Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung...

Carinal Pneumonectomy

Cameron Wright, MDThoracic Surgery

MGH2012 Focus on Thoracic Surgery:

Lung Cancer

Disclosures

None

Sleeve Pneumonectomy

• Can be performed on either side but right side much more common

• Typical case is a NSCLC involving the right tracheobronchial angle

• Careful bronchoscopy by the surgeon crucial to delineate the extent of endobronchial disease

• 4 cm of trachea is the most that can be resected in the average case

Squamous Cell RMB

Adenocarcinoma RMB and Trachea

Submucosal Spread in RMB

Adenocarcinoma RMB with Subcarinal Nodal Invasion

Evaluation and Treatment

• Chest CT with IV contrast

• Metastatic survey (CT/PET for nodes, distant disease)

• Consider EBUS-FNA as preferred technique to stage the mediastinum

• Delay mediastinoscopy to day of resection so as to not limit tracheal mobility

• Ensure POP-FEV1 is adequate (Quantitative V/Q to accurately predict)

• Use CT/RT induction with particular caution-would favor induction chemotherapy alone if needed

Technique of Right Sleeve Pneumonectomy

• Bronchoscopy to ensure enough LMB and trachea are present for reconstruction

• Mediastinoscopy to sample nodes and free up anterior trachea (blood supply is lateral)

• Use long wire reinforced ETT (not DL ETT) to intubate LMB for thoracotomy

• Thoracotomy in 4th interspace, or median sternotomy

Technique of Sleeve Pneumonectomy

• Explore chest, confirm resectability

• Decide about SVC involvement

• Measure extent of tracheal involvement

• Divide vessels first

• Bring sterile ETT and airway circuit onto field (rarely need jet ventilation)

Technique of Sleeve Pneumonectomy

• Encircle trachea and LMB at proposed division sites (avoid L RLN!)

• Free up anterior LMB to enhance mobility

• Divide LMB after pulling back indwelling ETT

• Ventilate LMB from the field ETT

• Divide trachea and check margins

Technique of Anastomosis

• Place 2-0 Vicryl stay sutures 2 rings deep at 3 and 9 o’clock around 1 ring with knot outside

• Place circumferential 4-0 Vicryl sutures about 4 mm deep and 4 mm apart while adjusting for size discrepancy

Anastomotic Sutures

Technique of Sleeve Pneumonectomy

• Flex chin and tie stay sutures first (left wall will have least tension)

• Tie 4-0 sutures next-cartilage first, then membraneous wall

• Check for airleaks

• Wrap anastomosis with fat pad or other tissue buttress

• Extubate patient at end of case

Right Sleeve Pneumonectomy

Left Sleeve Pneumonectomy

Left Sleeve Pneumonectomy-Use of Tracheal and Aortic Sling

Sternotomy Exposure

Results of Sleeve Pneunonectomy

• Operative mortality usually 7-10% (was 25%)

• Post-pneumonectomy ARDS most common cause of early mortality

• Anastomotic complications uncommon but life-threatening

• Five year survival 20 to 40%

• Prognostic factors: nodal status, FEV1

Results of Sleeve Pneumonectomy

Author # Cases Mortality 5Y Survival

Mitchell

1999

35 10% 42%

Roviaro

2000

49 8% 25%

Mezzetti

2002

27 7% 20%

Porhanov

2002

166 16% 25%

7% if N2

Jiang

2009

11 10% 27%

7% if N2

Survival According to Nodal Status at the MGH

Tracheal Closure of Jack-A Way to Resect Up To The Carina

Sleeve Pneunonectomy-Conclusion

• Rare subset of pulmonary resections

• Avoid N2 disease and induction chemoradiotherapy

• Avoid lengthy resections of trachea

• Mobilize airway to reduce tension

• Careful anastomotic technique

• Wrap anastomosis