Carinal Resection Research Articles

A new approach to left sleeve pneumonectomy: complete VATS left pneumonectomy followed by right thoracotomy for carinal resection and reconstruction

BackgroundLeft sleeve pneumonectomy is a challenging operation that requires individualized approaches. Here, we present a new minimally invasive combined thoracoscopic approach.Case presentationA 61-year-old woman was diagnosed with tracheobronchial adenoid cystic carcinoma. The tumor originated from the left main stem bronchus, and tumor with carinal involvement was observed. We judged that complete resection would be possible via left sleeve pneumonectomy. However, because tumor involvement with the esophagus and descending aorta was suspected, evaluation of resectability in advance was necessary. After confirmation via examination thoracoscopy of no involvement with the surrounding organs, complete VATS left pneumonectomy was performed and followed by right thoracotomy for carinal resection and reconstruction.ConclusionsWhen thoracoscopic surgery becomes mainstream, this minimally invasive combined thoracoscopic approach might be an optimal option for patients who require left sleeve pneumonectomy.

Tubeless major pulmonary resections.

From its inception, cutting edge minimally invasive thoracic surgery has pursued to barely produce patient perturbation. Although state of the art techniques such as uniportal approach have achieved a remarkable reduction in postoperative morbidity, there is still a way to go in patient comfort. A new 'tubeless' concept has surfaced as an alternative to double-lumen intubation with general anaesthesia combining non-intubated spontaneous breathing video-assisted thoracic surgery (VATS) surgery under loco-regional blockade with the avoidance of central line, epidural or urinary catheter and chest tube in selected patients. Those procedures combine the most evolved and less invasive techniques in anaesthesia, video-assisted surgery and perioperative care to cause the least trauma and allow for faster recovery. Non-intubated thoracic surgery used to rise some concerns regarding spontaneous breathing collapse, oxygenation, cough reflex triggering and mediastinal shift. Today, experienced teams in high-volume centers have proven non-intubated major lung resections are feasible and safe once those drawbacks have been overcome with the proper techniques and extensive previous expertise in VATS. Tubeless thoracic surgery is currently evolving, challenging former exclusion criteria and expanding indications to major lung resections or even tracheal and carinal resections to provide better intraoperative status and promote minimal need for recovery.

Subxiphoid pneumonectomy: the new frontier?

Over the last decade there has been a significant drive towards minimally invasive thoracic surgery. The reported benefits of video-assisted thoracic surgery (VATS) over open surgery include reduced postoperative pain, reduced postoperative complications, reduced length of hospital-stay and period of recovery to normal function (1-4). With increased experience, more advanced procedures are now reportedly performed by VATS in high volume centres, including sleeve and carinal resections (5,6).

How to treat right post‐pneumonectomy fistula with carinal sleeve resection

How to treat right post‐pneumonectomy fistula with carinal sleeve resection

Carinal resection: technical tips

Carinal resection (CR) is defined as the resection of the trachea-bronchial bifurcation with or without lung resection. It is an uncommon challenging surgery performed in case of NSCLC, primitive airway tumors or benign lesions invading the carina. A well-organized team is essential to manage patients undergoing CR and it must involve several specialists experienced in diagnosis, operative treatment and postoperative care. Before and during surgery a strict cooperation between surgeon and anesthesiologist is essential; cross-field ventilation is generally used to maintain the adequate gas exchange during surgical airway reconstruction, but also high frequency jet ventilation (HFJV) or extracorporeal membrane oxygenation (ECMO) could be valid alternative options when cross-field ventilation is not feasible. Right-sided lesions requiring a CR with pulmonary resection are better approached through an ipsilateral thoracotomy (IV intercostal space), whereas tumor involving the carina as well as the left main bronchus and requiring a left carinal pneumonectomy could be treated using a left thoracotomy with subaortic dissection (only for very limited tracheal resection due to a bad exposure of the trachea after moving the aortic arch). Instead, CR without pulmonary resection and left carinal pneumonectomy are better approached through a median sternotomy. Reconstruction of the airway could be performed in different ways according to the extension of the resection and to the surgeon experience with the sole purpose to obtain a tension-free anastomosis to reduce as much as possible the possible post-operative complications due to impairment healing of the suture. Based on tumor histology and the pathological staging the patient should be referred to the oncologist and/or radiotherapist for the further medical treatments. Improved patient selection, anesthetic management, surgical technique and better postoperative management are essential in such a challenging surgery to have the lowest possible rate of postoperative morbidity and mortality.

Single-port video-assisted thoracic surgery (VATS)-advanced procedures & update.

The uniportal approach for major pulmonary resections began in 2010, with the first case being reported by D González-Rivas and colleagues in La Coruña, Spain. Since then, in different countries, thoracic surgeons had been performing hundreds of cases, with more advanced and complex procedures. Nowadays, there are reports of uniportal tracheal resection and reconstruction, carinal resection, bronchoplastic procedures, lobectomies with en bloc chest wall excision, and vascular reconstruction with optimal outcomes. The development of technologies and the potential benefits of a direct view, anatomic instrumentation, better cosmesis, and, potentially, less postoperative pain have led uniportal video-assisted thoracic surgery to grow exponentially worldwide.

Carinal resection is performed with an end-to-end anastomosis between the distal trachea and the left main bronchus and an end-to-side anastomosis is performed between the trachea and the right main bronchus

Carinal resection is performed with an end-to-end anastomosis between the distal trachea and the left main bronchus and an end-to-side anastomosis is performed between the trachea and the right main bronchus

Extended right upper sleeve lobectomy with double-barrel segmental bronchoplasty.

Extended sleeve lobectomy (ESL), which is defined as the atypical sleeve resection of more than one lobe, has been widely accepted to preserve the pulmonary function (1-3). Double-barrel anastomosis has been reported as a method of bronchial reconstruction after carinal resection; however, it is rarely applied in the reconstruction of segmental bronchi. We herein report a case in which ESL with double-barrel anastomosis of the middle lobar bronchus (MLB) and basilar bronchus (BB) was successfully applied in the treatment of a patient with centrally located lung adenocarcinoma.

Carinal resections

Carinal resections

Thoracoscopic surgery for tracheal and carinal resection and reconstruction under spontaneous ventilation

ObjectivesTo describe and assess the techniques of spontaneous-ventilation video-assisted thoracoscopic surgery (SV-VATS) for tracheal/carinal resections and compare the outcomes with the conventional thoracoscopic intubated method. MethodsFrom May 2015 to November 2016, some 18 consecutive patients with malignant or benign diseases invading distal trachea and carina who met the criteria for SV were treated by SV-VATS resection. To evaluate the feasibility of this novel technique, they were compared with a control group consisting of 14 consecutive patients with the same diseases who underwent VATS resection using intubated general anesthesia from October 2014 to April 2015. Data were collected with a median follow-up of 10.2 months 75 (range: 1-27). ResultsThe SV-VATS group consisted of 4 carinal resections and 14 tracheal resections. In the control group, 2 patients underwent carinal resection and 12 underwent tracheal resection. Median operative time was shorter in the SV-VATS group compared with the intubated group (162.5 minutes vs 260 minutes), as was the median time for tracheal end-to-end anastomosis (22.5 minutes vs 45 minutes) and carinal reconstruction (40 minutes vs 86 minutes). The lowest oxygen saturation during the procedure was 94.2% ± 4.9% in SV-VATS group and 93.9% ± 4.5% in the control group. The peak carbon dioxide level at the end of expiration was greater in the SV-VATS group (47.7 ± 4.2 mm Hg vs 39.1 ± 5.7 mm Hg). No conversion to tracheal intubation was needed in the SV-VATS group. Postoperative complications occurred in 6 patients in the SV-VATS group and 9 in the control group. Patients who underwent SV-VATS had a trend toward shorter postoperative hospital stays (11.5 ± 4.3 days vs 13.2 ± 6.3 days). One recurrence (SV-VATS group) and 2 deaths (one in each group) were observed during follow-up. ConclusionsSV-VATS is a feasible procedure in tracheal and carinal resection and reconstruction in highly selected patients. It can be a valid alternative to conventional intubated VATS for airway surgery.

Video-assisted thoracoscopic surgery (VATS) for central airway tumors: VATS carinal resection and reconstruction

This review article focuses attention on the feasibility of airway management and technical strategies for complex anastomosis during carinal reconstruction under the video-assisted thoracoscopic surgery (VATS) approach. Between April 1992 and March 2017, English studies published worldwide were retrieved from a listing of bibliographic references obtained from the National Institutes of Health using the specific keywords “vats”, “thoracoscopic”, “carinal”, and “reconstruction”. Technical issues specific to the VATS approach, including airway management, port strategy, reduction of anastomotic tension, extent of resection, modes of reconstruction, suturing techniques, types of suture thread, and prophylactic wrapping are discussed in this review. VATS carinal resection and reconstruction remain challenging due to the limited modes of carinal reconstruction as well as problems specific to the VATS approach, such as airway management, reduction of anastomotic tension, and suturing techniques. However, VATS carinal surgery with or without anatomic pulmonary resection may be feasible using certain devices, such as high-frequency jet ventilation (HFJV) using a blocker tube, effective traction using endoscopic devices, and continuous suture techniques, and should be performed either by or with skilled and experienced VATS surgeons. In addition, non-intubated anesthesia and a uniportal strategy for VATS carinal surgery may be feasible at centers with a great deal of experience. The current indications for VATS carinal surgery are quite narrow and include the second diameter of the lesion ≤5 cm, minimal invasion to the surrounding organ, and extent of resection ≤4 cm between the lower trachea and contralateral main bronchus.

Video-assisted thoracoscopic surgery (VATS) for central airway tumors: VATS carinal resection and reconstruction

This review article focuses attention on the feasibility of airway management and technical strategies for complex anastomosis during carinal reconstruction under the video-assisted thoracoscopic surgery (VATS) approach. Between April 1992 and March 2017, English studies published worldwide were retrieved from a listing of bibliographic references obtained from the National Institutes of Health using the specific keywords “vats”, “thoracoscopic”, “carinal”, and “reconstruction”. Technical issues specific to the VATS approach, including airway management, port strategy, reduction of anastomotic tension, extent of resection, modes of reconstruction, suturing techniques, types of suture thread, and prophylactic wrapping are discussed in this review. VATS carinal resection and reconstruction remain challenging due to the limited modes of carinal reconstruction as well as problems specific to the VATS approach, such as airway management, reduction of anastomotic tension, and suturing techniques. However, VATS carinal surgery with or without anatomic pulmonary resection may be feasible using certain devices, such as high-frequency jet ventilation (HFJV) using a blocker tube, effective traction using endoscopic devices, and continuous suture techniques, and should be performed either by or with skilled and experienced VATS surgeons. In addition, non-intubated anesthesia and a uniportal strategy for VATS carinal surgery may be feasible at centers with a great deal of experience. The current indications for VATS carinal surgery are quite narrow and include the second diameter of the lesion ≤5 cm, minimal invasion to the surrounding organ, and extent of resection ≤4 cm between the lower trachea and contralateral main bronchus.

Complex Tracheocarinal Reconstructions Using Extrathoracic Muscle Flaps as Airway Substitutes

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. Evaluation of all patients undergoing tracheocarinal reconstructions with extrathoracic muscle flap patches as airway substitutes in our institution from 1996 to2016. 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. 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.

Definition of an advanced lung cancer and associated survival after video-assisted thoracoscopic surgery resection

The definition of “advanced lung cancer” is unclear, especially considering surgical treatment. For a surgeon, who prefers video-assisted thoracoscopic surgery (VATS) approach, identification of specific problems, which make the VATS resection much more difficult, is quite understandable. But such variations in the definition make any productive comparing or collecting data very complicated, and incomparable with the traditional thoracic oncology studies. Randomized controlled trials for VATS for the locally advanced non-small cell lung cancer (NSCLC) have not been conducted yet. However, there are several relatively large series with the cohort of patients with advanced stages, treated by VATS. These publications are analyzed in this review. Many articles address the feasibility of VATS resections for challenging cases, such as sleeve broncho- and angioplasty, chest wall resection, Pancoast tumor, SVC resection, carina resection et cetera. But advanced or challenging surgery does not always signify the advanced stage of the cancer. One of the theoretical goals of minimally invasive surgery (MIS) is to reduce immunosuppression after the procedure. Thus, patients with the advanced stages could benefit from VATS due to a better preservation of the patient’s immunity and potential to optimize long-term survival. It seems to be necessary to organize a multi-institutional trial with strict inclusion criteria for patients with the stage III lung cancer, who underwent VATS major pulmonary resections, in order to generate sufficient and reliable analytical data for this topic.

Carinal resection and sleeve pneumonectomy

Carinal pneumonectomy and carina resection are one of the special technical operative dilemma in the field of chest surgery. The most common indication for these extended resections is bronchogenic carcinoma. The morbidity and mortality rate in these operations is higher compared to standard thoracic surgical procedures (1,2). These patients should be assessed carefully before the operation.

AB001. Carina resection and reconstruction

Background: In tracheal tumor and trachea, the incidence of trachea cancer is lower in respiratory diseases, which only accounts for about 2% of the incidence. This type of patient is often encountered clinically. Pathologic processes that involve the carina challenge to thoracic surgeons. Few institutions have accumulated sufficient experience to allow meaningful conclusions about the indications and the morbidity and mortality rates for this type of surgery. The treatment of tumors in the lower trachea and Carina is also a challenge to the decision and judgment of surgeons.

Right pneumonectomy with carinal wedge resection

Right pneumonectomy with carinal wedge resection

VATS pneumonectomy and sleeve carinal resections—full thoracoscopic and uniportal approach

Advantages of thoracoscopic pulmonary resections can’t be doubted and are confirmed by numerous studies. These procedures allow significantly reducing surgical trauma and blood loss, decreasing the length of hospital staying and less the need for anesthetics. Other benefits include early recovery, rapid rehabilitation and improvement of quality of life. Moreover, if needed, adjuvant chemotherapy might be provided earlier. Despite the high incidence rates of lung cancer in the world and the fact, which most patients present with stage II or, predominantly, stage III of the disease, there has been a decrease in the number of pneumonectomies over the past years. It is attributed to novel neoadjuvant schemes of treatment, which has recently come into play, as well as to the emphasis on organ sparing surgeries with angioplasty and bronchoplasty. However, for some patients with centrally located lung tumors or with tumor infiltrating of hilar structures or interlobar fissure, the only possible surgical procedure is radical pneumonectomy. One of the major problems in selecting patients for thoracoscopic pneumonectomy is unavailability of palpation and lack of full intraoperative revision in order to evaluate tumor spreading. Nevertheless, there is a small group of patients for whom broncho-angioplasty is not possible and who require radical lung removal often with the resection of the surrounding structures and sleeve carinal resections.

Carinal Resection for Adenoid Cystic Carcinoma of Left Main Bronchus under Cardio-Pulmonary Bypass

Carinal Resection for Adenoid Cystic Carcinoma of Left Main Bronchus under Cardio-Pulmonary Bypass

MTE 03.01 Do Extended Resections Improve T4 Lung Cancer Outcomes?

MTE 03.01 Do Extended Resections Improve T4 Lung Cancer Outcomes?