted with two continuous sutures, which meet at the inferior vena cava. During this part of the procedure, we have found that a retractor inserted into the cavity through the future drain site (anterior axillary line) aids access to the most posterior diaphragmatic rim by retracting the liver caudally (Fig 1). The pericardium is replaced on the right side with a loose Prolene mesh patch anchored to the pericardial edges with interrupted monofilament Prolene sutures. Care should be taken to avoid excess tension in the patch that could compromise right atrial venous drainage. Through the sternotomy approach, we patch the pericardium early in the operation before excision of the diaphragm to minimize cardiac displacement and hemodynamic compromise. The finished reconstruction of diaphragm and pericardium is shown in Figure 2.

View larger version (151K): [in this window] [in a new window]   Fig 1. A retractor is placed through the future drain site in the anterior axillary line to aid caudal retraction of the liver, increasing the surgical view of the posterior pleural recess.

View larger version (170K): [in this window] [in a new window]   Fig 2. Final view before sternotomy closure after prosthetic reconstruction of the diaphragm and pericardium.

Patients recover in our Thoracic High Dependency Unit where cardiac rhythm, arterial blood pressure, central venous pressure, and urine output are continuously monitored. The intercostal drain remains clamped during the first postoperative day and is unclamped hourly to monitor postoperative bleeding. The intercostal drain is removed routinely 36 hours after surgery, and the patients are drinking free fluids and starting ambulation within 48 hours after surgery unless complications have arisen.

All procedures were performed for epithelioid or biphasic malignant pleural mesothelioma. The entire procedure was completed through median sternotomy in 7 of the 10 patients. In the other 3 cases, the resection was completed by the addition of a limited low lateral thoracotomy at the level of the eighth intercostal space: in 2 cases, owing to the presence of bulky disease in the costophrenic angle; and in 1 case, owing to severe hemodynamic unstability of the patient due to manipulation of the pericardium to achieve adequate exposure.

Among the 7 patients who underwent the full procedure through median sternotomy, there were no in-hospital or 30-day deaths. There was 1 postoperative death of a patient who underwent resection through sternotomy and thoracotomy owing to perioperative myocardial infarction. The median hospital stay was 10 days (range, 6 to 30). Macroscopic excision was achieved in all procedures, and microscopic complete local excision (R0) was reported in 71% of cases.

There were no local complications related to the median sternotomy in this group of patients. At follow-up, all wounds had healed to satisfaction, and no sternal instability was identified. At a median follow-up of 8 months (range, 1 to 15), 6 of the 7 patients are alive, and we have not encountered tumor progression in the sternotomy scars, although 1 of the patients has developed wound progression on the previous drain site at the level of the anterior axillary line. That was treated with palliative chemoradiotherapy.

	Comment

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Median sternotomy has been used for pulmonary resection. Although most of its use has been described for bilateral metastatectomy [3], some authors have even considered it their standard approach [6]. Anatomical resections of right lung and the left upper lobe have been described, but there is more reluctance to perform resections that include the left lower lobe, especially in the presence of adhesions [6, 7], owing to the location of the left inferior pulmonary vein and heart. The main benefits of median sternotomy over posterolateral thoracotomy for pulmonary surgery reported in the literature are decreased postoperative pain, shorter hospital stay, lower incidence of respiratory complications, and less analgesic requirements [3, 6, 7].

We have not encountered infective wound complications after median sternotomy in our limited experience. We have also not seen tumor implantation in the incision (well described after other incisions for mesothelioma), perhaps because the skin incision is distant to the pleural boundaries when median sternotomy is employed.

We have only encountered a single report in the literature describing the use of median sternotomy with the adjunct of a supraclavicular incision for a case of malignant pleural mesothelioma with involvement of supraclavicular lymph nodes [8].

Patient selection is important and may be influenced by a learning curve. Two of the patients who needed additional thoracotomy were in the earlier part of our experience and may represent a learning process. With experience, we have developed technical variations in the procedure: use of interrupted sutures to place the diaphragmatic patch, and use of a drain hole to place a retractor during diaphragm replacement and dissection around the inferior vena cavae. We currently consider chest wall involvement and very bulky disease in the costophrenic angle as contraindications for median sternotomy, as they are more easily approached through thoracotomy.

In summary, we report an initial favorable experience, as we have been able to complete the procedure to satisfaction in 70% of cases. To determine the impact of this approach on postoperative pain, ambulation, and recovery as well as long-term follow-up, further studies are required.

	References

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1. Sugarbaker DJ, Heher EC, Lee TH, et al. Extrapleural pneumonectomy, chemotherapy, and radiotherapy in the treatment of diffuse malignant pleural mesothelioma J Thorac Cardiovasc Surg 1991;102:10-15.[Abstract]
2. Rusch VW, Piantadosi S, Holmes EC. The role of extrapleural pneumonectomy in malignant pleural mesothelioma J Thorac Cardiovasc Surg 1991;102:1-9.[Abstract]
3. Cooper JD, Nelems JM, Pearson FG. Extended indications for median sternotomy in patients requiring pulmonary resection Ann Thorac Surg 1978;26:413-420.[Abstract]
4. Stewart D, Waller DA, Edwards JG, Jeyapalan K, Entwisle J. Is there a role for pre-operative contrast-enhanced magnetic resonance imaging for radical surgery in malignant pleural mesothelioma? Eur J Cardiothorac Surg 2003;24:1019-1024.[Abstract/Free Full Text]
5. Pilling JE, Stewart DJ, Martin-Ucar AE, Muller S, O’Byrne KJ, Waller DA. The case for routine cervical Mediastinoscopy prior to radical surgery for malignant pleural mesothelioma Eur J Cardiothorac Surg 2004;25:497-501.[Abstract/Free Full Text]
6. Urschel Jr HC, Razzuk MA. Median sternotomy as a standard approach for pulmonary resection Ann Thorac Surg 1986;41:130-134.[Abstract]
7. Asaph JW, Handy Jr JR, Grunkermeier GL, et al. Median sternotomy versus thoracotomy to resect primary lung canceranalysis of 815 cases. Ann Thorac Surg 2000;70:373-379.[Abstract/Free Full Text]
8. Murata S, Kohiyama R, Tanaka M, Miyamoto H, Hata E. Extended extrapleural pneumonectomy by median approach for advanced malignant mesothelioma with right supraclavicular lymph node metastasis—a case report Nippon Kyobu Geka Gakkai Zasshi 1994;42:404-408.[Medline]

This article has been cited by other articles:

				J. G. Edwards, A. E. Martin-Ucar, D. J. Stewart, and D. A. Waller Right extrapleural pneumonectomy for malignant mesothelioma via median sternotomy or thoracotomy?: Short- and long-term results Eur. J. Cardiothorac. Surg., May 1, 2007; 31(5): 759 - 764. [Abstract] [Full Text] [PDF]

				C. D. Wright Pleuropneumonectomy for the Treatment of Masaoka Stage IVA Thymoma. Ann. Thorac. Surg., October 1, 2006; 82(4): 1234 - 1239. [Abstract] [Full Text] [PDF]

				I. Hunt and L. Lang-Lazdunski Is Median Sternotomy an Appropriate Approach to Right Extrapleural Pneumonectomy for Mesothelioma? Ann. Thorac. Surg., August 1, 2006; 82(2): 767 - 767. [Full Text] [PDF]

				D. Waller Reply Ann. Thorac. Surg., August 1, 2006; 82(2): 767 - 767. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Antonio E. Martin-Ucar Duncan J. Stewart David A. Waller Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Martin-Ucar, A. E. Articles by Waller, D. A. Search for Related Content PubMed PubMed Citation Articles by Martin-Ucar, A. E. Articles by Waller, D. A. Related Collections Pleura