Endobronchial Laser Application

Endobronchial Laser Application


Bernward Passlick

Professor of Thoracic Surgery

Dept. of Thoracic Surgery

University Medical Center Freiburg, Germany


Indications for Endobronchial Laser Applications

Bollinger CT et.al. Eur J Resp (2006) 27: 1258

Palliative treatment/Recanalisation

With potentiallycurative Intent


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


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


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


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


Practical Setting




Palliative treatment/Recanalisation


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


Basic Types of Central Airway Stenosis

Bollinger CT, Eur. Respir J., 2006


Different exampels of endobronchial stenosis

Mixed

extraluminal

endoluminal


Mixed Central Airway Stenosis

The aim is recanalisation!


Techniques of endobronchial recanalisation Mechanical: debulking with a forceps ( flexible,

optical forceps; rigid tube)

Argon beamer: coagulation of the tumor surface

Alternative: LASER DESOBLITERATION


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


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%


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


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


Case Report: Endobronchial metastases



Endoluminal Stenosis:Squamous cell carcinoma of the trachea

Endotracheal polypoid tumor


Tumor resection by a rigid bronchoscope

Endoluminal stenosis:Squamous cell carcinoma of the trachea



Laser treatment of the tumor basis



Final result


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%)


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 situation

Treatment of mixed Central Airway Stenosis


Laser recanalisation



Situation after implantation of a bifurcation stent



Initial CT scans

Typical carcinoid tumor:Preoperative recanalisation


UL

Complete obstructionof the lower lobe bronchus

Bronchoscopy: Initial findings

Typical carcinoid tumor: Preoperative recanalisation


Tumor basis

Präoperative Recanalisation

Laser-dissected part of the tumor

Typical carcinoid tumor: Preoperative recanalisation


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


OL

Seg. 8,9,10

Anastomosis

Bronchoscopy: 3 months postoperatively

Segment-6 sleeve resection after preoperative recanalisation




With potentiallycurative Intent


Benign stenosis due to Tracheal Papillomatosis


Situation after laser resection




Tracheal Papilloma prior Laser resection

Tracheal Papilloma 2 weeks after Laser resection


Basic Types of non-tumor-related Tracheal Stenoses

Web like stenosis;Tracheal wall preserved

Sand clock stenosis;Tracheal wall destroyed



Laser-Incision of a post intubation Web-like Lesion

Web-like Tracheal stenosis


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


Documents

Endobronchial Laser Application