Carinal resection

Carinal sleeve resections

Carinal resections are frequently performed for carinal tumors. Resection of the carina due to distal tracheal tumors may be required, and the extension of main bronchial tumors to the carina may lead to carinal resection. This is one of the rarely performed operations in thoracic surgery, which is technically challenging and has a high complication rate. In the early series, perioperative mortality rate was reported as 29% and the five-year survival rate as 15%. Due to its technical difficulties and high complication rates, it is performed only in certain centers. In this review, we discuss techniques related to carinal sleeve resection and prognostic factors in the light of literature data.

Extended Pulmonary Resection by Sleeve Lobectomy and Carinal Pneumonectomy: Selection and Technique

Minimally invasive surgical approaches for extended pulmonary resections are becoming increasingly common as more surgeons gain experience in thoracoscopic and robotic technique. Outcome studies demonstrate improved decreased morbidity as compared with an open surgery.

Uniportal video-assisted thoracoscopic lung sparing tracheo-bronchial and carinal sleeve resections

Pathology arising from the intrathoracic portion of the trachea (distal trachea), the carina and the main bronchi is usually neoplastic and is mainly treated with surgery. Resection of the intrathoracic portion of the trachea, the carina and the main bronchi for neoplastic lesions does not necessitate lung resection and is traditionally being conducted via open surgery. Video-assisted thoracic surgery (VATS) is witnessing an exponential growth and is the treatment of choice for early-stage non-small cell lung cancer (NSCLC). The experience accumulated over the past two decades along with the introduction of reliable and ergonomic technology, has led to the expansion of its indications. In this article we provide a detailed description of lung sparing distal tracheal, carinal and main bronchi resection for primary neoplasms of the airway, without involvement of the lung, with the uniportal video-assisted technique. The chest is entered through the fourth intercostal space, mid-axillary line. Dissection of the paratracheal space anteriorly, the tracheoesophageal groove posteriorly and the subcarinal space and division of the azygos arch are essential to mobilize the distal trachea and carina. Lateral dissection should be avoided beyond the points of division of the airway, as it may hinder the blood supply to the anastomosis. Any tension to the anastomosis should be relieved by release maneuvers. Ventilation is achieved through an endobronchial catheter, inserted into the left main bronchus through which a high-frequency jet ventilation catheter can be also inserted through it. The rationale of applying a minimally invasive technique for the conduction of tracheal and carinal resections, is to exploit its advantages, namely less pain, earlier mobilization and lower morbidity. Uniportal video-assisted resections of the distal trachea, carina and the main bronchi, are safe when conducted by experienced surgical and anesthetic teams.

Two cases of carina resection for bronchogenic tumor with lung parenchyma sparing: A brief report

INTRODUCTION

Carinal resection (CR) with or without lung parenchyma sparing is one of the challenging issues in thoracic surgery and performed rarely. It is usually not used for the difficulty of the technique, or, in the majority of the situations, it is replaced by pneumonectomy when the patient conditions and the tumor characteristics allow the radical surgical approach. The difficulty includes the dissection of the trachea and main bronchi, the resection of the carina and the reconstruction of the trachea and bronchus. In spite of the knowledge of the technique, one of the most important problem is the incidence of postoperative complications which is higher compared to standard resections.

CLINICAL CASES

We show two cases of carina resection for a bronchogenic tumor with lung parenchyma sparing and good postoperative outcomes.

CONCLUSION

Our results demonstrate that this type of surgery is possible in selected centers with good quality of life for the patient after surgery.

Thoracoscopic tracheal resection and reconstruction using two ports approach

Tracheal resection and anastomosis for benign and malignant tracheal disease are a well-described procedure. Intra-thoracic tracheal lesions used to be addressed through sternotomy, thoracotomy, or via combined techniques. In the recent decade, minimal invasive surgical techniques have become an innovative trend in treatment of surgical thoracic conditions. Some recent papers have described and proven the feasibility and safety of tracheal and carinal surgeries via 3-4 port video-assisted thoracoscopic surgery (VATS) approaches. Even better results regarding morbidity and mortality were achieved using these new techniques. In this article, we publish a video that demonstrates our technique in tracheal resection and reconstruction using two portal thoracoscopic techniques.

Carinal resection and sleeve pneumonectomy

Carinal resection (CR) and sleeve pneumonectomy (SP) are one of the challenging issues in thoracic surgery and performed rarely. In spite of the knowledge of the technique, the incidence of postoperative complications is higher compared to standard resections. Adequate patient selection, improved anesthetic management, surgical technique and better postoperative management might reduce the rate of postoperative morbidity and mortality.

Left carinal pneumonectomy through median sternotomy: Surgical experience of two patients

Endobronchial tumors infiltrating the carina is a formidable challenge to surgeons in view of difficult surgical access to the carina, especially on the left side, problems of securing the airway intra-operatively, technically challenging anastomosis due to anatomical location, and high post-operative morbidity and mortality. We present our surgical experience of two cases of left carinal pneumonectomy which was undertaken for resectable primary salivary gland type tumors of lung.

Perioperative management of carinal pneumonectomy: a retrospective review of 13 patients

Carinal pneumonectomy is a challenging procedure because of the difficulties in surgical technique, intraoperative airway management, and postoperative respiratory and anastomotic complications. However, information regarding the anesthetic and intraoperative respiratory management of this procedure is scarce. This report describes our routine anesthetic and respiratory management strategy in patients undergoing carinal pneumonectomy. Medical records of 13 patients who underwent carinal pneumonectomy under combined general and epidural anesthesia between 2008 and 2012 were analyzed retrospectively. Eleven patients underwent right carinal pneumonectomy and two underwent left carinal pneumonectomy. A left double-lumen tube was used in all but one case, in which endobronchial intubation was difficult because of intrabronchial invasion of the tumor. A 6.0-mm-long reinforced endobronchial tube was intubated into the main bronchus of the non-operative side from the surgical field during carinal resection. There were no episodes of severe hypoxemia or hypercapnia during surgery. Twelve patients were extubated immediately after surgery. No patient developed post-thoracotomy acute lung injury or required postoperative reintubation despite poor preoperative respiratory function. The 30-day mortality rate was 0%. Our airway management protocol for carinal pneumonectomy enables positive surgical outcomes.

Carinal surgery: experience of a single center and review of the current literature

Background

To report our experience for the treatment of lung tumors of the right main bronchus (RMB) invading the carina.

Methods

From February 2000 till January 2007 we have identified 8 cases (1.09%) requiring carinal surgery.

Plan of action: Close cooperation with anaesthetics, long flexible ET tube, Right posterolateral thoracotomy, no irrevocable steps until resection guaranteed, mobilization of trachea and main bronchus, division of the trachea & Left main bronchus. Intubate across surgical field. Tailoring for airway size discrepancies, appropriately. Construction of the tracheobronchial anastomosis around the ventilatory tube. Skillfull reintubation, over a long boogie.

Results

Mortality: 12.5% due to ARDS (one patient)

Morbidity: anastomotic stenosis requiring stent (one patient). Follow-up 52 ± 11 months.

Recurrences: 2 patients (both with pathological N2 disease on histology).

Conclusions

Success of carinal surgery depends on careful patient selection, team approach and attention to detail. Patients with N2 disease carry the worst prognosis.

Malignant tumor of the trachea in children: diagnostic pitfalls and surgical management

Primary tracheal malignant neoplasms are very rare. Histologically, squamous cell and adenoid cystic carcinomas are the most common types of malignant primary tracheal tumors when all age groups are studied. In the past 5 years, we treated 2 children with tracheal mucoepidermoid carcinoma. Herein we report both cases and review the literature on the subject with particular emphasis on diagnosis and surgical management.

Surgical resection and survival of patients with unsuspected single node positive lung cancer (NSCLC) invading the descending aorta

BACKGROUND

Surgical treatment of non-small cell lung cancer (NSCLC) with aortic invasion is still debated.

METHODS

Thirteen patients with locally advanced (T4) NSCLC and invasion of the descending aorta underwent pneumonectomy (n=9) or lobectomy (n=4) together with aorta en bloc resection and reconstruction (n=8) or subadventitial dissection (n=5), complete lymph node dissection, and had microscopic unsuspected node metastasis at N1 (n=5) and N2/3 (n=8) levels of whom 12 received radiation therapy. Clamp-and-sew was used to resect and reconstruct the aorta.

RESULTS

Operative mortality and morbidity rate was 0% and 23%, respectively. Four patients died of systemic tumor relapse and 2 of local recurrence. Six patients were alive after a median follow-up of 40 months (range 15-125 months). Overall 5-year survival rate was 45%. Median survival time and 5-year survival rate of patients after aortic resection was 35 months and 67%, respectively, and was 17 months and 0%, respectively, after aortic subadventi-tial dissection (p=0.001). N1 and N2 nodal status adversely affected survival, but survival difference was not significant (N1 versus N2/3; 52% versus 39% at 5 years; p=0.998).

CONCLUSIONS

Aortic resection with single station node positive T4 lung cancer can achieve long-term survival. The data indicate that aortic resection-reconstruction is associated with better outcome than subadventitial dissection.