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Right Carinal Lobectomy and Pneumonectomy

  • Paolo Macchiarini
    Correspondence
    Address reprint requests to Paolo Macchiarini, MD, PhD, Department of General Thoracic Surgery, Hospital Clinic of Barcelona, University of Barcelona, 170 Villaroel, E-30889 Barcelona, Spain.
    Affiliations
    Department of General Thoracic Surgery, University of Barcelona, Ciber Enfermedades Respiratorias, and Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Spain.
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      The most common indication for carinal lobectomy or pneumonectomy is non-small-cell lung cancer (NSCLC) extending from the lung to the carina.
      • Mathisen D.J.
      • Grillo H.C.
      Carinal resection for bronchogenic carcinoma.
      Eligibility should be restricted to the following: patients less than 75 years of age with a performance status of 0 to 1; an NSCLC approaching (<0.5 cm) or invading the main carina; no distant metastases; and normal cardiopulmonary, liver, and renal function. Prior chemoradiation is not a contraindication provided that no more than two N2 nodal levels below station 2R/L or N3 lymph nodes are involved.
      • Macchiarini P.
      • Altmayer M.
      • Thorsten Walles
      Technical innovations of carinal resection for non small-cell lung cancer.
      Preoperative rigid bronchoscopy is mandatory to establish whether either operation can be performed without anastomotic tension. For carinal pneumonectomy, the distance from the right distal tracheal margin to the proximal medial left main stem should not exceed 4 cm. For carinal lobectomy, any neoplasm extending more than 2 cm below the left tracheobronchial angle precludes a secondary end-to-side reimplantation of the residual bronchus into the distal left mainstem bronchus. This operation should be avoided in patients with positive mediastinal nodes. Preoperative findings of asymptomatic invasion of the superior vena cava (SVC) or limited infiltration of the muscular wall of the intrathoracic esophagus are not contraindications. Long-term steroid use should be reduced to 5 mg/d. Specific preoperative assessment includes quantitative ventilation/perfusion scans, spirometry, transthoracic echocardiography, and, in patients with latent or symptomatic pulmonary hypertension, basal and vasoreactive right heart catheterization with endoluminal blockage of the ipsilateral pulmonary artery.

      Operative Technique

      Figure thumbnail gr1
      Figure 1For either procedure, before being positioned for the operation, the patient should be anesthetized and attached to appropriate monitors, the goal being immediate extubation after skin closure whenever possible. The patient can initially be ventilated using a left-sided, double-lumen tube with low-tidal-volume (volume or pressure) controlled techniques. High inspiratory oxygen concentrations, multiple lung collapses and re-expansions, hypoxic pulmonary vasoconstriction and hypoperfusion of the ipsilateral lung, and fluid overload should be avoided, especially in patients who have received chemoradiation. When invasion of the SVC is suspected, continuous monitoring of cerebral venous pressure may be indicated, associated with large venous accesses into the inferior vena cava.
      • Macchiarini P.
      • Altmayer M.
      • Thorsten Walles
      Technical innovations of carinal resection for non small-cell lung cancer.
      The patient should be in the left lateral decubitus position, and a classical muscle-sparing right dorsal thoracotomy should be made in the 5th intercostal space. One should begin the initial dissection by dividing the azygous vein to expose the carina and evaluate the upper mediastinum. In induction therapy for naive and node-negative patients, one should open the pretracheal fascia cephalically to gain airway flexibility; in previously chemoradiated patients, the lymphadenectomy should be thorough, resecting the nourishing vessels with ligatures rather than metallic clips to ensure proper reconstruction. The distal trachea and right and left mainstem bronchi are then dissected and encircled, being careful, when performing the lymphadenectomy or resection of the pericardial reflections beyond the left tracheobronchial angle and at the level of the ascending aorta, to avoid injury to the left recurrent nerve.
      Figure thumbnail gr2
      Figure 2Once the criteria for accomplishing a pathologically complete resection have been met, the operative steps should be as follows: If the SVC is invaded, first clamp the vessel proximally (innominate veins confluence) and distally (cavoatrial junction), after systemic heparinization. Then excise completely the invaded segment of the vein, which further exposes the intrapericardial and retrocaval right pulmonary arteries for safer control. a. = artery; n. = nerve.
      Figure thumbnail gr3
      Figure 3Different materials can be used for superior vena cava (SVC) revascularization. We prefer arterial cadaveric homografts because they do not need postoperative anticoagulation therapy and are completely resistant to infection.

      Macchiarini P: Superior vena cava obstruction, in Pearson FG, Cooper JD, Deslauriers J, et al (eds): Thoracic Surgery (ed 3). New York, Churchill Livingstone (in press)

      Usually, for truncular SVC replacement, a descending aortic homograft has an SVC-compatible diameter; almost all aortic collaterals are secured but few are left for de-airing. Revascularization is then started on the proximal stump, using a continuous 5-0 polypropylene suture started at the posterior aspect of the homograft in an inside-to-outside pattern. Following its completion, the distal anastomosis is then performed in the same way. Before tightening the stretches of the distal suture, the proximal clamp is released and the homograft is flushed with saline heparinized solution and extensively de-aired. The distal clamp is then released and the knots are tied. To avoid any kinking, the length of the homograft should be adapted so that the distal anastomosis rests under mild tension.
      Figure thumbnail gr4
      Figure 4The pneumonectomy is then started by dividing and securing the ligamentum pulmonalis between ligatures; we perform an extra- or intrapericardial pneumonectomy in the usual fashion. We prefer to secure all vessels individually with polypropylene sutures (Prolene; Ethicon Inc., Somerville, NJ). Afterward, the right lung can be completely lifted upwards to accomplish a complete lymphadenectomy of the lower mediastinal nodal stations before sectioning the airway. During this lifting, be careful to avoid contamination of the left lung by excessive mobilization of the endotracheal tube. Under the surgeon’s guidance, the tube is then gently withdrawn by the anesthetist up to the distal cervical trachea. Once the tube is withdrawn and before the dissection is completed, patients are preoxygenated and hyperventilated with 100% oxygen (O2) for about 10 minutes to reach arterial pO2 and pCO2 levels of at least 450 and 28 to 35 mm Hg, respectively. Then, and under flexible bronchoscopical guidance, the distal trachea is incised in tumor-free margins, leaving the right lung attached to the left mainstem bronchus. Evaluation of frozen section margins throughout the operation is imperative.
      Figure thumbnail gr5
      Figure 5The distal left main bronchus is sectioned in tumor-free margins; the right lung, along with the main carina and proximal left main bronchus, is removed and sent for frozen section evaluation. Ventilation is assured through the apneic (hyper) oxygenation technique by placing a small (10 F) catheter across the surgical field into the contralateral main bronchus, fixing it to the cartilaginous ring (about at 12 o’clock) to prevent its dislocation and connecting it to a sterile line that delivers 10 to 15 L/min O2 continuously under minimal breathing pressure (0 to 1 mm Hg).
      • Go T.
      • Altmayer M.
      • Richter M.
      • et al.
      Decompressing manubriectomy under apneic oxygenation to release the median thoracic outlet compartment in Bechterew disease.
      Before reconstruction, an exploration with dissection of the contralateral nodes (4 L, 10 L) is made through the aperture generated by the resection of the tracheobronchial bifurcation.
      Figure thumbnail gr6
      Figure 6Reconstruction of the airways is then begun with an end-to-end anastomosis between the distal trachea and distal left main bronchus. A double-ended polydioxanone (PDS; Ethicon Inc.) 3-0 or 4-0 suture is started on the middle of the deepest anastomotic part of the left half of both cartilaginous walls, picking up the full layers of the respective bronchial walls. It must be left untied to allow a number of stitches to be placed to complete the entire deepest anastomotic aspect but without passing beyond the “newly made” left tracheobronchial angle, leaving the membranous wall undisturbed.
      Figure thumbnail gr7
      Figure 7The double-ended suture is then pulled tight as the distal trachea and residual left main bronchus are parachuted. Two additional PDS sutures of the same size are placed to fix definitively the parachuted suture. We recommend using an exact mucosa and stitch apposition through nerve hooks to avoid purse-string and narrowing effects.
      Figure thumbnail gr8
      Figure 8Several concentric interrupted 3-0 to 5-0 polyglactin (Vicryl; Ethicon Inc.) sutures are placed on the remaining quadrants 3 to 4 mm apart and 3 to 4 mm from the cut edge of the airway, leaving the membranous wall bronchus until last to allow balancing of any anastomotic disparity and to prevent excessive traction. Each individual suture is positioned sequentially in a suture guide designed specifically for cardiac procedures, keeping them separate and equidistant.
      Figure thumbnail gr9
      Figure 9Once placement is completed, the wall and sutures are gently approximated; knots are tied and placed outside the walls.
      Figure thumbnail gr10
      Figure 10The anastomosis is completed by placing small Vicryl sutures (eg, 5-0) on the membranous wall, thereby reducing the risk of injury due to manipulation. Care should be taken to avoid placing sutures on the cartilage-membranous angle because of the almost irreversible risk of tearing the airway. The completed anastomosis is then tested for air leaks up to 40 mm Hg and eventually repaired or covered with viable tissues, eg, pedicled flap of pericardial fat, pleura, or intercostal muscle. Sometimes, especially in previously chemoradiated patients, it is wiser to accept a minimal air leak rather than to risk overtearing the anastomosis. The chest is closed in the standard fashion.
      Figure thumbnail gr11
      Figure 11A particularly challenging operation is creation of a secondary end-to-side anastomosis.
      • Di Rienzo G.
      • Go T.
      • Macchiarini P.
      Simplified technique for the secondary end-to-side anastomosis in complex tracheobronchial reconstruction.
      The choice to reimplant the residual bilobe end to side either onto the trachea or onto the left main bronchus depends on (1) the length of the residual intermedius bronchus; (2) the status of the trachea (fibrotic, malacic); (3) the extent of node dissection; and (4) the degree of traction on the residual hilar vessels. We prefer to perform the end-to-side secondary anastomosis onto the left main bronchus, regardless of the length of the residual bronchus.
      • Macchiarini P.
      • Altmayer M.
      • Thorsten Walles
      Technical innovations of carinal resection for non small-cell lung cancer.
      During the end-to-side reimplantation, the residual ipsilateral pulmonary artery is always left unclamped to avoid hypoxic pulmonary vasoconstriction and hypoperfusion of the residual lobe(s) or hyperperfusion of the contralateral lung. a. = artery.
      Figure thumbnail gr12
      Figure 12(A) A double-ended polydioxanone (PDS; Ethicon Inc.) 3-0 or 4-0 suture is started on one or the other edge of the deepest or posterior aspect of the anastomosis, picking up the full layers of the respective bronchial walls and inserting the needles from inside the lumen. (B) The suture must be left untied to allow a number of stitches to be placed to complete the entire deepest aspect of the anastomosis before the reimplanted bronchus is pulled down onto the hosting structure. LMSB = left main-stem bronchus.
      Figure thumbnail gr13
      Figure 13The double-ended suture is pulled tight as the reimplanting and recipient lumens are parachuted. We recommend using the exact mucosa and stitch apposition through nerve hooks to avoid purse-string and narrowing effects.
      Figure thumbnail gr14
      Figure 14Several concentric interrupted 3-0 to 5-0 polyglactin (Vicryl; Ethicon Inc.) sutures are placed on the remaining quadrants 3 to 4 mm apart and 3 to 4 mm from the cut edge of the airway, leaving the membranous wall of the reimplanting bronchus until last to allow balancing of any anastomotic disparity and excessive traction on it. Small Vicryl sutures (eg, 5-0) are then placed on the membranous wall; this is usually less risky than the same positioning during carinal pneumonectomy. Once placement is completed, the wall and sutures are gently approximated, placing knots outside walls.

      Conclusions

      Right carinal pneumonectomy and lobectomy(ies) are challenging operations that are indicated in fewer than 1% of operable patients with NSCLC or benign neoplasms invading the carina. Unfortunately, these operations are performed in only a few centers worldwide, probably because of their technical complexity and the generally accepted opinion that their benefits are limited.
      Recent advances have, however, reduced morbidity and mortality rates and improved long-term outcome of such operations. The advances include the following: (1) contraindicating surgery in “massive” N2 disease and performing routine mediastinoscopy and radical lymphadenectomy; (2) minimizing the risk of a potentially fatal postcarinal complication, acute respiratory distress syndrome, by using intraoperative lung-protective ventilation techniques and avoiding high inspiratory oxygen concentrations, multiple collapses and re-expansions, hypoxic pulmonary vasoconstriction during hypoperfusion of the ipsilateral lung parenchyma or hyperperfusion of the contralateral lung, and fluid overload; and (3) carefully clearing secretions, including the use of a temporary tracheostomy.
      Carinal plus lobar resection is rarely performed, but when reimplantation is necessary (either bronchus intermedius or right lower lobe bronchus), the secondary end-to-side anastomosis should be to the side of the left main bronchus and not to the trachea, not only to avoid excessive tension but because, if a minimal anastomotic leak occurs, it will heal spontaneously through the collapse of the mediastinal and lung tissue over its surface, provided the pleural space is drained sufficiently.

      References

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        • Grillo H.C.
        Carinal resection for bronchogenic carcinoma.
        J Thorac Cardiovasc Surg. 1991; 102: 16-23
        • Macchiarini P.
        • Altmayer M.
        • Thorsten Walles
        Technical innovations of carinal resection for non small-cell lung cancer.
        Ann Thorac Surg. 2006; 82: 1989-1997
      1. Macchiarini P: Superior vena cava obstruction, in Pearson FG, Cooper JD, Deslauriers J, et al (eds): Thoracic Surgery (ed 3). New York, Churchill Livingstone (in press)

        • Go T.
        • Altmayer M.
        • Richter M.
        • et al.
        Decompressing manubriectomy under apneic oxygenation to release the median thoracic outlet compartment in Bechterew disease.
        J Thorac Cardiovasc Surg. 2003; 126: 867-869
        • Di Rienzo G.
        • Go T.
        • Macchiarini P.
        Simplified technique for the secondary end-to-side anastomosis in complex tracheobronchial reconstruction.
        J Thorac Cardiovasc Surg. 2002; 124: 632-635