Role of VV ECMO tracheal surgery and carinal resection: Two case reports

The aim of this study is to describe the anaesthesia management of two patients undergoing carinal resection under veno-venous extracorporeal membrane oxygenation (VV ECMO). In both cases, anaesthesia was induced and then maintained with inhalational agents during pneumonectomy and mediastinoscopy (respectively). Then the jugular and femoral veins were cannulated and VV ECMO was started after heparinization. One of the patients presented bleeding during surgery, which was treated with low-dose vasopressors (norepinephrine) and transfusion of platelets, fresh frozen plasma, and concentrated red blood cells. During VV ECMO, anaesthesia was maintained with target-controlled infusion of propofol. VV ECMO can be expected to improve surgical conditions in tracheal surgery; however, it is still a novel technique in this context. In selected patients, it would guarantee ventilatory support during carinal resection, but it is essential to carefully plan anaesthesia maintenance and prepare for VV ECMO-related complications. This technique should only be used in tertiary centres with experience in VV ECMO management.

Pleomorphic adenoma of the trachea: A case report

INTRODUCTION AND IMPORTANCE

Although pleomorphic adenoma is the most common type of parotid gland tumor, its occurrence in the trachea is rare. Here, we describe a successfully resected pleomorphic adenoma of the trachea in a woman with severe respiratory failure that had been preoperatively misdiagnosed as asthma.

CASE PRESENTATION

A 69-year-old woman presented to the emergency department with symptoms of worsening dyspnea and subsequent loss of consciousness. She had a history of progressively worsening wheezing and stridor over the course of 2-years and had been diagnosed with asthma. Arterial blood gas sample analysis indicated type II respiratory failure. A chest computed tomographic scan revealed a tumor in the trachea, which was almost completely obstructing the lower tracheal lumen. The tumor was located just above the carina. To alleviate airway constriction and achieve complete resection, carinal resection with reconstruction was performed. The postoperative diagnosis was pleomorphic adenoma of the trachea.

CLINICAL DISCUSSION

Pleomorphic adenoma is a rare tracheal tumor that may present with obstructive airway symptoms that mimic asthma.

CONCLUSION

Tracheal tumors should be considered in patients with chronic respiratory symptoms that do not improve with medication.

Reconstruction of the carina using bronchial autograft: an alternative approach

We report successful engraftment by autologous transplantation of the bronchial wall of the resected specimen in extensive tracheobronchial resection with left pneumonectomy. Since the adenoid cystic carcinoma had spread beyond the carina to the right bronchus, we resected three rings of tracheal cartilage and three rings of left main bronchus cartilage. Reconstruction was performed using the bronchial wall of the resected specimen to relieve tension on the anastomosis. No stricture or recurrence was observed four years after the operation. Further research relating to maximization of blood flow to the reconstructed tissue based on engraftment area and shape is required.

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.

The Influence of Airway Closure Technique for Right Pneumonectomy on Wall Tension During Positive Pressure Ventilation: An Experimental Study

Bronchopleural fistula (BPF) remains a significant source of morbidity and mortality after right pneumonectomy (RPN). Postoperative mechanical ventilation represents a primary risk factor for BPF. We undertook an experiment to determine the influence of airway diameter on suture line tension during mechanical ventilation after RPN. RPN was performed in 6 fresh human adult cadavers. After initial standard bronchial stump closure (BSC), the airway suture lines were subjected to 5 cm H₂O incremental increases in airway pressures beginning at 5-40 cm H₂O. To minimize airway diameter, a carinal resection was then performed with trachea to left main bronchial anastomosis and the airway suture lines subjected to similar incremental airway pressures. Wall tension (N/m) at the suture lines was measured using piezoresistive sensors at each pressure point. As delivered airway pressure increased, there was a concomitant increase in wall tension after BSC and carinal resection. At every point of incremental positive pressure, wall tension was however significantly lower after carinal resection when compared to BSC (P < 0.05). Additionally the differences in airway tension became even more significant with higher delivered airway pressure (P < 0.001). Airway diverticulum after BSC leads to significantly increased tension on the bronchial closure with positive airway pressure as compared to a closure which minimize airway diameter after RPN. This supports the role of Laplacian Law where small increases in airway diameter result in significant increases on closure site tension. Techniques which reduce airway diameter at the airway closure will more reliably reduce the incidence of BPF following RPN.

Transposition of pulmonary veins for mobilization of residual right middle and lower lobes after carinal right upper lobectomy: a unique pulmonary hilar mobilization technique for safe tension-free airway anastomosis

Unique right hilar mobilization was performed by pulmonary venous transposition of the right middle and lower lobe veins to the opening of the right upper pulmonary vein to achieve tension-free airway anastomosis after carinal right upper lobectomy for a patient with adenoid cystic carcinoma. The right middle and lower lobes were reconstructed safely thereafter by side-to-end anastomosis between the side of the lower trachea and intermediate bronchus with acceptable suturing tension.

Sleeve pneumonectomy and carinal resection for management of primary adenoid cystic tumor of the lung with carinal extension: Report of two cases

Adenoid cystic carcinoma is a rare tumor of low frequency, low grade malignancy and slow growth originating from the major and minor salivary glands. Its primary pulmonary presentation is very rare, it can manifest with central airway obstruction and extensive lung involvement. Although it is slow growing, it has a tendency to local recurrence and late hematogenous metastases. The cornerstone of management consists in the complete resection of the tumor. Radiotherapy and adjuvant chemotherapy have been used in a limited number of patients with unsatisfactory results. Therefore, clinical judgment is of vital importance for early diagnosis and adequate selection of patients for surgical management. We present two cases of patients with primary pulmonary adenoid cystic tumor with invasion of the carina treated with sleeve pneumonectomy and carinal resection with adequate response to the intervention.

Carinal resection

Carinal resection is defined as the resection of tracheo-bronchial bifurcation, with or without lung parenchyma resection. It represents one of the most challenging areas of airway resection and reconstruction, basically due to the variability in the location and extent of the lesions. Main indications for this procedure are primary tumours of the carina or the distal trachea or, more frequently, bronchogenic carcinoma with carinal involvement. Very different approaches and reconstruction techniques have been experimentally and clinically described in the last 50 years, with some corner stone procedures in the history of modern thoracic surgery. Despite many technical and oncological difficulties encountered in this field, encouraging results have been reported in recent series, in particular an excellent 5-year survival rate of 50% in pN0 patients suffering form carinal infiltration form lung cancer. Several aspects of the multimodality approach to neoplastic carinal involvement still remain debatable like radio-chemotherapeutic approach instead of the extremely rare left carinal pneumonectomy as well as the role of induction treatments before embarking in such demanding procedures, according to the -pathological nodal status.

Anaesthetic management of carinal resection and reconstruction-a case report

SUMMARY

Anaesthetic management of surgery for tumors involving the carina is very challenging for an anaesthesiologist and has been associated with guarded prognosis. We describe the management of carinal resection and reconstruction due to a tracheal tumor involving the carina. The various anaesthetic issues involved and experienced in this clinical setting are described.