akciğer kanser cerrahisi ‘’evre i ve ii’ ’ vats lobektomi paradigma...
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Akciğer Kanser Cerrahisi ‘’Evre I ve II’’
VATS Lobektomi Paradigma değişimi
Dr Alper Toker İstanbul Üniversitesi İstanbul Tıp Fakültesi ve
Grup Florence Nightingale
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Erken evre akciğer kanseri
Evre Sıklık TNM
IA 13% T1 N0 M0
IB 23% T2 N0 M0
IIA 1% T1 N1 M0
IIB 7% T2 N1 M0
Mountain CF. Chest. 1997
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Evre I de standart cerrahi nedir
§ Lobektomi + komplet MLND
§ Torakotomi § VATS
Ginsgerg RJ et al. Ann. Thorac. Surg. 1995. Ludwig MS et al. Chest. 2005.
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Torakotomi Video-Assisted Thoracoscopic Surgery (VATS)
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CALGB 39802
VATS vs. Açık Cerrahi § Daha düşük komplikasyon oranı § Daha kısa tüp drenaj süresi § Daha kısa hastane yatış § Eşit sağkalım
Swanson et al. JCO. 2007
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30 Günlük Mortalite
§ Açık lobektomi: 1 - 4.5% § VATS lobektomi: 0.4 - 2%
Swanson SJ, et al. Surg. Clin. N. Am. 2002. Little AG et al. Ann. Thorac. Surg. 2005.
Ginsberg RJ et al. J. Thorac. Cardiovasc. Surg. 1983. Allen MS et al. Ann. Thorac. Surg. 2006.
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Walker Semin Thorac CV Surg 1998
Postoperatif Ağrı
Açık N = 123
VATS N = 104
p-‐value
Ağrı skoru 26 24.2 <0.05
Morphine miktarı
84.9 54.9 <0.001
Ek Morphine 1.94 1.26 <0.01
Uyku düzeni 1.57 2.1 <0.01
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Postoperatif hastane kalış
Açık (Gün)
VATS (Gün)
p-value
D’Amico (Duke)
5 (2-63) 3.5 (3-6) 0.0024
McKenna (CSMC)
------ 5 ± 3.4
Nakajima (Japan)
23.8 ± 7.8 17.3 ± 7.8 <0.0001
Kirby (UPMC)
8.3 ± 5.7 7.1 ± 5.5 NS
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Yaşam Kalitesi
* †
*questionnaire: @ 13 months †questionnaire: @ 33 months
Sugiura Surg Lap Endo Percut Tech 1999
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İşe dönme
Çalışmanın designı İşe dönüş
Demmy (1999) Case-Control VATS - 2.2 months*
Open - 3.6 months
Sugiura (1999) Prospective cohort
VATS - 2.5 months*
Open - 7.8 months
*P < 0.05 Hoang & Maddaus Thorac Surg Clin. 2004
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Kosmetik: VATS vs. Torakotomi
VATS Torakotomi
3-4 cm 10-12 cm
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Sistematik Nodal Diseksiyon
VATS ile güvenle uygulanabilir Eşit sayıda lenf nodu diseke edilebilir
Watanabe A et al. Eur J of Cardio Thorac Surg. Watanabe A et al. Surgery. 2005.
Sagawa M et al. Ann Thorac Surg. 2002.
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Postoperatif immün fonksiyonlar: VATS vs Torakotomi
§ Post-op immun supresyon derecesi travma şiddetiyle ilgili § VATS :
§ Daha az IL-6, CRP, ROS § Azalmış monocytes & PMN aktivasyonu
Craig Eur J Cardio Thorac Surg 2001
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VATS lobektominin amaçları
Whitson BA, Surgery for early stage non-small cell lung cancer: asystematic review of the video-assisted thoracoscopic surgery vs. thoracotomy approaches to lobectomy. Ann Thorac Surg, 2008
• Daha az komplikasyon • Artan yaşam kalitesi • Hızlı iyileşme • Torakotomiden ekonomik • Adjuvant tedaviye tolerans artışı • İmmünolojik supresyon yok • İş hayatına daha çabuk dönüş
• McKenna RJ Jr, Houck W, Fuller CB: Videoassisted thoracic surgery lobectomy: Experience with 1,100 cases. Ann Thorac Surg 81: 421-426, 2006
• Nagahiro I, Andou A, Aoe M, et al: Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: A comparison of VATS and conventional procedure. Ann Thorac Surg 72:362-365, 2001
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VATS LOBEKTOMİ
• ESTS Database 43,330 KAYIT
• 2.7% (2007-2009) • 11.3% (2010-2012)
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VATS PNEUMONECTOMY FOR DESTROYED LUNG Ann Thorac Surg, Toker et all.
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