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Carinal Resection and Sleeve Pneumonectomy Using a Transsternal Approach

  • Robert J. Ginsberg
    Correspondence
    Address reprint requests to Robert J. Ginsberg, MD, FRCS(C), Chief, Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021
    Affiliations
    From the Department of Surgery, Memorial Sloan-Kettering Cancer Center; and Cornell University Medical College, New York, NY
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      Carinal resection, with or without concomitant pulmonary resection is a relatively recent addition to the thoracic surgical armamentarium. Initially, partial-wall tracheal resections were carried out with autogenous or prosthetic material patches (eg, wire, polypropylene mesh) and were first reported by Belsey in 1946.
      • Belsey R
      Resection and reconstruction of the intrathoracic trachea.
      The first carinal resection with primary reconstruction was described by Barclay et al
      • Barclay RS
      • McSwann N
      • Welsh TM
      Tracheal resection without use of grafts.
      in the management of a cylindroma. In this first case report, an end-to-end anastomosis was performed between the trachea and right mainstem bronchus with reimplantation of the left mainstem bronchus into the side of the bronchus intermedius. During the past 30 years, significant contributors to the carinal resection technique have included Grillo,
      • Grillo HC
      Carinal reconstruction.
      Perelman,
      • Perelman M
      • Koroleva N
      Surgery of the trachea.
      Pearson,
      • Pearson FG
      • Todd TRJ
      • Cooper JD
      Experience with primary neoplasms of the trachea and carina.
      Jensik,
      • Jensik RJ
      • Faber LP
      • Milloy FJ
      • et al.
      Tracheal sleeve pneumonectomy for advanced carcinoma of the lung.
      Eschapasse,
      • Eschapasse H
      Les tumeurs tracheales primitives: Traitement chirurgical.
      Dartevelle,
      • Dartevelle P
      • Macchiarini P
      Carinal resection for bronchogenic cancer.
      and Deslauriers.
      • Deslauriers J
      • Beaulieu M
      • Benazera A
      • et al.
      Sleeve pneumonectomy for bronchogenic carcinoma.
      The approaches to the carina include a transsternal or a right posterolateral thoracotomy approach. Only on rare occasions (usually unanticipated) should a left sleeve pneumonectomy be attempted using a left posterolateral thoracotomy incision.

      Indications

      Although the right posterolateral approach is preferred by most surgeons, the transsternal access is especially valuable for small carinal lesions requiring only a carinal resection and in those instances where a left sleeve pneumonectomy is contemplated. Airway control through this approach is superb.
      Resection of the tracheal carina may be required for management of benign or malignant tumors arising in the trachea or proximal bronchi. With primary bronchogenic carcinomas involving the lower trachea, a sleeve pneumonectomy is frequently necessary with the carinal resection. On the other hand, with less aggressive tumors (eg, small squamous cell tumors, carcinoid tumors) total or partial bilateral lung preservation is possible. Occasionally, benign structures at the carina may require resection.
      The common tumors requiring carinal resection include: squamous cell carcinoma, adenoid cystic carcinoma, and bronchogenic carcinomas involving the lower trachea, carina, or proximal bronchi. A whole variety of less malignant tumors can affect the carina, including carcinoid tumors and geographic tumors (fibroma, lipoma, chondroma, and myoepithelial tumors).
      Although carinal resection should be within the armamentarium of all well-trained cardiothoracic surgeons with an interest in general thoracic surgery, even the most authoritative surgeons experiences are quite limited, with few surgeons treating more than one or two such cases per year.

      Preoperative Evaluation

      Despite advances in imaging, surgical and anesthetic techniques, and improvements in perioperative care, perioperative morbidity and mortality are still significant after carinal resections, especially with concomitant lobectomy or pneumonectomy. It is imperative that surgeons embarking on these resections are skilled and have experience in all of the aforementioned areas. In all such cases, the disease should not be so extensive that, after resection and with mobilization techniques, excessive tension is created that eliminates the possibility of reanastomosis. The importance of accurate preoperative evaluation cannot be stressed enough.
      All patients require a complete preoperative medical evaluation including the usual cardiopulmonary evaluation. Chronic steroid dependency or acute inflammatory conditions of the tracheobronchial tree should be corrected before embarking on a major carinal resection. Previous high dose radiation therapy (>4,500 cGy) interferes with healing and requires special consideration.
      Preoperatively, the airway must be assessed with imaging techniques and endoscopy. Imaging techniques used to include plain tomography and bronchography, but these have been replaced by fine-cut spiral computed tomographic (CT) imaging. Occasionally, magnetic resonance imaging (MRI) may add information concerning the integrity of adjacent vascular structures. Although some surgeons still consider rigid endoscopy a necessity, flexible fiberoptic endoscopy is usually sufficient in most instances. The proximal and distal extent of the disease must be accurately measured.
      When dealing with primary malignancies, mediastinoscopy just before the planned surgical resection can be beneficial in ruling out extensive mediastinal nodal disease. This is especially important in dealing with primary lung cancer.
      Before considering a surgical approach, all tracheostomy tubes or stents, if present, should be removed, and the associated tracheitis should be allowed to resolve for a period of 1 or 2 weeks. Such a patient, in most cases, can be managed short-term without stents with the use of endoscopy with removal of obstructing lesions or repeated dilatation of strictures during this healing phase.
      If preoperative radiotherapy is to be considered part of the treatment protocol, doses should not exceed 4,500 cGy in 4 weeks. A 3- to 4-week healing period after this, but before surgical resection is advised.
      Principles of management include preservation of recurrent laryngeal nerves, as well as blood supply to the remaining trachea and bronchi, hilar releases to mobilize the bronchi, and accurate anastomoses without tension. It is rare that a supraglottic release is required for further mobilization of the trachea and carina.
      At the time of surgery, it is important that the surgeon avoid excessive resection precluding primary anastomosis. There are no good prosthetic materials presently available to replace the circumferential trachea without the risk of erosion of surrounding vascular structures and failure of epithelialization causing strictures.
      A variety of reconstructions can be performed, which include sleeve pneumonectomy, recreation of a new carina with tracheal bronchial anastomoses, or carinal resections combined with right upper-lobe sleeve lobectomies, preserving the bronchus intermedius. On occasion, implantation of one main bronchus into the other will avoid a sleeve pneumonectomy and preserve lung function.
      Technical expertise is required for these approaches. In expert hands, perioperative morbidity and mortality can be reduced to below 5%.

      Approaches

      For most situations, a right thoracotomy approach is preferable. However, for small tumors around the carina where only a carinal resection is anticipated or when a left sleeve pneumonectomy may be required, a transsternal approach is preferred. This latter approach is classically performed using a total sternotomy, thus allowing access to both hemithoraces. Although never used by this author, the bilateral clam shell incision with a transverse sternotomy through the third or fourth interspace certainly could be used with similar facility. However, in using this latter approach, access to the very proximal trachea is unavailable without a separate cervical incision.

      Anatomic Considerations

      A detailed knowledge of mediastinal anatomy is essential. In dealing with the lower trachea through a transsternal approach, the left innominate vein and innominate artery are usually dissected and taped, and the superior vena cava and aorta are mobilized. Knowledge of the anatomy of the carina in its relation to the pericardium is also essential. In almost all circumstances, the anterior pericardium must be opened, the right pulmonary artery must be identified, dissected, and taped, and the posterior pericardium overlying the carina must be opened widely before dissection of the lower trachea and both mainstem bronchi can be achieved.
      Detailed knowledge of the relationship of the inferior pulmonary veins to the pericardium is required, as well, in order to effect bilateral hilar releases when necessary.
      The vascular supply of the trachea and carina is important to understand. Most intrathoracic tracheal blood supply arises from periesophageal vessels and enter the trachea bilaterally at the membranocartilaginous juncture. For this reason, the trachea should only be mobilized in its anterior two thirds, leaving as much attachment to the underlying esophagus as possible so as not to interfere with its blood supply. The carina and mainstem bronchi are supplied by bronchial vessels, which also supply the subcarinal lymph nodes. Whenever possible, the blood supply should be preserved to the distal bronchi beyond the anticipated resection.

      Anesthetic Considerations

      As important as it is for the surgeon to be experienced in carinal resections, without experienced anesthesia, disasters can occur. Before any carinal resection, interactive discussions between the anesthesiologist and surgeon are mandatory. There are a variety of methods of ventilating the open airway that have been well described. These include: (1) high or low frequency catheter ventilation to one or both lungs, passing the catheter(s) through the retracted endotracheal tube; (2) intermittent apneic ventilation, passing the endotracheal tube intermittently across the open airway to one or other bronchus; (3) using a large endotracheal tube and passing a smaller (4F or 5F) endotracheal tube through it across the divided airway to ventilate one or the other lung (which allows continuous ventilation with a small tube such that anastomoses can be carried out around the tube); (4) transoperative “in-field” ventilation, employing sterilized endotracheal tubing, inserting it into one or the other distal bronchus, and ventilating the patient using a second anesthetic set up; (5) a combination of the above.
      In all instances, the endotracheal tubes passed into the distal airway should be armored and have small cuffs with minimal tube length beyond the cuff in order to avoid obstructing distal bronchi.
      Intraoperative division of the airways can be monitored by flexible fiberoptic bronchoscopy during the operation. This procedure is also valuable to assess the anastomosis and provide pulmonary toilet before the extubation.

      SURGICAL TECHNIQUE

      A transsternal approach allows maximum control of both airways. It is an extremely satisfactory approach for diseases of the lower trachea with minimal (<2 cm) involvement of either mainstem bronchus. In most instances, if extensive resections of either mainstem bronchus are required, a right transthoracic approach is preferable.
      Figure thumbnail fx1
      1A mid-line sternotomy incision is used, (A) although a bilateral anterior thoracotomy/transverse sternotomy (clamshell incision) is an option. If a mediastinoscopy has been performed just before the sternotomy, that incision is often best placed vertically rather than transversely. After median sternotomy, the anterior mediastinal fat and thymus are mobilized to clearly identify the innominate vein and artery (B).
      Figure thumbnail fx2
      2The pericardium is incised vertically in its upper two thirds. The superior vena cava and aorta are encircled and retracted laterally, exposing the pretracheal fascia and posterior pericardium. To facilitate dissection of the trachea, a finger placed beneath the pretracheal fascia at the thoracic inlet will allow blunt dissection of the whole anterior and lateral walls of the trachea down to the carina. If a mediastinal lymph node dissection is required, this can be performed at this time, carefully preserving the recurrent nerves. At no point should the vascular supply of the trachea be interfered with. Because this originates from periesophageal vessels, the trachea should not be mobilized except anterolaterally, preserving the esophageal and posterolateral vascular attachments.
      Figure thumbnail fx3
      3The right pulmonary artery is dissected, mobilized, and isolated with tape. The posterior pericardium is incised in a cruciate fashion to allow for wide exposure of the carina and proximal mainstem bronchi.
      Figure thumbnail fx4
      4The portions of distal trachea and proximal bronchi to be resected are then dissected circumferentially, taking care not to injure the underlying esophagus. Identification of this structure is facilitated by using an endoesophageal tube (eg, endoesophageal thermometer, small Maloney Bougie, nasogastric tube, or when necessary, a pediatric endoscope). The extent of resection required should now be assessed. Although a hilar release is rarely required for small carinal resections, if it is deemed necessary, at this time the distal pericardium should be opened and bilateral hilar releases can be carried out taking care to avoid injury to either pulmonary vein. A left hilar release is more difficult because of the overlying ventricle.
      Figure thumbnail fx5
      5Stay sutures of 3-0 silk are placed at the membrano-cartilaginous junction bilaterally in the trachea and mainstem bronchi, proximal and distal to the anticipated resection. The trachea is then incised transversely between two cartilages just at the anticipated required proximal resection. When in doubt, this can be confirmed intraoperatively by fiberoptic bronchoscopy. The tumor or stenosis is inspected to ensure that a complete proximal resection has been carried out. Cooperation between the anesthesiologist and surgeon is mandatory to decide on the type of ventilation that is necessary. In most instances, one lung ventilation with a small lumen endotracheal tube passed across the resected area is all that is required. However, high frequency jet ventilation, catheter ventilation, or in-field ventilation may be necessary.
      With the cooperation of the anesthesiologist and by intermittently withdrawing the ventilating tube into the proximal trachea, the posterior membranous trachea is divided and dissected off the underlying esophagus, with care taken not to injure the left recurrent nerve. The dissection is carried out distally between trachea and esophagus beyond the carina and along both mainstem bronchi until the distal resection line is reached. The right, and then left, mainstem bronchi are then divided distal to the airway involvement. If a tumor is present, proximal and distal resection margins should be assessed by frozen section at this point. As well, if a subcarinal lymphnode dissection is required, it is appropriate to carry this out just before the bilateral bronchial division.
      Figure thumbnail fx6
      6Once resection margins are deemed adequate, reconstruction is carried out after assessment of tension has been made. In most instances, it is at this point that the neck should be fully flexed by the anesthesiologist to allow some further mobility of the trachea. If a hilar release has not been performed and is required, it should be done before reconstruction. Three or 4-0 braided or monofilament polyglycolic acid (PGA) is our preferred suture material. The carina is reconstructed bringing the medial walls of both mainstem bronchi together by interrupted sutures with the knots placed externally or internally.
      Figure thumbnail fx7
      7An end-to-end anastomosis is then carried out between the newly formed carina and proximal trachea with interrupted sutures, and all of these knots are placed externally. With this approach, the membranous trachea must be anastomosed first. If there is only minimal tension, the membranous sutures can be tied at this point before inserting the pericartilagenous sutures laterally and anteriorly. Unless in-field ventilation is required, all of these sutures can be placed while ventilating a single lung either with a long, small-gauge endotracheal tube or catheter ventilation.
      Figure thumbnail fx8
      8When all sutures are in place, they are tied, beginning laterally on both sides to relieve tension. Drs Grillo and Mathisen advocate tension-relieving sutures placed between trachea and bronchi proximally and distally.
      • Grillo HC
      Carinal reconstruction.
      • Wilson RS
      Anesthetic management for tracheal reconstruction.

      Mitchell JD, Mathisen DJ, Wright CD: Clinical experience with carinal resection. Thorac Cardiovasc Surg 1998 (in press)

      have used this with success.
      The anastomosis is reinforced circumferentially with vascularized tissue, usually adjacent pericardium, pericardial fat, or mobilized thymus gland.
      A routine sternal closure is carried out. The operation is completed by inserting a stitch between chin and manubrium to avoid any tension on the anastomosis by limiting the patient's neck extension.
      Figure thumbnail fx9a
      9A variety of resections and reanastomoses can be carried out transsternally (B-E). Certainly, a left or right sleeve pneumonectomy can be performed. Reimplantation of the left mainstem bronchus into the trachea or bronchus intermedius is also possible but somewhat cumbersome. On the other hand, reimplantation of the bronchus intermedius into the left mainstem bronchus is almost impossible using this approach because of the overlying aortic arch. (A) These latter reimplantation procedures are best carried out through a standard right-posterolateral approach.
      Figure thumbnail fx9b
      9A variety of resections and reanastomoses can be carried out transsternally (B-E). Certainly, a left or right sleeve pneumonectomy can be performed. Reimplantation of the left mainstem bronchus into the trachea or bronchus intermedius is also possible but somewhat cumbersome. On the other hand, reimplantation of the bronchus intermedius into the left mainstem bronchus is almost impossible using this approach because of the overlying aortic arch. (A) These latter reimplantation procedures are best carried out through a standard right-posterolateral approach.
      Figure thumbnail fx9c
      9A variety of resections and reanastomoses can be carried out transsternally (B-E). Certainly, a left or right sleeve pneumonectomy can be performed. Reimplantation of the left mainstem bronchus into the trachea or bronchus intermedius is also possible but somewhat cumbersome. On the other hand, reimplantation of the bronchus intermedius into the left mainstem bronchus is almost impossible using this approach because of the overlying aortic arch. (A) These latter reimplantation procedures are best carried out through a standard right-posterolateral approach.

      Commentary

      These patients require maximum attention postoperatively. Their management is no different than any other sleeve resection or pneumonectomy when this is performed. Although many surgeons feel that daily postoperative bronchoscopy is required, my own preference is to bronchoscope when indicated. Most often, the patients are never bronchoscoped (avoiding potential contamination). However, when clinical examination suggests a problem (eg, stridor, hemoptysis) immediate CT scan and bronchoscopy can avoid potential tragedies (eg, perianastomotic infection, impending bronchovascular fistula, anastomotic dehiscence with impending airways obstruction). I defer routine follow-up bronchoscopy (if asymptomatic) for 4 weeks.
      It has always been my practice to circumferentially protect the anastomosis with adjacent vascularized tissue (eg, pleura, pericardium pericardial fat pad, intercostal muscle). If the patient has been heavily irradiated (eg, >5,000 cGy) mobilizing omentum before the surgery (my preference) or an appropriate chest wall muscle at the time of surgery for maximum protection.
      In a recent report by the Massachusetts General group reviewing the largest series of carinal resections, it was noted that where carinal resection was required, when the extent of resection was equal or greater than 4 cm, the incidence of anastomotic problems tripled. Those patients who required a carinal plus lobar resection also had increased anastomotic problems. Almost certainly, these complications were related to excessive tension on the anastomosis. The postoperative mortality in this review of 135 patients was over 12%.

      Mitchell JD, Mathisen DJ, Wright CD: Clinical experience with carinal resection. Thorac Cardiovasc Surg 1998 (in press)

      References

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        • Koroleva N
        Surgery of the trachea.
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        J Thorac Cardiovasc Surg. 1984; 88: 511
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        • Milloy FJ
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      1. Mitchell JD, Mathisen DJ, Wright CD: Clinical experience with carinal resection. Thorac Cardiovasc Surg 1998 (in press)