Bedah

Thoraks
Kardiak &
Vaskular
=BTKV=

Oleh: dr. Muhammad Riendra, SpBTKV

 Thoraks

Bedah
Thoraks
Kardiak &
Vaskular
=BTKV=
Kardiak

Vaskular
 BTKV SUMATERA BARAT dr. Juli Ismail, SpB, SpBTKV (K)

dr. Muhammad Riendra, SpBTKV

Bedah SDM
Thoraks
Kardiak & dr. Aulia Rahman, SpBTKV
Vaskular
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Btkvpadang

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@btkvpadang
In US: 226,000 cases/yr

Only 25% are localized enough for surgery

Overall 5-yr survival is 16%

Situation is changing
• Peripheral small adenocarcinomas
• Increasing incidence in non-smokers
• Screening CT scans for lung cancer
• Therapies are improving including surgical resection and radiation treatment
 Smoking Previous cancer
Age Family history
history history

Exposure to infectious agents (eg,

Other lung disease
endemic areas of fungal infections,
(chronic obstructive
Occupational tuberculosis) or risk factors or
pulmonary disease
exposures history suggestive of infection (eg,
[COPD], pulmonary
immune suppression, aspiration,
fibrosis)
infectious respiratory symptoms)
 CT scan +/-
Chest X-Ray MRI PET scan
Biopsy

Bone scan Bronchoscopy EBUS-TBA

 70% of NSCLC
NSCLC is most often
diagnosed with
lung malignancy, in Giving burden on
advanced disease at
USA, 85% of Lung health system
diagnosis  unsuitable
Cancer is NSCLC.
for curative treatment

Molina JR, yang p, Cassivi SD. Schild SE, Adjei AA. Non Small cell lung cancer: epidemiology, risk factor, treatment, Suvivorship. Mayo Clin Proc.
2008 May ; 83(5): 584–594
Besse B, Adjei A, Baas P, et al. 2nd ESMO Consensus Conference on Lung Cancer: non-small-cell lung cancer first-line/second and further lines of treatment in
advanced disease .Annals of Oncology 25: 1475–1484, 2014
 Small cell carcinoma (20-25%)
 Squamos cell carcinoma (25-40%)
 Adenocarcinoma (25-40%)
 Large cell carcinoma (10-15%)
 Combined histology (10%)
  Lobectomy
 Pneumonectomy  Stage (TNM)
 Segmentectomy  Lung Physiologic
 Wedge Resection function
 VATS  Cardiac Function
 Lymph node  Preopeative assesment
dissection

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et
al. Philadelphia: Elsevier; 2008
Detterback FC, Boffa DJ, Kim AW, Tanoe LT. The Eight editiion lung stage clasification. CHEST 2017; 151(1):193-203
 surgery without further
investigations  patients
No surgery 30 days of MI
≤2 risk factors and good
cardiac functional capacity.

Revascularization before
surgery for chronic angina
• Measure lung carbon monoxide transfer factor in all patients regardless of
spirometric values. (C)

• Offer surgical resection to patients with low risk of postoperative dyspnoea. [C]

• Offer surgical resection to patients at moderate to high risk of postoperative

dyspnoea if they are aware of and accept the risks of dyspnoea and associated
complications. [D]

• Consider using ventilation scintigraphy or perfusion scintigraphy to predict

postoperative lung function if a ventilation or perfusion mismatch is suspected. [C]

• Consider using quantitative CT or MRI to predict postoperative lung function if the

facility is available. [C]
Consider using ventilation scintigraphy or
perfusion scintigraphy to predict
postoperative lung function if a ventilation or
perfusion mismatch is suspected.
Consider using shuttle walk testing as
functional assessment in patients with
moderate to high risk of postoperative
dyspnoea using a distance walked of >400
m as a cut-off for good function.
Consider using quantitative CTorMRI to
predict postoperative lung function if the
facility is available.
Consider cardiopulmonary exercise testing
to measure peak oxygen consumption as
functional assessment in patients with
moderate to high risk of postoperative
dyspnoea using >15 ml/ kg/min as a cut-off
for good function.
Both ACCP 2013 and BTS 2010
recommend spirometry and
transferfactor evaluation post
operatively and calculate predicted
post operative.

ACCP 2013  ppo FEV1 or DLTCO

30-60% predicted the do low
technology exercise test.

ACCP 2013  ppo FEV1 or DLTCO <

30% do CPET and measure VO2max

ACCP 2013  O2max,10mL/kg/min

or ,35% predicted it is recommended
that they are counseled about
minimally invasive surgery,sublobar
resections or nonoperative treatment
  Surgical standart for those who
tolerance
 NSCLC stage I  Minor Sugery
increase recurance rate 30% 
decrease survival raye 30%
 Standart procedure for lobulated
NSCLC.
 The tumor extends accros the fissure
 bilobectomy
 ACCP 2013  medically fit stage I
and II patients should undergo
lobectomy rather than sublobar
resection

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al.
Philadelphia: Elsevier; 2008
  Sleeve lobectomy For solid
mass close to the main bronchus
 Sleeve lobectomy  If the
margin close to the main
bronchus is not tumor free.
 Avoiding pneumonectomy
 If undergoing the sleeve
lobectomy achieve the free
tumor margin  the 5 year
survival rate is better than
pneumonectomy (52% vs 31%)
perioperative mortality(1,6% vs
5,3%).

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al.
Philadelphia: Elsevier; 2008
  Indication fot NSCLC with involving  If reccurence after lobectomy 
extensive main bronchus and completion to pneumonectomy
tolerance with the operational High 30 day mortality rate (20%)
procedure. Bad 5 year survival rate(28%)

 Better to be avoided High

perioperative mortality (7%) 
High cardiorespiration complication

 wherever possible do lobectomy 

if the margin of free tumor is hard to
be achieved do bronchoplasty

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al.
Philadelphia: Elsevier; 2008
• BTS 2010 guidelines  pneumonectomy should be avoided 
bronchoangioplastic resection

• ACCP 2013 guidelines  clinical stage I or II central NSCLC in whom

a complete resection can be achieved, a sleeve or bronchoplastic
resection is suggested over a pneumonectomy

• Meta analysis by Shi W et al  sleeve lobectomy better than

pneumonectomy (odds ratio 0.50; 95% CI 0.34-0.72)
 • Anatomical Sublobar resection For patient with bad tolerance undergoing
lobectomy

• Inferior than lobectomy in reccurance rate and 5 year suvival rate, but better
lung function

• More complicated technique than lobectomy or wedge resection

• For T1 Case (<2cm), the 5 year surival rate 82%, if N0 reccurance is

equivalent with lobectomy)

• ACCP 2013  Segmentectomy is preferable than wedge resection

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al.
Philadelphia: Elsevier; 2008
 Non anatomical sublobar ressection.

For lobulated NSCLC patient but intolerance

undergo lobectomy.

Problem on wedge resection  High reccurance

rate even free tumor margin achieved

Worse 5 year survival rate than lobectomy (58%

vs 70%)  High chance of death because of
undergoing the wedge resection, Not because of
the tumor  Patients who undergo wedge
resection are significantly older.

Post Operative radiation  minimize the reccurence

 decrease the already bad lung function

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al.
Philadelphia: Elsevier; 2008
 ACCP 2013  For patients
with a clinical stage I
predominantly GGO lesion ≤
2 cm, a sublobar resection
with negative margins is
suggested over lobectomy
Zhang Y et al  The combined HR of segmentectomy versus lobectomy was 1.231 (95% CI:1.070–1.417, P :0.004)
Wenfei et al,  tumor size ≥2cm  segmentectomy better than wedge resection
(combined HR: 0.82, 95% CI: 0.70–0.97, P=0.02
Tumor size ≤ 1cm not significant  (HR: 1.07, 95% CI: 0.78–1.46, P=0.68)
 Video Assisted thoracoscopic Surgery  populer
VAT surgical approach

S In the past  oncologic surgery need wide

operation field view
New scientific publication support VATS for the
first stage case
ACCP 2013  recommended for stage I over
thoracotomy
5 year survival
Tetapi secara VATS vs Open
bermakna juga Surgery,
memiliki VATS lebih
rekurensi
Reccurance rate is not significantly different,
superior
lokal OR
yang 1,62tinggi
lebih (127-2,07)
OR 95%(1,35-3.43)
2,15 CI 95% CI
OR 0,91 (0,33-2,48) 95% CI
Perioperative mortality
is not significantly VATS morbidity is lower.
different
  Important for staging
 Controversial  which one is needed
complete mediastinal node dissection vs
sampling mediastinal dissection?
 BTS 2010  Perform systematic nodal
dissection in all patients undergoing
resection for lung cancer.
 ACCP 2013  stage I intraoperative N0 
no need mediastinal resection
 ACCP 2013  stage II mediastinal lymph
node dissection sugested than sampling

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s
thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia:
Elsevier; 2008
 Lympadenectomy had better long term survival (Hazard Ratio 0.78; 95% CI 0.69–0.89)but
not significant perioperative survival (Odds Ratio 0.59; 95% CI 0.25–1.36 )
 Perioperative morbidity slightly higher on lymphadenectomy but not significant.
• Stage I  surgery  best option

• Peripheral tumor location  controversial (Segementectomy vs Lobectomy)

• Do we need chemoterapy on stage T1 and T2  basically No  research the

function of adjuvant on stage I

• BTS 2010  Offer postoperative chemotherapy to patients with TNM 7th edition
T1-3N1-2M0 non-small cell lung cancer. [A]

• ACCP 2013  Stage II (N1)  post-op chemotheraphy recomended

Lobectomy is the best
choice

Post-operative radiation 
decreasing reccurency on
stage II  not decreasing
mortality
Perbandingan jumlah nodus limfa yang
terlibat dengan survival

Survival Comparison of NSCLC Patient beetwen adjuvant

theraphy and Observation only.
T3 is the condition where the tumor already invade through the chest wall,
pericardium parietal, mediastinal pleura, or 2cm from the carina without involving the
carina

Chest Wall. Problem on closing the dissection deffect on chest wall.

Pancoast tumor  Udergo surgery 4-6 weeks after the induction theraphy
Contraindication for operation if N2 Or N3

Tumor 2 cm from karina  make sure there is no disease on the carina

bronchoscopy
Low 5 year survival  15%

Stage IIIA
• N2 clinically undetected just found out intra-operatively  ressection as clean as
possible
• N2 clinically undetected If possible to be cut then do the surgery, if not then do
chemoradiation
Stage IIIB
• Basically has very bad outcome
• T4 involved carina  if N0/N1 5 year survival 53%, if N2/N3 the 5 year survival is15%
• Satelite nodul Good survival if appear on the same lobe
• Involving mediastinal organ  able to undergo en block ressection 5 year survival 18%
• T4 Pleura  very bad difficult to do clean ressection 5 year survival close to 0
• N3  Worst prognosis  contraindication for operation
The worst prognosis, if the far metastase has already found then the disease
cannot be cured by surgery

Brain metastasis  the worst (2-month life expectancy with steroid 6- months
whole brain radiation)

Adrenal Metastasis  detectable with CT/MRI

No surgical procedure is necessary

 The availble operation
NSCLC is the most often
technique is vary and has
malignancy on the lung.
weaknees and benefit

Eventhough surgery is the main Every stage has each

modality on first stage NSCLC therapetical approach 
treatment, but the role is Staging process must be done
deacreasing as the disease eminently with variance of
advance modality

Beside of the stage, clinical

condition of the patient
determine the operatin
technique
1. Molina JR, Yang P, Cassivi SD, Schild SE, Adjei AA. Non-small cell lung cancer: epidemiology, risk factors, treatment, and
survivorship. Mayo Clin Proc. 2008;83(5):584-594. doi:10.4065/83.5.584
2. Patterson GA, Cooper J, Deslauriers J, Lerut A, Luketich J, Rice TW. Pearson’s Thoracic and Esophageal Surgery. 3rd ed.
Philadelphia: Elsevier Inc.; 2008. doi:10.1016/B978-0-443-06861-4.50014-9
3. Zoysa MK De, Hamed D, Routledge T, Scarci M. Is limited pulmonary resection equivalent to lobectomy for surgical
management of stage I non-small-cell lung cancer ? 2012;14(February):816-820. doi:10.1093/icvts/ivs031
4. Society BT, Party IW. Guidelines on the selection of patients with lung cancer for surgery. 2001:89-108.
5. Shi W, Zhang W, Sun H, Shao Y. Sleeve lobectomy versus pneumonectomy for non-small cell lung cancer: A meta-analysis.
World J Surg Oncol. 2012;10(1):1. doi:10.1186/1477-7819-10-265
6. Xue W, Duan G, Zhang X, Zhang H, Zhao Q, Xin Z. Meta-analysis of segmentectomy versus wedge resection in stage IA non-
small-cell lung cancer. Onco Targets Ther. 2018;Volume 11:3369-3375. doi:10.2147/OTT.S161367
7. Cai Y, Fu X, Xu Q, Sun W, Zhang N. Thoracoscopic Lobectomy versus Open Lobectomy in Stage I Non-Small Cell Lung Cancer: A
Meta-Analysis. PLoS One. 2013;8(12):e82366. doi:10.1371/journal.pone.0082366
8. Cao C, Manganas C, Ang SC, Peeceeyen S, Yan TD. Video-assisted thoracic surgery versus open thoracotomy for non-small cell
lung cancer: A meta-analysis of propensity score-matched patients. Interact Cardiovasc Thorac Surg. 2013;16(3):244-249.
doi:10.1093/icvts/ivs472
9. Mokhles S, Macbeth F, Treasure T, Younes RN, Rintoul RC, Fiorentino F. Systematic lymphadenectomy versus sampling of
ipsilateral mediastinal lymph-nodes during lobectomy for non-small-cell lung cancer : a systematic review of randomized
trials and a meta-analysis. 2017;51(January):1149-1156. doi:10.1093/ejcts/ezw439
10. Wright G, Manser RL, Byrnes G, Hart D, Campbell DA. Surgery for non-small cell lung cancer: systematic review and meta-
analysis of randomised controlled trials. Thorax. 2006;61:597-603. doi:10.1136/thx.2005.051995