Carinal Resection and Reconstruction in Surgical Treatment of Bronchogenic Carcinoma with Carinal Involvement

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.

Short- and medium-term outcomes of video-assisted thoracoscopic surgery versus thoracotomy for carinal lung resection combined with carina reconstruction in locally advanced non-small cell lung cancer patients

BACKGROUND

The application of video-assisted thoracoscopic surgery (VATS) for complex carina surgeries in treating non-small cell lung cancer (NSCLC) patients with involved carina is controversial. This study compared short- and medium-term outcomes of VATS versus thoracotomy for carinal lung resection with carina reconstruction in treating locally advanced NSCLC, aiming to assess the potential benefit of VATS over thoracotomy for these patients.

METHODS

A total of 37 consecutive NSCLC cases receiving VATS (n = 14) or thoracotomy (n = 23) for carinal lung resection with carina reconstruction from 2016 to 2021 were retrospectively identified. Baseline clinicopathological characteristics, perioperative outcomes, and survival profiles were investigated.

RESULTS

Patients in the VATS and thoracotomy groups had comparable baseline clinicopathological characteristics (all p > 0.050). VATS decreased postoperative drainage volume compared with thoracotomy (1280 [1170-1510] vs. 1795 [1510-1905] mL, p = 0.012). Regarding surgical-related pains, VATS reduced numeric rating scale scores on the postoperative day 1 (4 [3, 4] vs. 5 [4, 5], p = 0.021) and day 2 (3 [3, 4] vs. 5 [3-5], p = 0.023) than thoracotomy. No difference was found between the VATS and thoracotomy groups in other perioperative outcomes, postoperative complications, and assessment of lymph nodes (LNs) and LN stations (all p > 0.050). Moreover, patients in the two groups had comparable 3-year disease-free survival (DFS), overall survival (OS), and recurrence and mortality patterns. Further subgroup and Cox hazards regression analyses also observed no difference in DFS or OS between the two groups.

CONCLUSIONS

VATS reduced postoperative drainage volume and ameliorated surgical-related pain, and achieved comparable medium-term survival compared to thoracotomy for carinal lung resection with carina reconstruction in treating locally advanced NSCLC.

Reconstruction of the trachea and carina: Surgical reconstruction, autologous tissue transplantation, allograft transplantation, and bioengineering

There have been significant advancements in medical techniques in the present epoch, with the emergence of some novel operative substitutes. However, the treatment of tracheal defects still faces tremendous challenges and there is, as yet, no consensus on tracheal and carinal reconstruction. In addition, surgical outcomes vary in different individuals, which results in an ambiguous future for tracheal surgery. Although transplantation was once an effective and promising method, it is limited by a shortage of donors and immune rejection. The development of bioengineering has provided an alternative for the treatment of tracheal defects, but this discipline is full of ethical controversy and hindered by limited cognition in this area. Meanwhile, progression of this technique is blocked by a deficiency in ideal materials. The trachea together with the carina is still the last unpaired organ in thoracic surgery and propososal of a favorable scheme to remove this dilemma is urgently required. In this review, four main tracheal reconstruction methods, especially surgical techniques, are evaluated, and a thorough interpretation conducted.

Intraoperative airway management for patients with tracheal tumors: A case series of 37 patients

BACKGROUND

Tracheal tumors are rare. The aim of this case series was to investigate airway selection during radical surgery for patients with tracheal tumors.

METHODS

Here, we performed a retrospective case review of patients with tracheal tumors who underwent tracheal surgery in our center. A total of 37 cases, including 26 patients with primary tracheal tumors and 11 cases with advanced thyroid cancer, were enrolled into the study. Baseline characteristics and differential prognosis of included patients were estimated. We summarize the strategies for intraoperative airway selection and analyze the risk factors associated with delayed extubation.

RESULTS

There is a trend for primary tracheal tumors to appear toward the upper (9 of 26) and middle third (9 of 26) of the trachea, followed by the lower third airway (8 of 26). Advanced thyroid cancers occur most frequently in the upper trachea (7 of 11) and then the middle trachea (4 of 11). All primary and secondary patients underwent R0 resection. Minor histological subtypes were found to correlate with a poor prognosis. Extracorporeal support and tracheotomy intubation were applied in high-risk cases, and a total of 32 patients achieved intrathoracic intubation during the surgical process. Intensive care unit (ICU) delay (>1 day) was observed among 25 patients, which were not enriched in cases who underwent cross-field endotracheal intubation. Additionally, temporal suboptimal oxygenation (SpO2 < 95%) was an independent risk factor of ICU delay.

CONCLUSIONS

Airway selection plays an important role in successful tracheal surgery, and an appropriate ventilation routine depends on the patient and a surgical process which is safe and effective.

Carinal Resection and Reconstruction for Tracheo-bronchial Neoplasms-Surgical Outcomes of 20 Consecutively Operated Cases

Carinal resections for trachea-bronchial neoplasms are technically challenging and have high operative morbidity and mortality. This study examines the clinical experience of carinal resections for various tracheo-bronchial tumors in a dedicated thoracic surgery center. Medical records were retrospectively reviewed from March 2012 to December 2019 to identify all patients who underwent carinal resection. An analysis of demographic characteristics, perioperative variables including complications, was carried out. Perioperative outcome was the primary outcome measure. Twenty carinal resections were performed with a median follow-up of 2.4 years (range 0.5-4.1). Procedures included 8 isolated carinal resections (40%), 6 right carinal pneumonectomy (30%), 1 left carinal pneumonectomy (5%), and 5 carinal right upper sleeve lobectomy (25%). Age of the patients range from 18 to 62 years with 9/11 male-female ratio. Mean duration from symptom onset to diagnosis was 6.1 months. All post-operative complications occurred in 7 (35%) patients. Anastomotic complications occurred in 2 (10%) patients. Out of these, 1 patient was initially managed with stent placement, ultimately requiring pneumonectomy. Post-operative events were significantly higher in group of patients who underwent carinal resection with concomitant pulmonary resection (P = 0.01). No perioperative (90-day) mortality was found. Despite advances in perioperative management, carinal resection poses challenges for both patient and surgeon. Concomitant pulmonary resection was associated with increased risk of peri-operative complications. Appropriate patient selection, meticulous surgical technique, and stringent post-operative protocols are the key for success.

Complex Tracheocarinal Reconstructions Using Extrathoracic Muscle Flaps as Airway Substitutes

BACKGROUND

Extrathoracic muscle flaps can be used as airway substitutes for the closure of complex bronchopleural or tracheoesophageal fistulas or in the context of tracheocarinal reconstructions after resection for centrally localized tumors in order to alleviate excess anastomotic tension.

METHODS

Evaluation of all patients undergoing tracheocarinal reconstructions with extrathoracic muscle flap patches as airway substitutes in our institution from 1996 to 2016.

RESULTS

A total of 73 patients underwent tracheocarinal reconstructions using extrathoracic muscle flap patches as airway substitutes for the closure of bronchopleural fistulas (n = 17) and complex tracheoesophageal fistulas (n = 7), or in the context of airway reconstructions after carinal resections in combination with pneumonectomy/sleeve lobectomy for centrally localized lung tumors (n = 36) and noncircumferential tracheal resections for tracheal disease processes (n = 14). The size of airway defects replaced by muscle patches ranged from 2 × 2 to 8 × 4 cm and was at most 40% of the airway circumference. The postoperative 90-day mortality was 8.2% and was only observed after right-sided pneumonectomy. Complications at the airway reconstruction site occurred in 8 patients (10%): 4 airway dehiscence (5%) with uneventful healing after reoperation (n = 2) or temporary stenting (n = 2) and 4 airway stenosis (5%) that required repeated bronchoscopy and stenting. Overall, 63 of 67 surviving patients (94%) revealed intact airways without further bronchoscopic interventions or tracheal appliance during follow-up.

CONCLUSIONS

Extrathoracic muscle flaps used as airway substitutes are an interesting and sometimes life-saving option to close difficult tracheocarinal airway defects or to reduce anastomotic tension in the context of complex tracheocarinal surgeries.

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.

Non-intubated combined with video-assisted thoracoscopic in carinal reconstruction

Carinal reconstruction is a difficult technique combined with video-assisted thoracoscopic surgery (VATS). It has a high requirement on the operator's skills in operating thoracoscope and meanwhile requires the close cooperation from anesthesiologists. Tracheal intubation and ventilator-assisted ventilation are key steps to ensure the success of surgery. However, tracheal intubation itself may influence the exposure of surgical field and increase the difficulty of anastomosis. In close cooperation of anesthesiologists, we did not perform tracheal intubation; rather, we carried out non-intubated complete VATS carinal reconstruction in a patient with adenoid cystic carcinoma (ACC) of the lower trachea. The awake complete VATS carinal reconstruction was successfully performed. The anastomosis lasted about 36 hours, and the whole surgical procedure lasted 230 min. The intraoperative blood loss was about 80 mL. The patient recovered well 100 min after surgery. A semi-solid diet began 6 hours following the surgery. This non-intubated anesthesia method makes the surgery easier, especially during the anastomosis of stumps. It is feasible and safe to apply this anesthesia technique in carinal reconstruction.

Thoracoscopic double sleeve lobectomy in 13 patients: a series report from multi-centers

BACKGROUND

This study aims to explore the feasibility and safety of video-assisted thoracic surgery (VATS) double sleeve lobectomy in patients with non-small lung cell cancer (NSCLC).

METHODS

Between June 2012 and August 2014, 13 NSCLC patients underwent thoracoscopic double sleeve lobectomy and mediastinal lymphadenectomy at three institutions. A retrospective analysis of clinical characteristics, operative data, postoperative events and follow-up was performed.

RESULTS

Thirteen NSCLC patients (median age, 60 years; range, 43-67 years) underwent thoracoscopic double sleeve lobectomy. There were no conversions to thoracotomy. Left upper lobectomy was most frequently performed (eleven patients). Median operative time was 263 minutes (range, 218-330 minutes), and median blood loss was 224 mL (range, 60-400 mL). The learning curve revealed reductions in both operative times and blood loss of ten cases from one center. Median data were duration of blocking pulmonary artery (PA) 72 minutes (range, 44-143 minutes), resected lymph nodes 24 (range, 10-46), stations of retrieved lymph nodes 6 (range, 5-9), thoracic drainage 1,042 mL (range, 500-1,700 mL), duration of thoracic drainage 5 days (range, 3-8 days), postoperative hospital stay 10 days (range, 7-20 days), and ICU stay 1 day (range, 1-2 days). One patient (1/13, 7.70%) suffered from pneumonia after surgery. There were no deaths at 30 days. Median duration of follow-up was 6 months (range, 1-26 months). And no local recurrences or distant metastasis were reported.

CONCLUSIONS

Thoracoscopic double sleeve lobectomy is a technically challenging, but feasible procedure for NSCLC patients and it should be restricted to skilled VATS surgeons.

Carinal resection and reconstruction in thoracic malignancies

BACKGROUND AND OBJECTIVES

The purpose of this study was to present clinical outcomes of malignant tumors involving the carina after surgery in order to establish the management guidelines.

METHODS

Between 1996 and 2011, 30 patients underwent carinal resection and reconstruction for malignancy involving carina. We retrospectively analyzed their medical records. There were 22 cases of common type of NSCLC (squamous cell carcinoma/adenocarcinoma/large cell neuroendocrine carcinoma) and eight cases of carcinomas of salivary gland type (adenoid cystic carcinoma/mucoepidermoid carcinoma).

RESULTS

Seventeen right sleeve pneumonectomies, two left sleeve pneumonectomies, nine carinal sleeve right upper lobectomies, and two airway resections and reconstructions without lung resection were performed. There were no in-hospital mortalities. Eleven postoperative morbidities occurred including three cases of acute respiratory distress syndrome following pneumonectomy. Late complications occurred in eight patients including three cases of anastomotic stenosis. During follow-up, 12 mortalities occurred, including 6 cancer-related mortalities. The 5-year overall survival rate (OS) and disease-free survival rate (DFS) were 66.3% and 52.9%, respectively.

CONCLUSIONS

Malignant tumors involving the carina can be controlled with carinal surgery with acceptable mortality and morbidity. Patients with thoracic malignancy involving the carina should be considered as surgical candidate based on disease extent and functional status.

Left sleeve pneumonectomy via a clamshell incision for lung cancer with carinal invasion: report of a case

Surgery for lung cancer involving the carina is challenging as it requires special surgical techniques and airway management. We report how we successfully treated carinal invasion of primary lung cancer by performing left sleeve pneumonectomy through a clamshell incision, as bilateral thoracotomy through a transverse sternotomy. Without a cardiopulmonary assist device, adequate ventilation and oxygenation were maintained across the operative field with a spinal tube. Tracheo-bronchial anastomosis was relatively easy to perform, with an excellent surgical view. The patient had an uneventful postoperative course and was discharged from hospital without oxygen support. There was no evidence of complications at the anastomosis on chest computed tomography and no sign of recurrence during 6 months of follow-up. The clamshell incision approach provided an excellent surgical view without the need to change the position of the patient during the operation. Thus, it could prove a useful procedure for carinal surgery; especially left sleeve pneumonectomy.

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.