Carinal Resection Research Articles

Bronchoplastic Procedure Versus Pneumonectomy After High-dose Radiation for Non-small Cell Lung Cancer

Studies have revealed that salvage surgery after definitive chemoradiotherapy (CRT) for unresectable advanced non-small cell lung cancer improves survival with acceptable surgical adverse events. Few reports exist regarding pneumonectomy or the bronchoplastic procedure in this setting. Between 2008 and 2018, 27 patients (21 men; median age, 61 years) underwent salvage surgery after definitive CRT for non-small cell lung cancer. We investigated postoperative short- and long-term outcomes of salvage surgery and aimed to elucidate the feasibility of pneumonectomy or the bronchoplastic procedure. The median radiation dose was 60 Gy. The median period from the last day for irradiation to the operative day was 8.5 months. Pneumonectomy was performed in 9 patients, including 2 carinal resections; lobectomy was performed in 18 patients, including 5 bronchoplasties. Bronchial wrapping was performed in 9 cases (33%), R0 resection was achieved in 24 (89%), and postoperative complications were detected in 16 (59%). Although bronchopleural fistulas were found in only 2 patients who underwent pneumonectomy, arrhythmia was observed more frequently in patients who underwent the bronchoplastic procedure (P= .05). Regarding major complications, no relationship with any factors were found. The 90-day mortality was 0%. The 5-year overall and recurrence-free survival were 63% and 27%, respectively. R0 resection was a good prognostic factor for recurrence-free survival (P= .001). Perioperative short- and long-term outcomes of salvage surgery after definitive CRT for non-small cell lung cancer were acceptable. Complete resection offered a better recurrence-free survival. The bronchoplastic procedure or pneumonectomy should be considered as an option even after administration of high-dose CRT.

Anaesthesia consideration for carinal resection and reconstruction - A case report

A 25- year old male patient, with subcarinal mass projecting into carina and lower tracheal lumen underwent carinal resection and reconstruction surgery. This was done through the laryngeal drop and bilateral thoracotomy approach. Intraoperative course was complicated by persistent hypoxia and arrhythmias. This report explores the various anaesthetic issues involved which were effectively managed.

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.

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 2.4years (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 62years with 9/11 male-female ratio. Mean duration from symptom onset to diagnosis was 6.1months. 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.

Uniportal video-assisted thoracoscopic carinal resections: technical aspects and outcomes.

Important benefits in uniportal video-assisted thoracoscopic surgery (VATS) for lung cancer have recently been achieved. However, the use of this technique for complex sleeve procedures is limited. We describe the technical aspects of and patient outcomes following carinal resections using uniportal VATS. Since 2015, 16 sleeve carinal resections, including 11 right pneumonectomies, 4 right upper lobectomies and 1 lung-sparing carinal resection, have been performed at the Regional Clinic Hospital, Tyumen, Russia. The mean surgical time was 215.9 ± 67.2 min (range 125-340 min). The mean blood loss volume was 256.3 ± 284.5 ml (range 50-1200 ml). There was 1 case of conversion to thoracotomy. The morbidity rate was 25%, and the mortality rate was 0%. The median overall survival was 38.6 ± 3.5 months. The use of uniportal VATS for carinal resections in certain patients allows for radical resections with low rates of morbidity and mortality.

Use of Extracorporeal Membrane Oxygenation for Major Cardiopulmonary Resections.

In thoracic surgery, utilization of extracorporeal membrane oxygenation (ECMO) is mainly established for patients undergoing lung transplantation. The aim of our study was to summarize our single-center experience with intraoperative use of veno-venous- or veno-arterial-ECMO in patients undergoing complex lung surgery involving the main carina, or the left atrium or the descending aorta. A total of 24 patients underwent combined complex lung, carinal, aortal, or left atrial resections. In cases of carinal resection, percutaneous veno-venous, jugular-femoral cannulation was considered suitable. For combined resection of lung and descending aorta, a percutaneous femoral veno-arterial cannulation was used. In cases of extended left atrial resection, a percutaneous jugular-femoral veno-venous-arterial cannulation was favored. Procedures were divided into three groups: carinal resections and reconstruction (n = 8), resections of the descending aorta and left lung (n = 7), resections of lung and left atrium (n = 9). No intraoperative complications occurred. Overall 30-day mortality was 25%. A complete resection was achieved in 18 patients. Median survival was 12 months. One- and 5-year survival were 48.1 and 22.7%, respectively. The present study shows that intraoperative use of ECMO for extended carinal, aortic, or atrial resections is feasible with minimal intraoperative complications allowing surgeons increased operating-field safety. Perioperative mortality is high, but this is rather an attribute of local extended disease and patient comorbidities.

Uniportal video-assisted thoracoscopic surgery pneumonectomy: an update in the evolution of this minimally invasive approach

Despite the widespread adoption of uniportal video-assisted thoracoscopic surgery (UniVATS) for lung cancer, some procedures are still rarely performed with this approach. A minimally invasive approach is seldom selected to perform a pneumonectomy for a number of different reasons, usually involving the experience of the surgeon and the specific characteristics of cases requiring pneumonectomy as a treatment. Some surgeons believe that because of the complexity of such cases involving large tumors and usually some sort of hilum compromise, a minimally invasive technique cannot be safely performed. Safety involved in performing this procedure is more related to the surgeon experience in the approach than to the procedure itself, and it mostly depends on prior exposure to complex uniportal cases. In a time when several groups around the world are performing bronchovascular reconstructions, carinal resections by UniVATS the question should not be if is possible to perform UniVATS pneumonectomy, but what are the factors and considerations the surgeon must take into account in order to perform these cases. This review aims to provide an update on current status of uniportal VATS pneumonectomy and to provide guidance for surgeons who face this sort of cases.

Technical aspects of uniportal video-assisted thoracoscopic double sleeve bronchovascular resections.

Double sleeve, bronchial and vascular reconstructions are challenging procedures indicated for centrally located tumours to avoid pneumonectomy. Traditionally, these resections have been performed by thoracotomy, but thanks to advances in imaging systems, better surgical instruments and the gained experience in video-assisted thoracic surgery (VATS), the scenario now is different. During the last decade, we have seen a rapid evolution of the uniportal VATS technique from simple lobectomies to advanced double sleeve bronchovascular procedures and carinal resections. The advantages of VATS over open surgery for major lung resections in terms of postoperative pain and morbidity, length of hospital stay and quality of life have prompted experienced surgeons to adopt uniportal VATS for cases requiring a sleeve resection. However, when a double bronchial and vascular sleeve resection is required, the adoption rate of minimally invasive surgery is still very low even for very experienced VATS surgeons. The difficulty of tumour mobilization, complexity of the suturing technique and the concern about possible uncontrolled massive bleeding during VATS are the main reasons for this low rate of adoption. In this article, we describe the technical aspects and tricks of this procedure when it is done by the uniportal VATS approach.

Complex pulmonary resections using extracorporeal membrane oxygenation

Background: The use and effect of extracorporeal membrane oxygenation (ECMO) in general thoracic surgery patients is still not clear. Although ECMO is being routinously used in lung transplantation patients, it’s benefits in oncological patients are still to be defined. Methods: In a period of 8 years, a total of 24 patients underwent complex lung resections under ECMO in our institution. In cases of carinal resection, percutaneous veno-venous, jugular-femoral cannulation (VV-ECMO) was considered suitable. For combined resection of lung a descending aorta a percutaneous femoral veno-arterial cannulation was used (VA-ECMO). In cases of extended left atrial resection, a percutaneous jugular-femoral veno-venous-arterial cannulation was favoured (VV-A-ECMO). Results: Carinal resections and reconstruction (n=8), resections of the descending aorta and left lung (n=7), resections of lung and left atrium (n=9). No intraoperative deaths occurred. Overall 30-day mortality was 25%. A complete resection was achieved in 18 patients. Conclusions: In conclusion, the present study shows that intraoperative use of ECMO in oncological general thoracic surgery patients is feasible, with minimal intraoperative complications allowing surgeons increased operating-field safety. Perioperative mortality is high, but this is rather an attribute of local extended disease and patient comorbidities.

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.

Devising the guidelines: the concept of uniportal video-assisted thoracoscopic surgery-incisions and anesthetic management.

Uniportal video-assisted thoracoscopic surgery (VATS) is an already established minimally invasive technique in the field of thoracic surgery. The feasibility, safety and efficacy of the technique are already well documented. Comparative studies and meta-analyses have shown a clear advantage over open surgery and other minimally invasive techniques in terms of pain, length of stay (LOS), chest drain duration and morbidity. It covers a broad spectrum of indications for both malignant and benign diseases, including pulmonary and mediastinal tumor resections, diaphragm procedures (plication), esophageal surgery and airway surgery (bronchial resections, carinal resections). Its swift and wide adoption has resulted into many variations, all of whom are common in the fact they utilize a single incision to enter the chest and conduct the planned procedure. With this article, we attempt to standardize the technique as to the incision and the anesthetic management.

Near-infrared imaging for complex thoracoscopic resections

Lobectomy by video-assisted thoracic surgery (VATS) is now considered as a standard in the treatment of early-stage lung cancer with equivalent oncologic outcome as open lobectomy (1). Consequently, the widespread practice of thoracoscopic procedures pushed surgeons to perform more extended and complex resections. The feasibility of pulmonary segmentectomy, pneumonectomy, sleeve or carinal resections by VATS has been demonstrated in expert centers (2-4). However, the clinical and oncologic safety of such procedures has yet to be established.

Reconstruction of Long Noncircumferential Tracheal or Carinal Resections With Bronchial Flaps

Removal of tumors that invade the trachea or carina often results in a massive defect that exceeds the limits of end-to-end anastomosis. The purpose of this study is to discuss the clinical value of bronchial flap for the closure of central airway defects after noncircumferential tracheal or carinal resection. From 1990 to 2016, 73 patients underwent noncircumferential tracheal or carinal resection. From size, location, and pulmonary function, there were six different types of bronchial flap reconstruction. We performed bronchial flap upturned reconstruction with right pneumonectomy (n= 45), right upper lobectomy (n= 9), left pneumonectomy (n= 7), left upper lobectomy (n= 3), and bronchial flap downturned reconstruction with right pneumonectomy (n= 5), left pneumonectomy (n= 4). The size of airway defects that were replaced by bronchial flap ranged from 0.5× 2 to 2.5× 7 cm and was at most 50% of the airway circumference. Postoperative major complications occurred in 17.8% (13 of 73) of patients: four bronchopleural fistulas (5.5%), five serious postoperative infections (6.8%), two pulmonary atelectasis (2.7%), and two airway stenosis (2.7%). However, no significant differences were found in postoperative complications between resection lengths shorter than 4 cm and longer than 4 cm (p= 0.295). The overall 30-day mortality rate was 2.7%. The overall survival rate was 63.5% and 23.6% at 2 and 5 years, respectively. The six different types of bronchial flap reconstruction present an efficient therapeutic strategy to close massive central airway defects after noncircumferential tracheal or carinal resection when the patient has poor pulmonary function or when an end-to-end anastomosis is unfeasible and risky.

Long-Term Outcomes of Carinal Sleeve Resection in Non-Small Cell Lung Cancer.

Carinal resections for non-small cell lung cancer (NSCLC) invading the carina are challenging cases that require a therapeutic strategy. The aim of this study was to compare the oncologic outcomes and complications of patients who underwent carinal resection. Sixty-four patients who underwent carinal resection between 2005 and 2016 were evaluated. Data were retrospectively reviewed for indications, complications, and factors influencing long-term survival. The study included 51 patients (79.7%) who underwent sleeve pneumonectomy (sP) and 13 patients who underwent carinal sleeve lobectomy (csL) as a curative therapy. Nine patients (14.1%) received induction chemotherapy. Complications were observed in 31 patients (48.8%), including 24 patients (47.1%) in the sP group and 7 patients (53.8%) in the csL group (p = 0.662). Six patients (9.4%) developed bronchopleural fistula. The 30-day mortality rate was 10.9% (n = 7). The 5- and 10-year survival rates were 42.2 and 23.1%, respectively. N2 and R1 were identified as factors affecting survival (p = 0.029 and p = 0.047). Carinal resections have acceptable morbidity, mortality, and long-term survival outcomes in central NSCLC. The main factors affecting survival are complete resection and nodal status. The results of csL were similar to those of sP. Therefore, we believe that csL should be performed in all eligible patients.

Extracorporeal membrane oxygenation (ECMO)‐assisted intratracheal tumor resection and carina reconstruction: A safer and more effective technique for resection and reconstruction

Carina resection and reconstruction is required when a tracheal tumor invades the tracheal carina. It is a relatively complicated surgical procedure that requires complex reconstruction to maintain airway continuity. The technical difficulty lies in minimizing the influence of anesthetic endotracheal intubation and maintaining good ventilation function during surgery by establishing appropriate ventilation channels, which are contradictory in many cases. Therefore, in order to achieve the optimal surgical outcome, we performed intratracheal tumor resection and carina reconstruction with the help of extracorporeal membrane oxygenation.

Carinal surgery: A single-institution experience spanning 2 decades

ObjectivesComplete resection of neoplasms involving the carina are technically challenging and have high operative morbidity and mortality. This study examines the last 2 decades of clinical experience at our institution. MethodsMedical records were retrospectively reviewed between 1997 and 2017 to identify all patients who underwent carinal resection. Primary outcome measures include risk factors for complications and overall survival. ResultsIn total, 45 carinal resections were performed with a median follow-up of 3.4 years (interquartile range 0.8-8.5). Procedures included 21 neocarinal reconstructions (48%), 14 right carinal pneumonectomies (30%), 9 left carinal pneumonectomies (20%), and 1 carinal plus lobar resection (2%). Age ranged from 27 to 74 years, and 23 of 45 patients were female. Eight received neoadjuvant chemotherapy and 6 preoperative radiation. Extracorporeal membrane oxygenation and cardiopulmonary bypass were intraoperatively used for 4 patients with no mortality. Four patients underwent superior vena cava resection and reconstruction. Anastomotic complications occurred in 5 patients, all of which were managed conservatively: 1 required stent placement and a second underwent hyperbaric oxygen therapy. Postoperative events were observed in 26 patients (58%), including pneumonia (n = 11), blood transfusion (n = 8), and atrial arrhythmias (n = 8). More serious complications, such as acute respiratory distress syndrome, occurred in 3 patients. Postoperative events were most closely associated with pulmonary resection (P = .040). There were 3 deaths, yielding an overall operative 30- and 90-day mortality of 6.8% and 7%, respectively. ConclusionsDespite advances in perioperative management, carinal resection poses challenges for both patient and surgeon. Preoperative chemotherapy, radiation, and concomitant pulmonary resection were associated with increased risk of complications. Patient selection and meticulous surgical technique contribute to reduction in morbidity and mortality.

Pneumonectomy with carinal resection in patients with non-small cell lung cancer: short and long-term results

Objective. With to compare short- and long-term treatment outcomes of different carinal resection techniques in patients with non-small cell lung cancer (NSCLC) and carina involvement. Materials and methods. We performed retrospective nonrandomized clinical trial with following groups of patients: patients underwent pneumonectomy with sleeve carinal resection (47 patients); patients underwent pneumonectomy with marginal and wedge carinal resection (18 patients). Statistical analysis was made using Statistic 6.0 program. Case-control analysis of the both groups was performed to evaluate short- and long-term treatment outcomes of different carinal resection techniques in patients with NSCLC and carina involvement. Results. Frequency of non-surgical and surgical complications was 27.7% and 18.5% correspondingly. Postoperative mortality was 8.5% in sleeve carinal resection group and 11.1% in marginal and wedge carinal resection group. Five-year survival rates were 32.6% in sleeve carinal resection group and 11.1% in marginal wedge carinal resection group.

Carinal resection.

Tracheobronchial tumors with involvement of the carina represent a challenging problem in the pulmonary surgery. Carinal resection is referred to removal and reconstruction of the airway itself, whereas concomitant removal of the lung parenchyma (usually a whole lung) is termed as carinal pneumonectomy. Thorough preoperative workup of these patients is mandatory. Meticulous surgical technique and aggressive postoperative management is required for the best outcomes in these difficult cases. In the paper authors review surgical technique, evaluation and management of this challenging patient population.

P3.01-114 Dissociation of Heart and Great Vessels for Long Tracheal Tumors and Lung Cancer Invaded Trachea: The Chinese Experience

The length limit of tracheal resection is less than five centimeters. Up to know, there is no any report about resection of more than five centimeters for tracheal tumors. We created a new technique and successfully remove 124 tracheal tumors more than 5 cm in length and 52 lung cancer invaded trachea through dissociation heart and great vessels. Here, we report the results of 176 patients surgically treated in series. All patients were given general anesthesia and single cavity endotracheal intubation. After thoracotomy, the right pericardium was totally excised, the heart, inferior vena cava, superior vena cava, ascending aorta and innominate artery were dissociated. Then, thoracic trachea, left and right main bronchus were dissociated; the proximal and distal end of trachea, or left and right main bronchus, or left main bronchus and right middle trunk bronchus were cut off. Fallowing, the distal end of trachea was anastomosed to the proximal end of trachea, or anastomosed to the left and right main bronchus, or anastomosed to the left main bronchus and right middle trunk bronchus with 3-0 micro Joe lines. Finally, the pulmonary artery sleeve reconstruction was performed, and resection and reconstruction of SVC was performed. There were 124 patients with tracheal tumor over than 5cm in length and 52 patients with lung cancer invaded trachea. The length of trachea tumor was 5.5 cm to 10.9 cm. 5 tracheal tumor involved SVC and combined with SVCS. The trachea length invaded by the cancer was 4.5cm-7.0cm in the 52 patients with lung cancer. Of the 52 cases, 10 cancer invaded right main pulmonary artery, 22 cancer involved right main pulmonary artery and SVC. The operative procedures included: (1) resection and reconstruction of trachea, or combined with carina in 124 cases, and combined with resection and reconstruction of SVC in 5 cases in the tracheal tumor group; (2) Sleeve right upper lobectomy combined with resection and reconstruction of trachea and carina in 52 cases, combined with sleeve pulmonary artery in 10 cases, combined with sleeve pulmonary artery, and resection and reconstruction of SVC in 32 cases of lung cancer group. There were 5 operative death in this series. The 1-, 3-, 5- and 10-year survival were 71.2%, 54.3%, 33.1% and 22.5%. We pioneered a new technique and treated 124 tracheal tumor more than 5 cm in length and 52 lung cancer invaded trachea in the world.

Patients experiencing early acute respiratory failure have high postoperative mortality after pneumonectomy

ObjectivePost-pneumonectomy acute respiratory failure leading to invasive mechanical ventilation carries a severe prognosis especially when acute respiratory distress syndrome occurs. The aim of this study was to describe risk factors and outcome of acute respiratory failure. MethodsWe retrospectively reviewed clinical files of all patients who underwent pneumonectomy in a single center between 2005 and 2015. Risk factors and outcome of acute respiratory failure were assessed in univariate and multivariate analysis. ResultsAmong the 543 patients who underwent pneumonectomy in the period of study, 89 (16.4%) needed reintubation within the 30th postoperative day and 60 of these (11% of all pneumonectomies) developed acute respiratory distress syndrome. In multivariate analysis, right-side of pneumonectomy (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.24-4.22), chronic cardiac disease (OR, 2.15; 95% CI, 1.08-4.25), Charlson Comorbidity Index (OR, 1.35; 95% CI, 1.14-1.61), carinal resection (OR, 3.23; 95% CI, 1.26-8.29), and extrapleural pneumonectomy (OR, 8.36; 95% CI, 3.31-21.11) were identified as independent risk factors of reintubation. Thirty-day mortality was 7.7% for all pneumonectomies, 41.6% (37/89) in the invasive ventilation group, and 53.3% (32/60) in patients with acute respiratory distress syndrome. In non-reintubated patients, 30-day mortality was 1.1% (5/454). In reintubated patients, 5-year survival was 27.1% (95% CI, 17.8-41.4). ConclusionsEarly acute respiratory failure requiring reintubation remains a severe complication of pneumonectomy with a poor outcome.