Tracheal Sleeve Pneumonectomy Research Articles

Repeated tracheal resection for endotracheal metastasis after sleeve pneumonectomy for squamous cell lung cancer

The incidence of endotracheal and endobronchial metastases of both pulmonary and non-pulmonary primary malignancies is very rare. However, endotracheal metastasis may occur either as a result of recurrent lung cancer or of non-pulmonary originated neoplasia. Furthermore, reoperation on the trachea is a rare and challenging procedure. We here report a case of endotracheal metastasis from a squamous cell lung carcinoma, after previous tracheal sleeve pneumonectomy, which was resected via a “T” neck incision. The thorough observation of the trachea and bronchial tree over a long follow-up period is crucial for the early detection of endobronchial or endotracheal metastatic disease. Also, reoperation on the trachea can be carried out successfully by experienced surgeons.

Right tracheal sleeve pneumonectomy with VV-ECMO assistance for non-small cell lung cancer through anterior thoracotomy: a single centre experience.

For a long time, non-small cell lung cancer (NSCLC) arising less than 2 cm distal to the carina has been usually considered unresectable and incurable with a radical or extended resection because of surgical technical difficulty and airway management. Recently, the introduction of more advanced surgical techniques, often including the use of extracorporeal life support (ECLS), has allowed us to extend the limits of conventional surgery, increasing the rate of complete surgical resection. ECLS also overcomes the limitation of conventional ventilation during complex tracheo-bronchial reconstruction, avoiding the presence of disturbing lines or tubes that obstruct the operative field during a challenging surgery. In this article, we share our experience in performing right tracheal sleeve pneumonectomy with veno-venous extracorporeal membrane oxygenation (VV-ECMO) in three cases by anterior right thoracotomy, reporting our tips and tricks.

Rescue Surgery after Immunotherapy/Tyrosine Kinase Inhibitors for Initially Unresectable Lung Cancer

Simple SummaryLocally advanced or metastatic non-small cell lung cancer (NSCLC) has been considered for a long time as an unresectable disease. Chemotherapy was considered the only therapeutic option for these conditions and the results were unsatisfactory. Recent advances in biology and immunology have led to the use of personalized treatments by using tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs), which produce significant and durable treatment responses. Large trials explored the utility of TKIs and ICIs in neoadjuvant or adjuvant settings, showing good results in terms of radiological response and long-term outcomes. Retrospective case series in patients with the previously unresectable disease who received treatment with TKIs, or ICIs showed important clinical changes that consider the possibility of pulmonary resection of the residual disease. They showed an overall feasibility for pulmonary resection but also raised concerns about the technical challenges. In the present study, we analyzed and reported the surgical and long-term outcomes of patients with initial unresectable, locally advanced, or oligometastatic NSCLC who were treated with TKIs or ICIs achieving a clinical downstaging so as to re-enter resectability.Background: We report the outcomes for unresectable patients with locally advanced or oligometastatic non-small cell lung cancer (NSCLC) treated with tyrosine kinase inhibitor (TKI) or immunotherapy who achieved a clinical downstaging so as to re-enter resectability. Methods: We retrospectively reviewed the clinical, surgical, and pathological data of 42 patients with histologically proven, inoperable NSCLC who received rescue surgery after a good response to TKI or immunotherapy between March 2014 and December 2021. Results: Of 42 patients, 39 underwent pulmonary resection with therapeutic intent (three explorative thoracotomies). There were 26 males, with a median age of 64 years (range, 41–78 years). Twenty-three patients received TKIs and 19 immunotherapies. Anatomic resection was performed in 97.4% of resected patients (38/39) including 30 lobectomies, one right upper sleeve lobectomy, five pneumonectomies, one tracheal sleeve pneumonectomy, and one bilobectomy; a patient underwent wedge resection. Of 10 procedures attempted via a robotic approach, two required conversion to thoracotomy. No intraoperative morbidity/mortality occurred. The median operative time was 190 (range, 80–426) minutes; estimated blood loss was 200 mL (range, 35–780 mL). Morbidity occurred in 13/39 (33.3%). The median length of hospital stay was 6.5 days (range, 4–23 days). Pathologic downstaging was 74.4% (29/39). With a median follow-up of 28.7 months, the 5-year disease-free interval was 46.5%, and the 5-year overall survival was 66.0%; 32/39 patients (82.1%) are alive, 10 with the disease. Conclusions: Lung resection for suspected residual disease after immunotherapy or TKIs is feasible, with encouraging pathological downstaging. Surgical operation may be technically challenging due to the presence of fibrosis, but significant morbidity appears to be rare. Outcomes are encouraging, with reasonable survival during the short-interval follow-up.

Combined right thoracotomy and left video-assisted thoracoscopic surgery for left tracheal sleeve pneumonectomy: a case report

: Left tracheal sleeve pneumonectomy (LTSP) is a challenging operation and traditional surgical approaches have their downsides. We describe the case of a 38-year-old patient affected by adenoid cystic carcinoma of the left main bronchus and the carina who underwent surgical excision of his tumor through a bilateral approach. En bloc tumor and carinal resection, followed by right main bronchial reimplantation were performed through right thoracotomy; while the left pneumonectomy was completed through a contralateral uniportal thoracoscopic approach. This is the seventh reported case of LTSP performed through a combined open and thoracoscopic approach. Some details, such as the side of the operation to approach first and the method of intraoperative ventilation, vary between reports; however, globally, the reported outcomes seem favorable. The growing number of published cases suggests that such approach should be acknowledged as a reasonable alternative to traditional surgical accesses for LTSP.

Combined right thoracotomy and left video-assisted thoracoscopic surgery for left tracheal sleeve pneumonectomy: a case report

: Left tracheal sleeve pneumonectomy (LTSP) is a challenging operation and traditional surgical approaches have their downsides. We describe the case of a 38-year-old patient affected by adenoid cystic carcinoma of the left main bronchus and the carina who underwent surgical excision of his tumor through a bilateral approach. En bloc tumor and carinal resection, followed by right main bronchial reimplantation were performed through right thoracotomy; while the left pneumonectomy was completed through a contralateral uniportal thoracoscopic approach. This is the seventh reported case of LTSP performed through a combined open and thoracoscopic approach. Some details, such as the side of the operation to approach first and the method of intraoperative ventilation, vary between reports; however, globally, the reported outcomes seem favorable. The growing number of published cases suggests that such approach should be acknowledged as a reasonable alternative to traditional surgical accesses for LTSP.

Preliminary Results of Extracorporeal Membrane Oxygenation Assisted Tracheal Sleeve Pneumonectomy for Cancer.

Tracheal sleeve pneumonectomy is a challenge in lung cancer management and in achieving long-term oncological results. In November 2018, we started a prospective study on the role of extracorporeal membrane oxygenation (ECMO) in tracheal sleeve pneumonectomy. We aim to present our preliminary results. From November 2018 to November 2019, six patients (three men and three women; median age: 61 years) were eligible for tracheal sleeve pneumonectomy for lung cancer employing the veno-venous ECMO during tracheobronchial anastomosis. Only in one patient, an intrapericardial pneumonectomy without ECMO support was performed, but cannulas were maintained during surgery. The median length of surgery was 201 minutes (range: 162-292 minutes), and the average duration of the apneic phase was 38 minutes (range: 31-45 minutes). No complications correlated to the positioning of the cannulas were recorded. There was only one major postoperative complication (hemothorax). At the time of follow-up, all patients were alive; one patient alive with bone metastasis was being treated with radiotherapy. ECMO-assisted oncological surgery was rarely described, and its advantages include hemodynamic stability with low bleeding complications and a clean operating field. As suggested by our preliminary data, ECMO-assisted could be a useful alternative strategy in select lung cancer patients.

Veno-venous extracorporeal membrane oxygenation tracheal sleeve pneumonectomy

Tracheal sleeve pneumonectomy is a complex surgical procedure consisting in removal of the whole lung together with the tracheo-bronchial bifurcation. Airway reconstruction is performed by an end- to-end tracheo bronchial anastomosis usually with cross-field ventilation with or without jet ventilation support. Extracorporeal membrane oxygenator (ECMO) represents an excellent alternative to cross-field ventilation during tracheal sleeve pneumonectomy, providing tissues oxygenation and CO2 removal, without disturbing lines or tubes in the surgical field, when performed with peripheral cannulation. The aim of this paper is to focus on the role of intraoperative ECMO during tracheal sleeve pneumonectomy, indications and contraindications as well as advantages and disadvantages.

Carinal pneumonectomy: a 36-year experience

Background: Tracheal sleeve pneumonectomy (TSP) is a rare and challenging procedure. In this paper, indications, techniques and outcomes of patients operated in a single centre over a time span of 36 years are presented. Methods: Hospital records of patients undergoing TSP were retrospectively reviewed. Survival was estimated with the Kaplan-Meier method. Univariable analysis of risk factors for survival was performed with the log-rank test. Results: Over the study period, we performed 59 right and 4 left tracheal sleeve pneumonectomies. Main indications were squamous cell carcinoma in 44 patients, adenocarcinoma in 10, adenoid cystic carcinoma (ACC) in 7, and other histology in 2. Twenty-three patients received induction chemotherapy. High-frequency jet ventilation (HFJV) was used in 53 cases (84%). Final pathology examination revealed N2 disease in 22 patients and N3 in 1. Resection margins were microscopically infiltrated in 11 patients. Twenty-six patients (41.3%) experienced postoperative complications, while postoperative mortality was 9.5% (6 patients). The 2-, 5- and 10-year overall survival (OS) rates were 52%, 31.6% and 20.9%, respectively. Survival was significantly worse for patients with N2 disease (P Conclusions: Morbidity and mortality rates following TSP remain elevated. Long-term follow-up is determined primarily by N status, and, therefore, accurate preoperative mediastinal staging is fundamental. Meticulous operative technique and attentive postoperative management are the foundation for good surgical results.

EP1.01-44 Early and Long-Term Results of Tracheal Sleeve Pneumonectomy for Lung Cancer After Induction Therapy

EP1.01-44 Early and Long-Term Results of Tracheal Sleeve Pneumonectomy for Lung Cancer After Induction Therapy

Combined approach using uniportal video-assisted thoracoscopic surgery in left tracheal sleeve pneumonectomy

Left tracheal sleeve pneumonectomy is rare and challenging surgical procedure with high postoperative complication and mortality rates. We describe the least invasive single-stage surgical approach using uniportal video-assisted thoracoscopic surgery (VATS) currently successfully applied for a left centrally located bronchogenic carcinoma with tracheal involvement. This case shows how uniportal VATS can be effectively used in challenging cases for reducing invasiveness without compromising patient safety nor oncological principles of complete surgical resection.

Right tracheal sleeve pneumonectomy and superior vena cava resection and reconstruction with bovine pericardial patch

Right tracheal sleeve pneumonectomy and superior vena cava resection and reconstruction with bovine pericardial patch

Early and Long-Term Results of Tracheal Sleeve Pneumonectomy for Lung Cancer After Induction Therapy

The role of induction therapy (IT) and its effects on morbidity and mortality of patients receiving tracheal sleeve pneumonectomy (TSP) are unclear. We evaluated early and long-term outcomes of patients who underwent TSP after IT. From 1998 to 2015, 32 patients (26 men; median age, 63 years) underwent TSP. Twenty-two patients (69%) received IT (cisplatin-based chemotherapy). The TSPs were all right sided and included three completion pneumonectomies. Superior vena cava resection was combined with TSP in 15 cases. Diaphragmatic and vertebral resection was also associated in 1 case each. Operative mortality was nil. Thirty-day mortality was 9% (n= 3). Major complications occurred in 7 patients (21.8%): bronchopleural fistulas in 3; acute respiratory distress syndrome in 2; cardiac hernia in 1; and empyema in 1. The IT had no significant effects on morbidity and mortality. Resection was complete in 31 patients (97%). Pathologic N status was N0 in 2 cases, N1 in 17, and N2 in 13. Nodal downstaging was diagnosed in 13 of 22 patients (59.1%) who received IT (11 passed from N2 to N1, and 2 to N0). Mean survival was 36 months (range, 1 to 181). Overall 5-year survival and disease-free survival were 30.3% and 27.7%, respectively. Patients receiving IT had a poor survival (p= 0.03). At multivariate analysis, nodal downstaging and adjuvant treatment significantly affected survival (p= 0.035 and p= 0.007, respectively). Tracheal sleeve pneumonectomy is a feasible but technically challenging surgical procedure and provides acceptable results in terms of early and long-term outcomes. Induction therapy did not significantly affect morbidity and mortality.

Tracheal sleeve pneumonectomy: indications and surgical operative techniques

Tracheal sleeve pneumonectomy is a challenging surgical procedure for resection of cancers involving lung, lower trachea, carina and tracheobronchial angle. The most common indications are non-small cell lung cancers, bronchogenic carcinoma, carcinoid tumor, adenoid cystic carcinoma or inflammatory strictures. Other common indication is a positive resection margin after a standard pneumonectomy. This type of surgery is currently still infrequent, because of the complexity and the high risk of complications. The recent improvement of surgical techniques, different ventilation modalities and postoperative management has reduced dramatically the mortality and morbidity, especially in high volume centers. The careful selection of the patient and the correct preoperative staging is the central point for a successful operation. In this chapter we summarize “at a glance” the main topics of this kind of surgery, focusing on tips and tricks of the right patients selection, surgical techniques, postoperative management.

Carinal sleeve pneumonectomy: oncological recommendations

Tracheal sleeve pneumonectomy is the surgical excision of a whole lung including carina and lower trachea resection. It is usually performed for tumors involving the tracheobronchial angle. Differently to traditional pneumonectomy, this surgical procedure is characterized by reconstruction of the residual contralateral airway entirety between lower trachea and the main bronchus.

Management of a case of left tracheal sleeve pneumonectomy under cardiopulmonary bypass: Anesthesia perspectives

The lung tumors with carinal involvement are frequently managed with tracheal sleeve pneumonectomy and tracheobronchial anastomosis without use of cardiopulmonary bypass (CPB). Various modes of ventilation have been described during tracheal resection and anastomosis. Use of CPB during this period allows the procedure to be conducted in a more controlled way. We performed tracheal sleeve pneumonectomy for adenoid cystic carcinoma of left lung involving carina. The surgery was performed in two stages. In the first stage, left pneumonectomy was performed and in the second stage after 48 h, tracheobronchial resection and anastomosis was performed under CPB. Second stage was delayed to avoid excessive bleeding (due to heparinization) from the extensive vascular raw area left after pneumonectomy. Meticulous peri-operative planning and optimal post-operative care helped in successful management of a complex case, which is associated with high morbidity and mortality.

Techniques of Right Extended Pneumonectomy

Tracheal sleeve pneumonectomy is considered the operation of choice for tumors involving the right tracheobronchial angle, even though the procedure is burdened by a high rate of perioperative morbidity and mortality. In this report, we present our experience with two different techniques to avoid sleeve pneumonectomy: the tangential tracheal suture and the tracheoplasty.

Tracheobronchial reconstructions with bronchoplastic closure: An alternative method in treatment of bronchogenic carcinoma involving the carina or tracheobronchial angle

Our objective was to summarize our experience with tracheobronchial reconstructions using bronchoplastic closure for airway defects after noncircumferential resections of bronchogenic carcinoma involving the carina or tracheobronchial angle. From January 1990 to December 2005, all patients who underwent tracheobronchial reconstructions with bronchoplastic closure for bronchogenic carcinoma involving the carina or tracheobronchial angle were included. The clinical data for patients were collected retrospectively, including demographic characteristics, occurrences of postoperative complications, and survival. A total of 40 patients were eligible, including 23 who had right pneumonectomies, 6 who had right upper lobectomies, and 11 who had left pneumonectomies, associated with lower lateral wall of the trachea resections or with partial carinal resections for centrally localized tumors. The airway defects ranged from 0.5×2 cm to 2×4 cm and involved up to 50% of the airway circumference. Microscopic residual disease was found postoperatively at the bronchial margin in 20% (8/40). Of 40 patients, 2 (5.0%) had pulmonary atelectasis develop, 2 (5.0%) arrhythmia, 2 (5.0%) bronchopleural fistula, and 1 (2.5%) airway stenosis after operation. Thirty-day mortality was 2.5% (1/40). Median survival for 40 patients was 18.5 months with a cumulative survival of 72.2%, 26.6%, and 21.3% at 1, 3, and 5 years, respectively. Tracheobronchial reconstruction using bronchoplastic closure might be a reasonable option for closing massive central airway defects for advanced bronchogenic carcinoma involving the tracheobronchial angle or carina, avoiding tracheal sleeve pneumonectomy with limited excision of the lateral wall of the trachea or carina.

Effective treatment of post-pneumonectomy bronchopleural fistula by conical fully covered self-expandable stent

The aim of the study was to assess the feasibility, efficacy and safety of the use of a conical self-expandable stent for the treatment of post-pneumonectomy bronchopleural fistula (PPBPF). Between April 2008 and November 2010, six patients underwent treatment for the PPBPF by the introduction of a tracheobronchial conical fully covered self-expandable nitinol stent with the aim of excluding the bronchial dehiscence from the airflow. We secured the prosthesis to the tracheal mucosa with titanium helical fasteners tacks. Five patients presented with a bronchial fistula larger than 5mm following right (4) or left (1) pneumonectomy. One patient had an anastomotic dehiscence after right tracheal sleeve pneumonectomy. A chest tube showed the absence of empyema in all cases. Immediate resolution of the bronchial air leak was obtained in all the patients. Permanent closure of the bronchial dehiscence without recurrence was achieved in all the patients at a mean follow-up time of 13 months (range 3-32). The bronchial stent was successfully removed in all patients without sequelae 71-123 days after its implantation. The use of the conical self-expandable Silmet(®) stent has proved to be an effective, safe and fast method to treat even large PPBPFs.

Supplement 2, Proceedings of the 14th World Conference on Lung Cancer, Book 2

Supplement 2, Proceedings of the 14th World Conference on Lung Cancer, Book 2

Reconstruction of the Lower Trachea Using a Pedicled Autologous Bronchial Flap

We describe a technique used in a patient for resection of adenoid cystic carcinoma arising from the left main bronchus and extending along the lateral wall of the lower trachea without carinal invasion. A flap was mobilized from the noninvolved lateral wall of the left main bronchus, which was left attached to the carina. This was used to close the defect in the lower trachea with the implantation of the left main bronchus, avoiding a tracheal sleeve pneumonectomy. Clinical course of this case was good. The pedicled autologous bronchial flap provides reliable material to repair and reconstruct a massive central airway defect.