State of the art: laser resections for lung metasectomy

1. State of the art: laser resections for lung metasectomy Axel Rolle, M.D., Ph.D Professor of Surgery Specialized Hospital for Pneumology and Thoracic Surgery Coswig, Dresden, Germany Affiliated to the Carl Gustav Carus University Dresden, Germany

3. Rolle A., Koch R., Alpard S.K., Zwischenberger J.B.: Lobe-sparing resections of multiple pulmonary mestastases with a new 1318 nm Nd:YAG Laser – First 100 patients. Ann. Thorac. Surg. 2002;74:865-869. Rolle A.,Koch R., Pereszlenyi A., Koch R. et al. Is surgery for multiple lung metastases reasonable? A total of 328 consecutive patients with multiple-laser metastasectomies with a new 1318- nm ND: YAG laser J. Thorac. Cardiovasc. Surg. 2006: 131: 1236-42.

4. Why LASER? Why 1318 nm wavelength?

5. Laser Lamp Lamp intensity Laser wavelength Qualities of Laser Light Collimation Coherence Monochromasy

6. Laserparameters and Tissue Determinants Absorption Tissue Density Wavelength + = Scattering Watercontent Power Reflection Haemoglobin Power Density Transmission Proteins Interaction Time

9. 1318 nm Quantum Dot Laser TOO LOW ABSORPTION = NO COAGULATION TOO HIGH ABSORPTION = NO PENETRATION DEPTH

10. Interaction with Tissue: Conclusion • Interaction depends on wavelength • Increase of power can not improve specific interaction of a wavelength • Increase of power accelerates specific interaction of a wavelength

11. Electrocautery Incision

12. Coagulation by 1318 nm

13. Incision 1318 nm Incision 1064 nm Coagulationzone 3 mm NO Coagulationzone

14. Demands on Surgical Technique • Parenchymasaving • Lobesparing • Oncological safe • Low complication rate • Good quality of life • Feasible for high number of metastases

15. Parenchymal loss stapler vs. laser = 7:1 1318 nm LASER STAPLER centrally located metastasis Precision Resection Loss: 27 cm³ Wedge Resection Loss: 173 cm³

16. Principle of lobesparing laserresection lobesparing laserresection multiple metastases

18. Resection of a 4cm metastasis

19. Conventional versus extended indicationsfor the resection of pulmonary metastases

20. Criteria of eligibility for metastasectomy • Any primary malignancy • Primary complete resected • No extrathoracic metastases or complete resected • Synchron and bilateral metastasis • No limit to number (functional and technical resectability) • Lymphnode involvement up to N2 unilateral • Previous extended chemotherapy

21. Operation strategy and Technical details • Axillary muscle sparing approach • Bilateral metastases two staged individual intervall • Start with difficult side • Parenchymal resections exclusive by 1318 nm laser or in combination with standard resection • No hemostyptica, bioadhesive or stapler • 5 mm visible tumour margin • Histological examination of every metastasis • Systematic lymphadenectomy

22. Unilateral vs. bilateral resections

23. Complete resection versus incomplete resectionp = 0,0001n (R0) = 278n (R1/ R2) = 50 Complete resections with or without lymph node involvementp = 0,2n (R0) = 238n (R1/ R2) = 40

24. Complete resection versus incomplete resectionp = 0,012n (unilateral) = 177n (bilateral) = 151 Complete resections with or without lymph node involvementp = 0,35n (unilateral) R0 = 165n (bilateral) R0 = 113

25. Patient Survival Curves for Number of Metastases with Complete Resections n = 278

26. Results according to number of metastases

27. Conclusion • The use of 1318 nm lasers improve parenchymal and lobe sparing resections and facilitate central, multiple and bilateral metastasectomy • Criteria of eligibility can be progressively expanded • The most important prognostic factor is complete resection • Resection for multiple metastases is reasonible • Long term survival was observed in patients with 20 or more lung metastases and also with tumor metastases to N2 lymph nodes

28. Resection of 269 metastases