carinal pneumonectomy cameron wright, md thoracic surgery mgh 2012 focus on thoracic surgery: lung...
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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