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)

References

  1. Present study.
  2. Park JS, Rentschler R, Wilbur D. Surgical management of pericardial effusion in patients with malignancies: Comparison of subxiphoid window versus pericardiectomy. Cancer 1991;67:76-80.
  3. Edoute Y, Kuten A, Beh-Haim SA, Muscovitz M, Malberger E. Symptomatic pericardial effusion in breast cancer patients: The role of fluid cytology. Journal of Surgical Oncology 1990;45:265-269.
  4. Sugimoto JT, Little AG, Ferguson MK, Borow KM, Vallera D, Staszak VM, Weinert L. Pericardial window: Mechanisms of efficacy. Ann Thor Surg 1990;50:442-5.
  5. Palatianos Gm, Thurer RJ, Pompeo MQ, Kaiser GA. Clinical experience with subxiphoid drainage of pericardial effusions. Ann Thor Surg 1989;48:381-5.
  6. Piehler JM, Pluth JR, Schaff HV, Danielson GK, Orszulak TA, Puga FJ. Surgical management of effusive pericardial disease. Influence of extent of pericardial resection on clinical course. J Thorac Cardiovasc Surg 1985;90:506-516.
  7. Gregory JR, McMurtrey MJ, Mountain CF. A surgical approach to the treatment of pericardial effusion in cancer patients. Am J Clin Oncol (CCT) 1985;8:319-323.
  8. Oscuh JR, Khandekar JD, Fry WA. Emergency subxiphoid pericardial decompression for malignant pericardial effusion. Amer Surg 1985; 51:298-300.
  9. Robertson JM, Mulder DG. Pericardiectomy: A changing scene. Amer J Surg 1984;148:86-92.
  10. Miller JI, Mansour KA, Hatcher CR. Pericardiectomy: Current indications, concepts and results in a university center. Ann Thor Surg 1982;34:40-46.
  11. Hankins JR, Satterfield JR, Aisner J, Wiernik PH, McLaughlin. Pericardial window for malignant pericardial effusion. Ann Thor Surg 1980;30:465-471.


Frederic W. Grannis Jr. M.D
If you have trouble contacting me with the address above, I may also be reached at 76516,2333@compuserve.com and at fgrannis@cris.com

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