Sleeve pneumonectomy for bronchogenic carcinoma

Birth of Airway Surgery and Evolution over the Past Fifty Years

Significant developments in airway surgery occurred following the introduction of mechanical ventilators and intubation with cuffed endotracheal tubes during the poliomyelitis epidemic of the 1950s. The resulting plethora of postintubation injuries provided extensive experience with resection and reconstruction of stenotic tracheal lesions. In the early 1960s, it was thought that no more 2 cm of trachea could be removed. By the late 1960s, this was challenged owing to better knowledge of airway anatomy and blood supply, tension-releasing maneuvers, and improved anesthetic techniques. Currently, about half of the tracheal length can be safely removed and continuity restored by primary anastomosis.

Sharing the Airway: The Importance of Good Communication Between Anesthesiologist and Surgeon

One of the most challenging tasks during airway surgery is ensuring adequate ventilation throughout the procedure. Because the airway is shared between surgeon and anesthesiologist, successful oxygenation and ventilation of the patient can only be accomplished through close collaboration during the various stages of the procedure. This includes periods in which surgical airway manipulation compromises adequate ventilation and periods in which ventilation interferes with the surgical environment. With continuous communication between surgeon and anesthesiologist, optimal outcomes can be achieved.

Tracheal sleeve pneumonectomy: Long-term outcome

Selected primary lung cancers less than 2cm from the carina or invading the tracheo-bronchial angle, formerly considered inoperable, can be amenable to tracheal sleeve pneumonectomy (TSP). Such a delicate technique, can entail remarkable post-operative morbidity and mortality, and only few clinical series are reported. Purpose of this paper is to examine complications and long-term survival of our personal series and those reported in literature. At our academic department from 1983 to December 2004, out of 99 patients with NSCLC less than 2cm from the carina, 35 (35.4%) were deemed inoperable after conventional staging; the remaining 64 underwent surgery. Since 1993 in every patient with lung cancer we perform a thoracoscopic exploration as the first step of the intervention. Unexpected causes of inoperability were found at thoracotomy in nine patients (14.1%) and at thoracoscopy in two other patients. Of the remaining 53 patients, 52 had a right TSP and one a left TSP. Intraoperative mortality was nil. Perioperative mortality was 7.5%. Major complications occurred in 11.3% of the patients. Thirty (56.6) patients are alive and disease-free 23-97 months after surgery; for 18 (33.4%) of these, more than 5 years have elapsed after the operation. TSP is the only concrete option for treating lung cancer originating less than 2 cm from the carina. The review of our experience and of other reported series suggests that, with careful selection of patients and meticulous surgical technique, operative mortality and complications are acceptable. Long-term survival and prognosis are encouraging.

Carinal resection

There are many challenges in performing carinal resection and, in particular, reconstruction. A better understanding of the safe limits of resection has contributed to the reduced mortality from anastomotic complications. Accurate selection of patients, a meticulous adherence to surgical precision, and optimal postoperative patient care have become mandatory to reduce the risk of the most serious complications, such as noncardiogenic pulmonary edema and suture dehiscence. With carinal resection for bronchogenic carcinoma, contemporary studies suggest that there are reasonable survival rates in the absence of involved mediastinal lymph nodes or distant metastatic disease. The role of neoadjuvant therapy for bronchogenic carcinoma involving the carina deserves further investigation; this type of therapy should be used with caution because of the deleterious effects on anastomotic healing.

Carinal resection and reconstruction

Successful outcomes for carinal resection and reconstruction depend upon many factors. Careful patient selection for patients who can tolerate the physiologic effects of the operation cannot be underestimated. Understanding the safe limits of resection, the technical details of airway reconstruction, and ongoing improvements in intraoperative and postoperative care should minimize the morbidity and mortality rates previously reported with this procedure. In addition, further work from institutions with considerable experience in carinal resection is needed to better define the long-term outcome for patients with bronchogenic carcinoma in close proximity to or involving the carina. Prior studies have suggested reasonable survival rates can be expected in the absence of involved mediastinal nodes or distant metastatic disease.

The history of tracheal surgery

Tracheal surgery, which did not exist in a coherent, systematic fashion 45 years ago, has developed techniques that allow resection of approximately half of the adult trachea with primary reconstruction, largely by anatomic mobilization procedures. Dependable methods have also been developed for laryngotracheal and carinal resection and reconstruction. The daunting problem of long congenital tracheal stenosis appears to be largely solved by slide tracheoplasty. In the past four decades much has also been learned about the etiology, natural history, pathology, and (in some cases) prevention of tracheal diseases including primary and secondary tumors, postintubation injuries, and idiopathic stenosis.

Complications of tracheal sleeve pneumonectomy: personal experience and overview of the literature

OBJECTIVES

Tracheal sleeve pneumonectomy, although technically demanding, is considered the choice for tracheobronchial angle cancers. Complications in our 49 tracheal sleeve pneumonectomies are reviewed. Results, complications, and technical aspects are critically discussed. Although series in the literature differ in selection of patients and surgical techniques and extend over long periods, we attempt to compare our experience with results from the literature.

METHODS

From 1983 to September 1999, 60 patients eligible for tracheal sleeve pneumonectomy after conventional staging underwent operation. A Sybilla Fome-Cuf ventilation tube (Bivona, Inc, Gary, Ind) was used starting in 1987 to facilitate anastomosis. Since 1993, all patients have undergone video-assisted thoracoscopy immediately before the operation.

RESULTS

There were 11 (18.3%) exploratory thoracotomies, 48 right tracheal sleeve pneumonectomies, and 1 left tracheal sleeve pneumonectomy. Among the tracheal sleeve pneumonectomies, we recorded 4 (8.2%) perioperative deaths (myocardial infarction, n = 1; heart failure, n = 1; pulmonary edema, n = 1; gastric ulcer hemorrhage, n = 1; and anastomotic fistula in a patient who received high-dose radiation before the operation, n = 1). We observed 5 (10.2%) complications (lung edema, n = 1; transitory recurrent nerve palsy, n = 2; empyema without fistula cured conservatively, n = 1; and pneumonia, n = 1). Anastomotic stenosis did not occur. Twenty-six (53%) patients are alive 14 to 87 months postoperatively, 12 (24.5%) of these more than 5 years postoperatively. Five (10.2%) died of mediastinal recurrence at 6 and 54 months. Two others (4.1%) died in road accidents.

CONCLUSIONS

Tracheal sleeve pneumonectomy is a demanding operation with a high risk of complications. Analysis of literature and personal experience shows that complications can be greatly reduced through accurate selection of patients, precise technique, and optimal postoperative care. Long-term survival equals that obtained after standard pneumonectomy.

Surgical management of tracheal tumors

BACKGROUND

Resection of tracheal tumors is particularly challenging when the neoplasm involves the carina or is located in close proximity. We reviewed our experience with 22 tracheal resections for tumor.

METHODS

In this retrospective review, adenoid cystic carcinoma was diagnosed in 13 patients, squamous cell carcinoma in 5, typical carcinoid in 2, and leiomyoma and benign fibrous histiocytoma, in 1 each. There were 19 segmental resections with direct anastomosis, and 3 complex resections in which the carina was involved.

RESULTS

One patient with tumor in the trachea and left main bronchus underwent resection through simultaneous bilateral thoracotomy and died. During 2 to 17 years of follow-up, 2 patients died of unrelated disease, 2 died of metastases, and 1 is receiving radiotherapy for recurrence. Sixteen patients are well and free of tumor.

CONCLUSIONS

Complete resection of all neoplastic tissue is mandatory, but benign and low-grade malignant tumors should be resected conservatively with preservation of lung parenchyma. Options for treatment of neoplasms involving trachea and left bronchus should include resection of the neoplasm in two stages, thus minimizing trauma of each operation.

Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy

The number of patients reported to have undergone bronchoplastic procedures has increased nearly fourfold in the past decade. These techniques represent excellent surgical therapy for patients with benign endobronchial lesions, traumatic airway disruptions, or tumors of low-grade malignant potential, and for select patients with surgically resectable lung cancer. Eighty-nine percent of bronchoplastic procedures are performed for malignancy. We reviewed 1,915 bronchoplastic procedures for carcinoma reported over the past 12 years to determine the incidence of complications and survival. Complications included local recurrence (10.3%), 30-day mortality (7.5%), pneumonia (6.7%), atelectasis (5.4%), benign stricture or stenosis (5.0%), bronchopleural fistulas (3.5%), empyema (2.8%), bronchovascular fistulas (2.6%), and pulmonary embolism (1.9%). Results were further stratified into sleeve lobectomy and sleeve pneumonectomy groups. Five-year survivals for stage I, II, and III carcinoma were 63%, 37%, and 21%, respectively. Sleeve lobectomy for carcinoma extends surgical therapy to select patients with complication rates comparable to pneumonectomy and long-term survival similar to that for conventional resections.

The "Kergin pneumonectomy"

Out of a series of 211 stage III (A and B) lung cancers radically resected with routine lymphadenectomy from 1971 to 1987, a total of 11 were squamous cell carcinomas invading the right main bronchus and lateral portion of the trachea. These patients were managed using a particular technique that we have always arbitrarily called, "Kergin pneumonectomy," after the Toronto surgeon who described it in 1952. These patients, today, are staged III B. There was no operative mortality and only 2 minor complications. Two patients survived 3 years and 1 is alive and free of disease 7 years from surgery. This technique should be considered before embarking on more perilous surgery such as "sleeve pneumonectomy," a procedure which still carries high mortality and morbidity rates and requires special equipment and intensive postoperative care.

Tracheal sleeve pneumonectomy for bronchogenic carcinoma: report of 55 cases

From 1966 to 1986, a total of 55 patients underwent a tracheal sleeve pneumonectomy (53 right and 2 left) for bronchogenic carcinoma. Preoperative radiotherapy was given in only 5 patients. The overall operative death rate was 10.9%, but no patient has died since 1975 (32 survivors). Seven patients had a postoperative empyema (12.7%); 4 of these patients had a bronchopleural fistula. Twenty-five patients had postoperative radiotherapy, 5 of whom also had chemotherapy. The actuarial survival rate, after exclusion of the 6 operative deaths, was 38% at 3 years and 23% at 5 years. Survival was correlated to regional lymph node involvement. The actuarial survival rate among patients with tumoral spread to bronchial lymph nodes was 43% at 3 years. Among the 13 patients with only subcarinal involvement, the actuarial survival rate was 34% at 3 years. None of the 8 patients with paratracheal lymph node involvement survived more than 30 months. These results indicate that tracheal sleeve pneumonectomy for bronchogenic carcinoma with extension to the carina is now fully justified considering the low operative mortality and the good results observed when lateral tracheal lymph nodes were not involved.

The clinical value of high-frequency jet ventilation in major airway reconstructive surgery

High-frequency jet ventilation (HFJV) via a catheter with internal diameter 2.4 mm was employed in 21 patients to facilitate airway reconstructive surgery. Tracheal reconstruction was performed in six cases, sleeve lobectomy in six and sleeve pneumonectomy in nine. An HFO-Jet-Ventilator was used at individually selected settings of 0.5-2.4 kg/cm2 for driving gas pressure and 4-10 Hz frequency. Intermittent positive pressure ventilation (IPPV) was used initially, with switch to HFJV at the time of tracheobronchial reconstruction. The time during which HFJV was employed ranged from 25 to 65 min. Except for transient hypoxia or hypercapnia in a few patients, the results of blood gas analyses during HFJV were satisfactory. The most appropriate HFJV settings for each surgical procedure and the advantages of HFJV over IPPV are discussed.

Results of surgical treatment of stage III lung carcinoma with carinal proximity. The role of sleeve lobectomy versus pneumonectomy and the role of sleeve pneumonectomy

Sleeve lobectomy in specific situations can be an alternative to pneumonectomy. Sleeve pneumonectomy is an aggressive resection for carcinoma involving the tracheobronchial angle, carina, or lower trachea and lung. Sleeve lobectomy is questioned because of its technical difficulties and its postoperative complications. Sleeve pneumonectomy is controversial in that its postoperative mortality and long-term survival rates are similar, it is a technically difficult procedure, and its mortality rate is greater than that of standard pneumonectomy. The indications for the procedures and patient selection are discussed.

Tracheal surgery

In the last 20 years the techniques for resection of the trachea with primary reconstruction have evolved to a point where most lesions involving up to 50% of the trachea can be successfully and dependably managed. A notable exception is the lengthy infiltrating adenoidcystic carcinoma. Postintubation stenosis is largely correctible in an initial operative approach. The operation has such a high degree of success that it appears to be the treatment of choice. Primary tracheal tumors and selected secondary tracheal tumors are often amenable to surgical resection, with the addition of radiotherapy for certain histologic types. Results strongly support this aggressive approach. Three problems of current interest seem to be yielding to surgical correction although decisions about the time of surgery, the delicacy of surgical execution from the postoperative management all present difficult problems. These are the repair of the rare congenital tracheal stenosis in children, resection and reconstruction of the carina and correction of subglottic and upper tracheal stenosis.

One-lung high-frequency ventilation for tracheoplasty and bronchoplasty: a new technique

Major airway surgery requires the maintenance of adequate ventilation and oxygenation during the period of resection and reconstruction, as well as an unobstructed surgical field and optimal access to the airway's circumference. High-frequency positive-pressure ventilation (HFPPV) at a frequency of 1 Hz (60 breaths/min) or more, along with a small tidal volume (50 to 250 cc), provides adequate ventilation and oxygenation with minimal impairment of pulmonic and systemic circulatory functions. We have used HFPPV of one lung through a 2 mm internal diameter catheter in six patients (three undergoing right sleeve pneumonectomies, two having carinal tumor resections, and one having tracheal resection). High-frequency positive-pressure ventilation of the left lung provided continuous and adequate ventilation and oxygenation during the period of resection and reconstruction of the airways, while the small catheter permitted unimpaired visualization and adequate access to the operative site.

Carcinoma of the lung: what can be done if the carina is involved?

When carcinoma of the lung invades the carina, it is by definition a stage III lesion and frequently incurable. However, when lymph node invasion does not preclude resection for cure and when there are no other contraindications to such resection, techniques are now available for resection of the carina and primary reconstruction. While tracheal sleeve pneumonectomy is the operation most frequently employed for invasion of the carina by bronchogenic carcinoma that is otherwise operable, occasionally the lower lobe may also be saved. When the carina is involved by a primary neoplasm of the airways, primary resection with carinal reconstruction with or without various amounts of pulmonary resection is clearly indicated when possible.