Master Techniques in Surgery: Thoracic Surgery: Lung Resections, Bronchoplasty, 1st Ed.

47. Carinal Resection: Pneumonectomy Stump Recurrence

Eric H. Twerdahl and Douglas J. Mathisen

 INDICATIONS

Resection and reconstruction of the carina remains challenging and one of the least common procedures performed in tracheobronchial surgery. In this chapter, we address the single entity: Resection and reconstruction for bronchial stump recurrence following pneumonectomy (Fig. 47.1). The principal indications for carinal resection in such an instance (1): Unanticipated tumor recurrence involving the bronchial stump, occurring months, years, or even decades from the time of pneumonectomy, and (2) a known positive margin resulting from an operation in which a more complete oncologic resection was not done due to unfamiliarity with the procedure of carinal resection, and (2) planned staged procedure with left pneumonectomy and known positive margins. It is helpful to place a pedicled intercostal muscle over the end of the stump to separate from the nearby pulmonary artery stump when approaching from the right chest (3). Carinal resection after pneumonectomy has also been reported for persistent bronchopleural fistula.

Mitchell et al. (2) reported 134 primary carinal resections from 1962 through 1996 and Porhanov et al. (3) reported 231 carinal resections from 1979 to mid-2001, with only 14 patients, or 4%, were noted to have undergone carinal resection for tumor recurrence following pneumonectomy. Despite the uncommon nature of this problem, an excellent outcome can be achieved in the carefully selected patient managed in accordance with the principles outlined below. Indeed, Grillo reported the case of a young woman, who had undergone carinal resection and reconstruction for recurrent carcinoid 14 years following left pneumonectomy and remained disease-free three decades later (4).

 CONTRAINDICATIONS

This operation should only be undertaken by an experienced team of surgeons, anesthesiologist and intensivists. Especially close cooperation is required between surgeon and anesthesiologist. Operating on the side of the only remaining lung and performing carinal resection may require a variety of techniques to manage the airway and maintain oxygenation. This could include intermittent cross-field ventilation, a high frequency ventilation, cardiopulmonary bypass or ECMO. A careful plan must be established with back-up available.

Figure 47.1 Tumor recurrence is depicted in the stump of the bronchus following pneumonectomy.

Careful evaluation of medical comorbidities, metastatic disease, and lung function must be done. Prior mediastinal radiation, high-dose steroids, or previous mediastinoscopy limiting mobility may be relative contraindications. Extensive involvement of the trachea or mainstem bronchi may preclude safe resection and reconstruction. Extensive extraluminal disease and esophageal or left recurrent nerve involvement are likely contraindications to resection.

 PREOPERATIVE PLANNING

Careful preoperative planning is essential. Contrast computerized axial tomography with three-dimensional reconstruction has become the preferred radiologic test to evaluate the extent of disease. Barium swallow, PET scans, brain imaging, and magnetic resonance imaging will add to the evaluation in certain instances. Careful endoscopic evaluation by the operating surgeon is essential. Rigid bronchoscopy provides superior optics and precise measurements of the involved airway. The amount of airway that can be resected varies by body habitus, prior operations, radiation, and the side of pneumonectomy. A prior left pneumonectomy allows for greater mobility of the trachea and right mainstem bronchus. A prior right pneumonectomy will have less airway mobility because of scarring and therefore less than can be resected and reconstructed. There is no real rule of thumb but if the distance of trachea and mainstem involvement exceeds 3 to 4 cm, resection is not advisable. Any concern about esophageal involvement should prompt esophagoscopy and endoscopic ultrasound to evaluate involvement.

 SURGERY

Anesthesia

The precise anesthetic technique should be left to the discretion of surgeon and anesthesiologist, working in concert, but the general principles are: Epidural analgesia, invasive blood pressure monitoring, mainstem bronchial intubation (initial endobronchial intubation with an extra long metal reinforced endotracheal tube, augmented by cross-field intubation, if necessary, once the airway is entered), and early extubation in the operating room both to assess the quality of the reconstruction and to avoid the complications attributable to prolonged mechanical ventilation. We do not advocate for the routine use of cardiopulmonary bypass or ECMO in carinal resection and reconstruction, though carinal resection following pneumonectomy is one scenario in which it is potentially of value (5,6). The literature contains at least two case reports, one from Moreno et al. (7) and the other from Lei et al., (8) describing carinal resection for bronchial stump recurrence performed with the assistance of venoarterial ECMO. In each case, the outcome was reported as excellent.

Approach

The first step in the operation is mediastinoscopy, even if performed previously, to increase tracheal mobility. Dissection at the carinal level should be attempted but may be limited by prior surgery. The patient is then placed in the left lateral decubitus position for approach via high right posterolateral thoracotomy. We prefer a right-sided approach for resection of either a right or left bronchial stump lesion, since both resection of the carina and the subsequent tracheobronchial reconstruction are more feasible from that side. (In the absence of cardiopulmonary bypass, treatment of a left bronchial stump necessitates gentle retraction of the right lung—a maneuver facilitated by hand ventilation or high-frequency jet ventilation.) Alternatively, median sternotomy affords very good exposure and the ability to manage the pulmonary artery. Cardiopulmonary bypass should be available if problems with the pulmonary artery are anticipated. Porhanov et al. had three cases of carinal resection for bronchial stump recurrence successfully addressed via median sternotomy.

Dissection

The dissection is carried down to the level of the carina and mainstem bronchi. Penrose drains are placed around the trachea at the expected level of division and the uninvolved bronchus just below its origin. Meticulous dissection is required to avoid injury to the pulmonary artery. Care must be taken to avoid injury to the aortic arch and/or left recurrent laryngeal nerve as well. Further mobilization of the airway is achieved with intrapericardial hilar release—either partial or complete—and neck flexion, respectively (Fig. 47.2). The former is typically performed before the airway is divided, while the latter comes at the time of the tracheobronchial anastomosis and is maintained beyond the end of the procedure with the assistance of a heavy stitch between the chin and the anterior chest wall to maintain moderate flexion of the neck.

Right Stump Resection and Reconstruction

For the resection of a right bronchial stump, the patient is selectively intubated via the left mainstem bronchus. Following the dissection and mobilization noted above, the left mainstem bronchus is divided first, so that single lung ventilation can continue. The trachea is then divided, the specimen removed, and the end-to-end tracheobronchial anastomosis performed in the manner described by Grillo (Fig. 47.3). Traction sutures of 2-0 Vicryl are placed in the midlateral position proximally and distally. These are useful for approximation of the airway to assess tension. The traction sutures are approximated and tied after placement of all anastomotic sutures. These are left in place. The anastomotic sutures are 4-0 Vicryl. They are placed with the knots ending up outside. They are carefully spaced to accommodate any size discrepancy in the two ends of the airway. The first stitch is placed posteriorly (6 o’clock position) 3 to 4 mm in depth and 3 to 4 mm from the next stitch. The sutures are clipped to the drapes in an orderly fashion. Each suture is placed “inside” the prior sutures so that when tied in reverse order of placement, subsequent sutures are not tied down. It is important to note that the limitation of anastomotic tension is more challenging in this instance than in that of anastomosis involving the right mainstem bronchus, as the left mainstem bronchus is less mobile than the right on account of the aortic arch. Once completed, the anastomosis is covered with a pedicled tissue flap—typically pericardial fat pad, or pedicled intercostal muscle or omentum in high-risk cases.

Figure 47.2 Limited mobility (arrow) is attained by a “U” incision beneath the inferior pulmonary vein (B) for optimal mobilization (dotted line), the entire pericardium around the hilar vessels is incised (A).

Figure 47.3 A: 2-0 Vicryl traction sutures are placed proximally and distally in the midlateral position. B: Individual anastomotic sutures of 4-0 Vicryl are placed to allow knots on the outside. They are carefully spaced for any size discrepancy. These sutures are typically 3 to 4 mm apart and a depth of 3 to 4 mm.

Left Stump Resection and Reconstruction

For the resection of a left-sided lesion, the patient is selectively intubated via the right mainstem bronchus. As noted above, the favored approach is through the right hemithorax. Exposure is provided by gentle retraction of the ventilated right lung, facilitated by hand ventilation or high-frequency jet ventilation. Otherwise, the steps involved in resection and reconstruction are similar to those described for the management of a right-sided lesion.

 POSTOPERATIVE MANAGEMENT

Postoperative management following carinal resection and reconstruction begins in the operating room. Bronchoscopy is performed to assess the quality of the reconstruction and to monitor for laryngeal edema. If possible, the patient should be extubated while in the operating room, where he can be safely reintubated if necessary. Should early extubation prove impossible, however, owing to inappropriate mental status, poor respiratory mechanics, and/or inadequate gas exchange, the endotracheal tube should be positioned under bronchoscopic guidance so as to avoid contact with the anastomosis. Extubation should be achieved as soon as possible upon arrival to the ICU. In an analysis of 143 carinal resections performed over a 35-year period, Mitchell et al. found postoperative mechanical ventilation to be associated with mortality with an odds ratio of nearly 15.

In the ICU, epidural analgesia is continued for as long as possible but typically not beyond the fourth or fifth postoperative day. Respiratory secretions are managed with chest physiotherapy and periodic bronchoscopic suctioning. Prophylaxis against deep venous thrombosis—subcutaneous unfractionated heparin or low-molecular-weight heparin—is started as soon as the risk of postoperative bleeding is judged to be acceptably low and ambulation is encouraged as soon as the patient’s pain level will permit. It is best to inspect the anastomosis with bronchoscopy on or around the seventh postoperative day, after which discharge planning can commence. The chin stitch is divided on day 7.

 COMPLICATIONS

Close observation, assiduous physical examination, and attention to even the subtlest detail in the laboratory and radiographic studies are of essential importance in effective postoperative management. This is especially true for the patient who has undergone carinal resection following pneumonectomy, in whom even a small disturbance in anatomy or physiology can have a life-threatening consequence. A list of commonly encountered postoperative complications follows. The management of each has been addressed elsewhere in this book and will not be restated here (chapter on carinal resection).

 Atrial arrhythmia

 Pneumonia

 Empyema

 Pulmonary edema

 Acute respiratory distress syndrome (ARDS)

 Delayed intrathoracic hemorrhage (e.g., from the pulmonary artery stump)

 Pulmonary embolism

 Anastomotic problems (including necrosis, dehiscence, stenosis, and excessive granulation tissue formation)

 Bronchopleural fistula

 Vocal cord palsy

Lethal postoperative complications generally fall into two categories: Early and late. Early fatal complications are respiratory in nature: Pneumonia or ARDS. Careful intraoperative management of fluids and barotrauma are important in avoiding ARDS. Aggressive pulmonary toilet, pain control, and frequent bronchoscopy are important to avoid pneumonias. Delayed mortality is usually related to anastomotic complications. Patient selection, attention to technical detail, avoidance of anastomotic tension, and careful preservation of bronchial blood supply are all essential to avoiding anastomotic complications.

 RESULTS

On account of the rarity of the operation, the largest case series of carinal resection and reconstruction for bronchial stump recurrence following pneumonectomy is that published by Mitchell et al., in which the total number of patients is 11. In that cohort, there was one postoperative death, four instances of significant postoperative morbidity, and two anastomotic complications. Nevertheless, we believe it fair to say that one cannot draw any general conclusion on the basis of so small a sample, particularly a sample that accumulated over the course of three-and-a-half decades of advancement in anesthesia, operative technique, and critical care. Careful patient selection, vigorous preoperative planning, adherence to sound principles of anesthesia and surgery, and diligent postoperative management are essential and successful outcomes can be achieved.

Recommended References and Readings

1. Chan V, Shamji F, Sundaresan S. Carinal sleeve resection for persistent bronchopleural fistula after completion right pneumonectomy. Ann Thorac Surg. 2010;89:1266–1268.

2. Mitchell J, Mathisen D, Wright C, 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.

3. Porhanov V, Poliakov I, Selvaschuk A, et al. Indications and results of sleeve carinal resection. Eur J Cardiothorac Surg. 2002;22:685–694.

4. Grillo H ed. Surgery of the Trachea and Bronchi. Canada, ON: BC Decker; 2004.

5. Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anesth. 1999;46:439–455.

6. Peterffy A, Konstantinov I. Resection of distal tracheal and carinal tumours with the aid of cardiopulmonary bypass. Scand Cardiovasc J. 1998;32:109–112.

7. Moreno P, Lang G, Taghavi S, et al. Right-sided approach for management of left-main-bronchial stump problems. Eur J Cardiothorac Surg. 2011;40:926–930.

8. Lei J, Su K, Li X, et al. ECMO-assisted carinal resection and reconstruction after left pneumonectomy. J Cardiothorac Surg. 2010;5:89.



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