Invited Commentary

Abstract

Resection of locally advanced thoracic tumors have challenged surgeons for many years and often left patients and physicians with few options. The article by Lang and associates [1Lang G. Taghavi S. Aigner C. et al.Extracorporeal membrane oxygenation support for resection of locally advanced thoracic tumors.Ann Thorac Surg. 2011; 92: 264-271Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar] in this issue of The Annals offers impressive results implementing extracorporeal membrane oxygenation (ECMO) support in the management of these patients. Prior studies in patients with locally advanced thoracic tumors have not consistently demonstrated the excellent survival results reported here. The reasons for this include the preoperative nodal status and low operative mortality. This study included only patients with preoperative staging confirming N0 status before or after neoadjuvant therapy. Even adhering to these principles, pathologic staging led to upstaging in 4 of their 9 patients. These 4 cases showed microscopic nodular involvement and may not have been detected by preoperative positron emission tomography–computed tomography imaging. Routine preoperative surgical staging in this group of patients may be a reasonable recommendation in patients planned for resection using ECMO support. The other aspect of the surgical procedure and inherent on the success of this radical approach is complete surgical resection, confirmed by intraoperative frozen section analysis, accomplished in eight of the nine patients in this series. Relating specific to the application of ECMO, a number of features are important to safe and successful implementation of this technique in this patient group. First, the surgical team must have experience in ECMO. These investigators have reported their extensive expertise in this strategy in the lung transplant population [2Aigner C. Wisser W. Taghavi S. et al.Institutional experience with extracorporeal membrane oxygenation in lung transplantation.Eur J Cardiothorac Surg. 2007; 31: 468-474Crossref PubMed Scopus (166) Google Scholar]. Second, this intervention should only be considered in the most extreme cases. Other options such as jet ventilation could be applied in some situations possibly negating the need for this more invasive technique. This is not to imply, however, that if one technique is not successful, conversion to ECMO should be performed. A controlled, planned operative procedure using ECMO is clearly an important aspect of the success of this endeavor. Third, while many other groups have reported the use of cardiopulmonary bypass in the management of locally advanced thoracic tumors [3Byrne J.G. Leacche M. Agnihotri A.K. et al.The use of cardiopulmonary bypass during resection of locally advanced thoracic malignancies A 10-year two-center experience.Chest. 2004; 125: 1581-1586Crossref PubMed Scopus (54) Google Scholar], the unique aspects of ECMO include a heparin-coated circuit and the requirement for minimal heparinization (approximately 4000 IU, with a target activated clotting time of 180 to 200 seconds). This limits the bleeding complications commonly reported with the use of full cardiopulmonary bypass in this setting. Fourth, the ECMO circuit is a closed system, devoid of cardiotomy suction, an important factor in oncologic surgery. This obviates the possibility of tumor aspiration into the extracorporeal circuit and subsequent reinfusion to the patient. Finally, any immunomodulatory advantage of ECMO over cardiopulmonary bypass was not addressed in this study. The excellent outcomes presented by this group should only be approached by teams experienced in ECMO support. Realization that the need for this technology is uncommon, and should be applied only in extreme cases is important. Strict adherence to oncologic principles is tantamount to success of this intervention. Extracorporeal Membrane Oxygenation Support for Resection of Locally Advanced Thoracic TumorsThe Annals of Thoracic SurgeryVol. 92Issue 1PreviewThe international experience with resection of advanced thoracic malignancies performed with extracorporeal membrane oxygenation (ECMO) support is limited. We examined our results to assess the risks and benefits of this approach. Full-Text PDF