endobronchial laser application
DESCRIPTION
Endobronchial Laser Application. Bernward Passlick Professor of Thoracic Surgery Dept. of Thoracic Surgery University Medical Center Freiburg, Germany. Palliative treatment/ Recanalisation. With potentially curative Intent. Indications for Endobronchial Laser Applications. - PowerPoint PPT PresentationTRANSCRIPT
Endobronchial Laser Application
Endobronchial Laser Application
Bernward Passlick
Professor of Thoracic Surgery
Dept. of Thoracic Surgery
University Medical Center Freiburg, Germany
Endobronchial Laser Application
Indications for Endobronchial Laser Applications
Bollinger CT et.al. Eur J Resp (2006) 27: 1258
Palliative treatment/Recanalisation
With potentiallycurative Intent
Endobronchial Laser Application
Historical Developments
1976 first endobronchial laser resection with a CO2 Laser
1978 first endobronchial treatment with a Neodym YAG - Laser ( wave length 1064nm / depth 5 mm)
1982/1983 first publications in Germany about endobronchial laser application( Dierkesmann / Häussinger)
1988 first publication about the experience of more than 1000 patients
2001 MY 40 YAG Laser (wave length 1312 nm / depth 5-10 mm)
2010 Limax 60/120 Laser System
Endobronchial Laser Application
Different Laser Types
Modidfied from: Bollinger CT et.al. Eur J Resp (2006) 27: 1258 - 1271
Type of Laser
Wavelength
(nm)
Color Penetration (mm)
Vaporisation Coagulation
Nd –YAG 1312 Invisible 5-10 +++ +++
Nd-YAG 1064 Invisible 5 ++ +++
CO2 1060 Invisible 0,1 + -
Argon 488 -514 Blue-green 2-3 - ++
Excimer 193 - 351 green 2-3 Tissue destruction by
mechanical effect
Endobronchial Laser Application
Limax 60/ Limax 120:
1-60W or 1-120W of power Diode pumped Nd:YAG-Laser Integrated smoke evacuator Integrated gas flow Lung parenchyma and
endobronchial application
Current laser system: Limax
Endobronchial Laser Application
Practical Setting
- Use of the laser with rigid or flexible bronchoscopes
- Almost always combination of both
- Laser application always in narcosis
- Jet ventilation via rigid scope
- Power Setting 15-25 W, pulse duration: continuos mode
Endobronchial Laser Application
Practical Setting
Endobronchial Laser Application
Indications for Endobronchial Laser Applications
Bollinger CT et.al. Eur J Resp (2006) 27: 1258
Palliative treatment/Recanalisation
Endobronchial Laser Application
Palliative Treatment and Recanalisation
Symptomes (n =110)
After Han C et.al. J Thorac Oncol (2007) 2: 50 -64.
Patients with:
• End stage tumor recurrences
• Failed chemoradiation
• Unrecognized Metastases or Primary Tumors
Endobronchial Laser Application
Basic Types of Central Airway Stenosis
Bollinger CT, Eur. Respir J., 2006
Endobronchial Laser Application
Different exampels of endobronchial stenosis
Mixed
extraluminal
endoluminal
Endobronchial Laser Application
Mixed Central Airway Stenosis
The aim is recanalisation!
Endobronchial Laser Application
Techniques of endobronchial recanalisation Mechanical: debulking with a forceps ( flexible,
optical forceps; rigid tube)
Argon beamer: coagulation of the tumor surface
Alternative: LASER DESOBLITERATION
Endobronchial Laser Application
Factors that influence success rate of laser recanalisation
Favorable UnfavorableLarge endobronchial component
Lesion extrinsic to airway
Polypoid lesion Primarily submucosal
Confined to trachea and mainstem bronchus
Upper lobe or segmental bronchus
Visible distal lumen Totally obstructed lumen
Duration of lung collapse < 4-6 weeks
Duration of collapse > 4-6 weeks
Blood flow to lung not compromised
Blood flow to lung compromised
Endobronchial Laser Application
Success rate of laser assisted recanalisation relation to the location of the tumor
Huala K. et. al. Eur Arch Otorhinolaryngol (2003) 260:219-222
85% 90%
76%
88%
74%
44%
70%
80%
50%
62%
Endobronchial Laser Application
10 Golden Rules of Safe ND:YAG Laser Resection
1. Know the anatomic danger zones: aortic arch, pulmonary artery and esophagus being the main hazard areas
2. Have a well-trained laser team, including an experienced anesthesiologist
3. Screen patients carefully: purely external compression is beyond the reach of the technique
4. Use the rigid bronchoscope technique for any high-grade obstruction, especially if malignancy is involved
5. Monitor blood gases and cardiac performance. At least sign of hypoxemia, interrupt treatment long enough to oxygenate the patient
Endobronchial Laser Application
10 Golden Rules of Safe ND:YAG Laser Resection
6. Fire the laser parallel to the wall of the airway; never aim directly to it
7. Coagulate at will but avoid using the laser at high power settings
8. Do not neglect hemorrhage, for even slow bleeding will lead to hypoxemia if left unattended
9. Terminate each procedure with a tracheobronchial toilet to remove all secretions and/or debris
10.Keep the patient under observation in a special room for a reasonable period of time
Endobronchial Laser Application
Case Report: Endobronchial metastases
Endobronchial Laser Application
Endobronchial Laser Application
Endoluminal Stenosis:Squamous cell carcinoma of the trachea
Endotracheal polypoid tumor
Endobronchial Laser Application
Tumor resection by a rigid bronchoscope
Endoluminal stenosis:Squamous cell carcinoma of the trachea
Endobronchial Laser Application
Endoluminal stenosis:Squamous cell carcinoma of the trachea
Laser treatment of the tumor basis
Endobronchial Laser Application
Endoluminal stenosis:Squamous cell carcinoma of the trachea
Final result
Endobronchial Laser Application
Complications
Autor N Vessel perforation
Airway fire
Pneumo-thorax
Hemorrhage
Arrythmia Death Complications
(%)
Personne 2289 3 0 24 0 0 18 1,18
Dumon 1503 1 0 4 14 3 1 0,34
Cavaliere 2008 0 0 8 19 5 12 0,03
Metha 330 1 1 5 5 2 4 2,12
Brutinel 176 3 0 1 10 0 3 2,27
Kvale 82 0 0 0 0 1 1 0,01
Total 6388 8 (<0.1%)
1 (<0.1%)
42(0.6%)
48(0.6%)
11(0.1%)
39(0.5%)
149(2.3%)
Endobronchial Laser Application
Long term survival after Laser desoblitaration
Huala K.et.al. Eur Arch Otorhinolaryngol (2003) 260: 219 – 222.
Pathologic diagnosis %
Epidermoid carcinoma 75,3
Adenocarcinoma 9
Small Cell carcinoma 4,5
Anaplastic carcinoma 3,4
Sarcoma 2,2
Papillaric carcinoma 1,1
Mesothelioma 1,1
Metastasis breast 1,1
Carcinoid tumor 1,1
Glomus tumor 1,1
N = 89
Endobronchial Laser Application
Endobronchial situation
Treatment of mixed Central Airway Stenosis
Endobronchial Laser Application
Laser recanalisation
Treatment of mixed Central Airway Stenosis
Endobronchial Laser Application
Situation after implantation of a bifurcation stent
Treatment of mixed Central Airway Stenosis
Endobronchial Laser Application
Initial CT scans
Typical carcinoid tumor:Preoperative recanalisation
Endobronchial Laser Application
UL
Complete obstructionof the lower lobe bronchus
Bronchoscopy: Initial findings
Typical carcinoid tumor: Preoperative recanalisation
Endobronchial Laser Application
Tumor basis
Präoperative Recanalisation
Laser-dissected part of the tumor
Typical carcinoid tumor: Preoperative recanalisation
Endobronchial Laser Application
S6
S8-9S10
Resection margins „Neo-Carina“ S8-9/10;Running Suture dorsal part (PDS 5-0)
Single suture ventral part
Segment-6 sleeve resection after preoperative recanalisation
Endobronchial Laser Application
OL
Seg. 8,9,10
Anastomosis
Bronchoscopy: 3 months postoperatively
Segment-6 sleeve resection after preoperative recanalisation
Endobronchial Laser Application
Indications for Endobronchial Laser Applications
Bollinger CT et.al. Eur J Resp (2006) 27: 1258
With potentiallycurative Intent
Endobronchial Laser Application
Benign stenosis due to Tracheal Papillomatosis
Endobronchial Laser Application
Situation after laser resection
Benign stenosis due to Tracheal Papillomatosis
Endobronchial Laser Application
Benign stenosis due to Tracheal Papillomatosis
Tracheal Papilloma prior Laser resection
Tracheal Papilloma 2 weeks after Laser resection
Endobronchial Laser Application
Basic Types of non-tumor-related Tracheal Stenoses
Web like stenosis;Tracheal wall preserved
Sand clock stenosis;Tracheal wall destroyed
Endobronchial Laser Application
Endobronchial Laser Application
Laser-Incision of a post intubation Web-like Lesion
Web-like Tracheal stenosis
Endobronchial Laser Application
Summary
- Relevant tracheobronchial stenosis are a common clinical problem
- Assessment: Chest CT when ever possible
- Rigid bronchoscope + experienced anaesthesiologist
- Determine the type and localization of bronchial stenosis
- Aim is the complete recanalisation
- Morbidity and mortality after laser resection is low
- Modern laser systems allow different applications in lung parenchyma surgery and endobronchial applications
Endobronchial Laser Application