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KÜÇÜK HÜCRELİ DIŞI AKCİĞER KANSERİNDE (KHDAK) EVRELEME AMAÇLI GENİŞLETİLMİŞ TRANSSERVİKAL MEDİYASTİNAL LENFADENEKTOMİ ( …

ABSTRACT GİRİŞ Küçük hücreli dışı akciğer kanseri (KHDAK) teda-visinde evre I ve II hastalarda primer radikal cerra-hi uygulanması gerekliliği konusunda görüş birliği mevcuttur. Evre III (N2) olduğu preoperatif dönem-de belirlenen hastalar neoadjuvan kemoterapi ya da kemo-radyoterapi ile tedavi edilmeli ve takiben opere edilmelidir. Bu sebeple mediyastinal evreleme, KHDAK hastalarında en uygun tedavi seçeneğinin belirlenme-sinde esas rolü oynamaktadır (1, 2). Uzun dönem sürvi oranına mediyastinal lenfadenek-tominin terapötik etkisi çok muhtemel olmakla beraber henüz ispatlanmamıştır (3-6). Son yıllarda yeni görün-tüleme tekniği olan Bilgisayarlı Tomografiyle Pozitron Emisyon Tomografisi (PET/BT) ve transbronşiyal ince iğne biyopsisiyle endobronşiyal ultrasonografiyi içeren endoskopik teknikler (EBUS/TBNA), endoözofajiyal ultrasonografi ve ince iğne aspirasyonu (EUS) yöntem-leri gelişmiştir (7-9). Bununla birlikte invazif teknikler preoperatif mediyastinal evrelemenin temel taşı olarak kalmaktadır (2). Mediyastenin preoperatif invazif evreleme metod-ları klasik servikal mediyastinoskopi, videotorakos-kopi (VTS), anterior mediyastinotomi, video-yardımlı mediyastinoskopik lenfadenektomi (VAMLA) ve trans-servikal genişletilmiş mediyastinal lenfadenektomi (TEMLA)'yi içermektedir ve TEMLA bu makalenin ilk sıradaki yazarı (MZ) tarafından 7 yıl önce evreleme ve muhtemelen KHDAK tedavisi sonuçlarını geliştirmek amacı ile sunulmuştur (10-14). TEMLA'DA CERRAHİ TEKNİK TEMLA ile 9 no'lu istasyon nodları olan pulmoner liga-man dışında tüm mediyastinal lenf nodu istasyonları ve çevresel yağlı doku çıkarılmaktadır. Operasyon boyun-da 5-8 cm'lik Collar insizyonu ile başlar. Subplatismal flepler genişce diseke edilerek kaslar ve vasküler yapılar işlem sırasında daha iyi bir gözlem için genişce serbest-leştirilir. Tüm vakalarda her iki laringiyal rekürren sinirin görülmesi zorunludur (Şekil 1, 2). Sol reküren sinir işlem sırasında özellikle tehlike altındadır, bu yüzden çok dikkatlice diseke edilmeli ve yaralanmasından dikkat-lice korunmalıdır. Sinirin çevresel diseksiyonu öneril-mez. Siniri saran fasyanın son tabakasının korunması tercih edilir. Her iki vagal sinir de ayrıca korunmalıdır.

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