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Techniques of Performing Left Carinal Pneumonectomy

      Carinal pneumonectomy and reconstruction remains one of the most technically demanding of all thoracic surgery procedures. Bronchoplastic techniques refined from tracheal surgery and sleeve lobectomy have made carinal pneumonectomy possible, but successful outcome of this procedure depends on multiple factors such as patient selection, thorough preoperative evaluation, anesthetic management, meticulous surgical technique, and focused postoperative care. The first comprehensive approach to carinal resection and reconstruction was presented by Grillo and coworkers in 1963 and by Grillo in 1982.
      • Grillo H.
      • Bendixen H.H.
      • Gephart T.
      Resection of the carina and lower trachea.
      • Grillo H.C.
      Carinal reconstruction.
      • Grillo H.C.
      Carcinoma of the lung: what can be done if the carina is involved?.
      Most carinal resections are done for right-sided tumors because of the anatomy of the right upper lobe and shorter length of the right main stem bronchus. The proximity of right upper lobe orifice to the carina can result in extension of right upper lobe tumors to the carina, whereas left-sided bronchogenic tumors rarely extend to the carina without simultaneous extension to other unresectable structures. Right carinal resection is performed through a right posterolateral thoracotomy that gives a perfect exposure to carina, the right main stem bronchus, and the proximal left main stem bronchus. Left carinal pneumonectomy is performed much less commonly and is also technically a more challenging procedure since the exposure of the lower trachea and right main stem bronchus are covered by the aortic arch. However, the procedure can be performed via different approaches depending on the extension of the tumor.

      Indications

      Left carinal pneumonectomy is indicated for tumors that involve carina and the left main stem bronchus (Fig. 1).
      Figure thumbnail gr1
      Figure 1Different tumor locations with involvement of carina and left main stem bronchus requiring left carinal pneumonectomy. (A) Tumor of the left upper lobe with extension to <1 cm from carina. (B, C) Airway tumors involving carina and left main stem bronchus. (D) Cancer recurrence in the left main stem bronchus after pneumonectomy.
      Lung cancers considered for carinal pneumonectomy are at least T3 or T4 and select patients with these advanced cancers will benefit from resection and reconstruction. Primary airway neoplasms such as adenoid cystic carcinoma and carcinoid tumors, and a variety of unusual rare tumors, are occasional indications for carinal pneumonectomy,
      • Mitchell J.D.
      • Mathisen D.J.
      • Wright C.D.
      • et al.
      Resection for bronchogenic carcinoma involving the carina: long-term results and effect of nodal status on outcome.
      • Porhanov V.A.
      • Poliakov I.S.
      • Selvaschuk A.P.
      • et al.
      Indications and results of sleeve carinal resection.
      also rarely performed for benign or inflammatory strictures.
      • Mitchell J.D.
      • Mathisen D.J.
      • Wright C.D.
      • et al.
      Clinical experience with carinal resection.
      Anatomic indications are an inability to achieve a negative bronchial margin and have an adequate pneumonectomy stump for closure, ie, tumor <1 cm from carina, or involving the carina. Primary tumors of the carina with minimal extension into the left main stem bronchus may be amenable to carinal resection alone, without left pneumonectomy. However, if the total distance of airway resection (distal trachea plus proximal left main stem bronchus) is greater than 4 cm, it is unlikely that a safe, tension-free anastomosis is possible, and these patients should have a left pneumonectomy and right main stem to tracheal reconstruction.

      Contraindications to Surgery

      Absolute contraindications to carinal resection include mechanical ventilation and N2/N3 nodal disease. It is important to discriminate between direct invasion of the mediastinal lymph nodes by the tumor versus distant nodal metastasis. Since the former does not preclude resection, the presence of distant nodal metastasis should be thoroughly evaluated during mediastinoscopy. Other absolute contraindications include extensive involvement of trachea, carina, and main-stem bronchus in excess of 4 cm, predictive postoperative FEV1 (ppo FEV1) < 1000 mL, and major comorbidities. We would rarely consider this procedure for patients over the age of 70.
      Relative contraindications include steroid use and prior radiation including neoadjuvant therapy because of increased risks of anastomotic dehiscence. Carinal resection after preoperative radiation has been successfully performed after doses of 4000 to 5000 cGy and intervals from completion of radiation to surgery of approximately 3 to 4 weeks.
      • Muehrcke D.D.
      • Grillo H.C.
      • Mathisen D.J.
      Reconstructive airway operation after irradiation.
      We believe that this needs to be highly individualized and applied only to patients with excellent overall physiological and functional status and with a good response to neoadjuvant therapy. It is advisable to protect the anastomosis with an omental flap under these circumstances. Carinal reconstruction after radiation in excess of 5000 cGy is extremely dangerous and applicable to only a few special cases.
      • Muehrcke D.D.
      • Grillo H.C.
      • Mathisen D.J.
      Reconstructive airway operation after irradiation.

      Preoperative Evaluation

      Patient’s Evaluation

      Careful preoperative evaluation of each patient should include patient’s physiological and functional status, pulmonary function test, room air blood gas analysis, and electrocardiogram.

      Imaging

      Preoperative evaluation includes computed tomographic scan of chest with IV contrast. Positron emission tomography scan and brain magnetic resonance imaging are performed for patients with non-small-cell lung cancer. Quantitative ventilation perfusion scan may be indicated to assess ppo FEV1 depending on preoperative FEV1.

      Bronchoscopy

      We perform flexible and rigid bronchoscopy in all of our patients who are candidates for left carinal pneumonectomy. The proximal and distal extent of the tumor is carefully examined and measured to plan the surgical approach. The safe limit of airway resection is 4 cm between the lower trachea and contralateral main stem bronchus. This may require mucosal biopsies to precisely evaluate the longitudinal extent of the tumor. Core out of the tumor may provide temporary palliation of airway obstruction and allow clearing of postobstructive pneumonia to optimally prepare for surgery.

      Mediastinoscopy

      It is extremely important to perform mediastinoscopy before left carinal pneumonectomy for the three following reasons: First to assess presence of N2 or N3 nodal disease; second to develop a pretracheal plane, helping to mobilize the carina and each main stem bronchus; and third, as an external airway assessment of longitudinal extent of disease that complements the bronchoscopic assessment. It is mandatory to perform the mediastinoscopy at the same operative procedure as the planned resection to prevent mediastinal scarring from tethering the proximal trachea and complicating airway mobilization.

      Anesthesia

      Our preferred method of airway management is initial intubation with a long oral endotracheal tube that can be advanced to the opposite bronchus. A double lumen intubation can be used but is more rigid, harder to manipulate, and difficult to pass through the anastomosis at the later stage of the operation. Once the trachea and right main stem bronchus are divided, the right stem bronchus is intubated across the surgical field with a sterile flexible endobronchial tube and circuit. The endobronchial tube can be safely removed intermittently for brief periods of time to place the sutures precisely. During the completion of the anastomosis, temporary catheter ventilation facilitates airway approximation for the tying of the anastomotic sutures, but once the anastomosis is complete, the long single tube can be passed through the anastomosis, or left above the anastomosis for ventilation. Carinal pneumonectomy can be performed under cardiopulmonary bypass, but we believe that this is rarely necessary, adds further to the risks of bleeding and postpneumonectomy acute respiratory distress syndrome (ARDS), and that the indications to perform carinal pneumonectomy should be reconsidered if cardiopulmonary bypass is thought to be required.

      Operative Techniques

      Left carinal pneumonectomy can be performed via four major approaches: (1) left thoracotomy; (2) bilateral thoracotomies; (3) median sternotomy; and (4) clamshell (bilateral thoracosternotomy) incision. All these approaches are described in this article but generally our preferred approach is via posterolateral thoracotomy, either left thoracotomy or bilateral thoracotomies, and the choice of approach depends on the extent of the tumor into the carina and left main stem bronchus.
      During surgery for left carinal pneumonectomy, the following steps are consistently applied: (1) airway release maneuvers (pretracheal plane development and neck flexion, possibly contralateral hilar release) should be performed to minimize airway tension; (2) attention should be made to avoid devascularization of lateral blood supply of the trachea; (3) division of the trachea and right main stem bronchus should be performed sharply and perpendicular to the axis of the airway; size discrepancy usually exists between the proximal and distal ends of the airway; and no attempt should be made to tailor either end, narrowing the proximal end, or creating an extending “V” incision in the distal end; (4) interrupted 4-0 Vicryl stitches are used for the entire anastomosis with knots tied at the outside; (5) handling of the tissue should be done meticulously; (6) anastomosis should be covered with healthy vascularized tissue such as pericardial fat, intercostal muscle flap, omental or muscle flap; (7) patients should be extubated in the operating room; (8) patient’s neck should remain in semiflexion position and extension of neck is avoided by placing a guardian heavy stitch between the patient’s chin and sternum, which will be removed on postoperative day 7.

      Carinal Pneumonectomy Through a Left Thoracotomy

      Figure thumbnail gr2
      Figure 2(A) The aortic arch is mobilized and retracted laterally and cephalad; ligamentum arteriosum is divided, and pulmonary artery and aorta are separated. The left recurrent laryngeal nerve is on the floor of dissection and injury to this nerve should be avoided. An aortopulmonary window lymphadenectomy is performed. Umbilical tapes are placed around the right and left main stem bronchus and trachea, and the airway can be retracted caudally to gain access to the carina below the aortic arch. One should be careful to avoid injury to the thoracic duct when mobilizing the aortic arch and/or working in the aortopulmonary window. (B) An alternative mobilization of the aortic arch reflects the aorta anteriorly, working behind the proximal descending aorta. LMSB = left main stem bronchus; RMSB = right main stem bronchus.
      Figure thumbnail gr3
      Figure 3Trachea, right main stem bronchus, and left main stem bronchus are divided sharply and perpendicular to the airway. The margins of resection should be checked by frozen section. Left pneumonectomy is performed. Cross field ventilation is applied via an endotracheal tube placed directly into the right main stem bronchus (RMSB).
      Figure thumbnail gr4a
      Figure 4(A) Anastomosis is performed end to end first by placing traction sutures (2-0 Vicryl) in the mid-lateral portion of the each airway (total of four stitches: two in trachea and two in the right main stem bronchus). (B) The first stitch for anastomosis is placed at the mid lateral wall of the cartilaginous trachea farthest from the surgeon by using 4-0 Vicryl interrupted stitches from outside to inside, in 90 degree angle to the airway (traction sutures removed for simplicity). (C) Sutures are then sequentially placed in four quadrants from the farthest away from the surgeon, finishing on the side closest to the surgeon starting at quadrant 1 followed by quadrants 2, 3, and finally, quadrant 4. The sutures placed in quadrants 1 and 2 are shown in part D. In these right lateral quadrants it is important to hold the placed sutures out for each subsequent suture placement to prevent suture trapment when these are tied in reverse order. This is not generally difficult in the left lateral quadrants. All stitches are sequentially placed before any knots are tied. Size discrepancy between the trachea and the right main stem bronchus is common and should be corrected progressively with each suture rather than by airway tailoring procedure. Meticulous attention is necessary and systematic approach is needed to keep all the stitches in order on the surgical field. This can be achieved by individually placing each suture in a separate clamp and lining the clamps up in order. (E) When the anastomotic sutures are all placed, ventilation is achieved via a temporary catheter or repositioning of the orotracheal tube into the right main stem bronchus for the completion of anastomosis. We usually prefer temporary catheter ventilation during the tying of the stitches to decrease tension across the anastomosis that can be challenged by a stiff tube across the airway. (The suture ends are not depicted in the figure to avoid cluttering the illustration.) RMSB = right main stem bronchus.
      Figure thumbnail gr4b
      Figure 4(A) Anastomosis is performed end to end first by placing traction sutures (2-0 Vicryl) in the mid-lateral portion of the each airway (total of four stitches: two in trachea and two in the right main stem bronchus). (B) The first stitch for anastomosis is placed at the mid lateral wall of the cartilaginous trachea farthest from the surgeon by using 4-0 Vicryl interrupted stitches from outside to inside, in 90 degree angle to the airway (traction sutures removed for simplicity). (C) Sutures are then sequentially placed in four quadrants from the farthest away from the surgeon, finishing on the side closest to the surgeon starting at quadrant 1 followed by quadrants 2, 3, and finally, quadrant 4. The sutures placed in quadrants 1 and 2 are shown in part D. In these right lateral quadrants it is important to hold the placed sutures out for each subsequent suture placement to prevent suture trapment when these are tied in reverse order. This is not generally difficult in the left lateral quadrants. All stitches are sequentially placed before any knots are tied. Size discrepancy between the trachea and the right main stem bronchus is common and should be corrected progressively with each suture rather than by airway tailoring procedure. Meticulous attention is necessary and systematic approach is needed to keep all the stitches in order on the surgical field. This can be achieved by individually placing each suture in a separate clamp and lining the clamps up in order. (E) When the anastomotic sutures are all placed, ventilation is achieved via a temporary catheter or repositioning of the orotracheal tube into the right main stem bronchus for the completion of anastomosis. We usually prefer temporary catheter ventilation during the tying of the stitches to decrease tension across the anastomosis that can be challenged by a stiff tube across the airway. (The suture ends are not depicted in the figure to avoid cluttering the illustration.) RMSB = right main stem bronchus.
      Figure thumbnail gr4c
      Figure 4(A) Anastomosis is performed end to end first by placing traction sutures (2-0 Vicryl) in the mid-lateral portion of the each airway (total of four stitches: two in trachea and two in the right main stem bronchus). (B) The first stitch for anastomosis is placed at the mid lateral wall of the cartilaginous trachea farthest from the surgeon by using 4-0 Vicryl interrupted stitches from outside to inside, in 90 degree angle to the airway (traction sutures removed for simplicity). (C) Sutures are then sequentially placed in four quadrants from the farthest away from the surgeon, finishing on the side closest to the surgeon starting at quadrant 1 followed by quadrants 2, 3, and finally, quadrant 4. The sutures placed in quadrants 1 and 2 are shown in part D. In these right lateral quadrants it is important to hold the placed sutures out for each subsequent suture placement to prevent suture trapment when these are tied in reverse order. This is not generally difficult in the left lateral quadrants. All stitches are sequentially placed before any knots are tied. Size discrepancy between the trachea and the right main stem bronchus is common and should be corrected progressively with each suture rather than by airway tailoring procedure. Meticulous attention is necessary and systematic approach is needed to keep all the stitches in order on the surgical field. This can be achieved by individually placing each suture in a separate clamp and lining the clamps up in order. (E) When the anastomotic sutures are all placed, ventilation is achieved via a temporary catheter or repositioning of the orotracheal tube into the right main stem bronchus for the completion of anastomosis. We usually prefer temporary catheter ventilation during the tying of the stitches to decrease tension across the anastomosis that can be challenged by a stiff tube across the airway. (The suture ends are not depicted in the figure to avoid cluttering the illustration.) RMSB = right main stem bronchus.
      Figure thumbnail gr5
      Figure 5Once all the stitches are in place, the traction sutures are tied to achieve airway approximation and the knots are sequentially tied in the reverse order of which they were placed, ie, from closest to the surgeon to farthest away from the surgeon. The traction stitches are used to manipulate the airway during the tying of the anastomotic stitches. This maneuver, in combination with neck flexion and possible contralateral hilar release (via thoracoscopy or thoracotomy if needed), will allow for a tension-free anastomosis. The anastomosis is then covered with pericardial fat or intercostal muscle flap. The patient is returned to the supine position and a guardian stitch is placed between the chin and the sternum to prevent tracheal tension from neck extension. The patient is extubated in the operating room.

      Carinal Resection and Reconstruction via Right Thoracotomy Followed by Left Thoracotomy and Left Carinal Pneumonectomy

      This approach is used when tumor has grossly involved the carina and left main stem bronchus, and further mobilization of carina is required to obtain free surgical margins. The advantages of this particular approach are the following:
      • 1
        Carinal dissection and reconstruction is much easier from the right side since the exposure is not hindered by the aortic arch.
      • 2
        The left lung can be ventilated at all times via a single lumen tube while resection and reconstruction is performed between the trachea and right main stem bronchus, and following completion of the carinal resection and reconstruction, the right lung can again be ventilated.
      Figure thumbnail gr6
      Figure 6The pulmonary ligament is mobilized and usually extended to a hilar release, which is achieved by dividing the semicircle of pericardium around the caudal aspect of the inferior pulmonary vein (solid line), resulting in the hilum raising cephalad 1 to 2 cm with less tension. More extensive mobilization can be achieved by circumferential pericardial division around the hilum (dotted line), but care should be taken to preserve the bronchial blood supply, which may provide important collaterals for distal airway anastomosis. PA = pulmonary artery; RMSB = right main stem bronchus.
      Figure thumbnail gr7
      Figure 7The azygous vein is divided and subcarinal lymph nodes are resected, providing a free medial margin to the right main stem bronchus. The distal trachea and right main stem bronchus are encircled with umbilical tapes. Lateral 2-0 Vicryl traction sutures are placed in distal trachea and proximal right main stem bronchus.
      The right main stem bronchus and trachea are divided, allowing the carina to sit in situ with the left lung. The patient is oxygenated and ventilated with a sterile tube and circuit to the left lung. Circumferential 4-0 Vicryl anastomotic sutures are placed and subsequently tied to complete a trachea to right main stem anastomosis and the anastomosis wrapped circumferentially with a muscle flap. Ventilation is then resumed via an endotracheal tube into the right lung.
      The patient is then repositioned in the right lateral decubitus position and a left posterolateral thoracotomy is performed. The pulmonary vessels are divided and an aortopulmonary window lymphadenectomy is accomplished in continuity with left pneumonectomy. Attention is made to preserve the left recurrent laryngeal nerve. The previously divided carina is then delivered and the pneumonectomy specimen with attached trachea and carina is removed. LMSB = left main stem bronchus; RMSB = right main stem bronchus; RULB = right upper lobe bronchus.

      Left Carinal Pneumonectomy Through Median Sternotomy

      Figure thumbnail gr8
      Figure 8To perform left carinal pneumonectomy via median sternotomy, the pericardium is opened anteriorly. For exposure of the carina and proximal left main stem bronchus, the superior vena cava (SVC) is retracted to the right and the aorta is retracted to the left, dividing the posterior pericardium cephalad to the right pulmonary artery (RPA).
      Figure thumbnail gr9
      Figure 9For exposure of the distal left main stem, one retracts the aorta to the right, dividing the ligamentum arteriosus and retracting the pulmonary artery caudally. LMSB = left main stem bronchus.
      Figure thumbnail gr10a
      Figure 10(A) The portions of distal trachea and proximal bronchi to be resected are dissected circumferentially, with careful attention to underlying esophagus. It is advisable to place a nasogastric tube to facilitate identification of the esophagus. Careful attention must be made not to injure the recurrent laryngeal nerve. Generally a right hilar release is performed. The trachea and right main stem bronchus are divided. The interrupted anastomotic stitches are placed in the membranous trachea first and tied inside. (B) The stitches in the cartilaginous trachea are placed in interrupted fashion and tied outside. The left lung can be ventilated while the trachea to right main stem anastomosis is performed. Subsequently the right lung can be ventilated while a standard left pneumonectomy is performed. RMSB = right main stem bronchus; RULB = right upper lobe bronchus.
      Figure thumbnail gr10b
      Figure 10(A) The portions of distal trachea and proximal bronchi to be resected are dissected circumferentially, with careful attention to underlying esophagus. It is advisable to place a nasogastric tube to facilitate identification of the esophagus. Careful attention must be made not to injure the recurrent laryngeal nerve. Generally a right hilar release is performed. The trachea and right main stem bronchus are divided. The interrupted anastomotic stitches are placed in the membranous trachea first and tied inside. (B) The stitches in the cartilaginous trachea are placed in interrupted fashion and tied outside. The left lung can be ventilated while the trachea to right main stem anastomosis is performed. Subsequently the right lung can be ventilated while a standard left pneumonectomy is performed. RMSB = right main stem bronchus; RULB = right upper lobe bronchus.

      Left Carinal Pneumonectomy via Clamshell Incision

      This approach is similar to the median sternotomy with the advantages of broader anterolateral exposure to the hilum, but still with limited exposure to the posterior structures such as the trachea. We believe that access for meticulous oncologic dissection and airway reconstruction of the carina is not nearly as adequate through these anterior approaches in general and overall are inferior to that achieved with a posterolateral thoracotomy.
      We prefer sequential posterolateral thoracotomies for the more complex and extensive reconstruction because of the better posterior exposure to the airway. However, some prefer a clamshell approach because of the single incision and simultaneous management of right and left dissections.

      Postoperative Care

      Postoperative care is focused on pulmonary toilet and fluid management. Aggressive pulmonary toilet with vigorous chest physical therapy should be started early and done frequently. There should be low threshold for flexible bronchoscopy and/or minitracheostomy to aid in postoperative pulmonary care. Careful attention should be paid to management of fluids and electrolytes. We do not aggressively restrict fluid intake; patients will be hydrated as needed to have adequate urinary output but fluid administration is monitored closely and fluid overload is prevented.

      Postoperative Complications

      Major postoperative complications are higher after carinal pneumonectomy than other pulmonary resections including pneumonectomy. The two major types of complications are anastomotic problems and ARDS. Anastomotic complications occur in up to 17% of patients.
      • Simon K.
      • Ashiku D.J.M.
      Carinal resection.
      Early complications are necrosis, separation, and mucosal sloughing. Late complications are stenosis, excessive granulation tissue, and recurrent postobstructive pneumonia. Anastomotic related complications are associated with 44% mortality rate.
      • Simon K.
      • Ashiku D.J.M.
      Carinal resection.
      If anastomotic dehiscence occurs, internal stenting with a silastic T-tube, tracheostomy tube, or placement of a long endotracheal tube is necessary. Delayed stenosis is managed with dilation or stenting. Re-resection is possible in select patients after resolution of inflammation. Bronchopleural fistulas are treated with drainage and antibiotic coverage potentially combined with distal intubation or stenting.
      ARDS occurs in approximately 10% of patients and is associated with a 90% mortality rate. The cause of ARDS remains unclear, but it may result from a combination of barotrauma, excessive fluid administration, and disruption of mediastinal lymphatics.

      Prognosis

      The overall 5-year survival for left carinal pneumonectomies is reported to be as high as 38%.
      • Mitchell J.D.
      • Mathisen D.J.
      • Wright C.D.
      • et al.
      Resection for bronchogenic carcinoma involving the carina: long-term results and effect of nodal status on outcome.
      In patients with bronchogenic carcinomas, lymph node status and positive margin strongly influence survival. In patients with adenoid cystic carcinoma, on the other hand, neither lymph node nor margin status affects survival, and overall these tumors have a much more favorable prognosis compared with bronchogenic carcinomas.
      Postoperative radiation therapy is recommended in all cases of adenoid cystic carcinoma or primary squamous cell carcinoma of the airway, unless contraindicated by patients’ health status or anastomotic complications. The role of chemotherapy has not been established for primary airway tumors, but adjuvant chemotherapy does appear to improve survival in stage II-III non-small-cell lung cancer.
      We believe that carinal pneumonectomy is a safe but challenging procedure that requires thorough evaluation of the patients and thoughtful surgical planning. To obtain excellent results, this procedure should be performed in a high volume center with a combination of an expert group of surgeons, an anesthesiologist, and health care providers.

      References

        • Grillo H.
        • Bendixen H.H.
        • Gephart T.
        Resection of the carina and lower trachea.
        Ann Surg. 1963; 158: 889-893
        • Grillo H.C.
        Carinal reconstruction.
        Ann Thorac Surg. 1982; 34: 356-373
        • Grillo H.C.
        Carcinoma of the lung: what can be done if the carina is involved?.
        Am J Surg. 1982; 143: 694-695
        • Mitchell J.D.
        • Mathisen D.J.
        • Wright C.D.
        • et al.
        Resection for bronchogenic carcinoma involving the carina: long-term results and effect of nodal status on outcome.
        J Thorac Cardiovasc Surg. 2001; 121: 465-471
        • Porhanov V.A.
        • Poliakov I.S.
        • Selvaschuk A.P.
        • et al.
        Indications and results of sleeve carinal resection.
        Eur J Cardiothorac Surg. 2002; 22: 685-694
        • Mitchell J.D.
        • Mathisen D.J.
        • Wright C.D.
        • et al.
        Clinical experience with carinal resection.
        J Thorac Cardiovasc Surg. 1999; 117 (discussion 53, 1999): 39-52
        • Muehrcke D.D.
        • Grillo H.C.
        • Mathisen D.J.
        Reconstructive airway operation after irradiation.
        Ann Thorac Surg. 1995; 59: 14-18
        • Simon K.
        • Ashiku D.J.M.
        Carinal resection.
        in: Yang S.C. Cameron D.E. Current Therapy in Thoracic and Cardiovascular Surgery. Mosby, Philadelphia, PA2004: 179-182