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:

• Prep and drape awake in supine position.
• Univent tube with endoscopic placement of blocker.
• If unstable- then thoracoscopic pericardiocentesis.
• If stable- then turn into right lateral decubitus.
• Deflate left lung by inflating blocker balloon and apply suction to catheter.
• Monitor saturation and reinflate left lung prn.

Thoracoscopy:

• First incision in seventh intercostal space under direct vision and insert thoracoscope via trochar.
• Explore hemithorax; visualize phrenic nerve and plan resection.
• Make two further incisions under thoracoscopic vision (one usually anteriorly in fifth interspace and one postero-inferiorly in fifth interspace.
• Initial incision in pericardium anterior or posterior to phrenic nerve with sharp tip, right angle scissors.
• Grasp pericardium with long right angle clamp.
• Resect pericardium as extensively as possible with scissors and electrocautery.
• 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)

References

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