INDICATIONS/CONTRAINDICATIONS

Right carinal sleeve pneumonectomy (RCSP) is indicated for nonsmall cell lung cancer, low-grade malignant or benign airway tumors and, rarely, strictures of the airway. The first report of intentional carinal pneumonectomy for nonsmall cell lung cancer was by Gibbon in 1959. The first use of a transsternal approach to the carina was described by Abruzzini in 1961, for the management of a tuberculosis-related bronchopleural fistula. This transsternal approach to the carina was employed for the management of carinal neoplasms by subsequent pioneers in airway surgery including Grillo and Pearson.

The primary advantage of the transsternal approach include complete exposure of the superior and middle mediastinum for maximal mobilization of the trachea and left mainstem bronchus, the ability to gain maximal central control of the right pulmonary artery (PA), and the ability to easily perform concordant procedures such as lymph node dissection, superior vena cava (SVC) resection and reconstruction, and omental flap transposition. Disadvantages of the transsternal approach are related to the somewhat difficult exposure of the posterior mediastinum and posterior right pleural space if posterior hilar pathology or extensive intrapleural adhesions are encountered. These findings may require the addition of a right anterior thoracotomy to the median sternotomy.

Sleeve pneumonectomy is a technically challenging and potentially highly morbid procedure, although the overall rates of morbidity and mortality have improved in the last decade. Perioperative morbidity and mortality are significantly greater for right sleeve pneumonectomy as compared to left sleeve pneumonectomy or other forms of carinal resection and reconstruction. The additive risk of right sleeve pneumonectomy must be balanced against the potential favorable therapeutic outcome, such as cure of the underlying neoplasm or correction of the physiologic impairment induced by the airway stricture. Thus, RCSP should not be used in patients with significant cardiopulmonary dysfunction, a significant risk of systemic disease despite surgery (e.g., stage IIIA nonsmall cell lung cancer) or systemic morbidities, which may interfere with postoperative recovery, such as chronic steroid use. Finally, even with the mobilization afforded by a transsternal approach, if more than 4 cm of distal trachea or more than 1.5 cm of left main bronchus would need to be resected (in an adult patient), right sleeve pneumonectomy should not be performed because of the increased risk of anastomotic complications, morbidity, and mortality.

PREOPERATIVE PLANNING

All patients who are potential candidates for RCSP should undergo a complete preoperative physiologic evaluation, with particular attention to their pulmonary and cardiac function. Complete pulmonary function tests including spirometry lung volumes and diffusion capacity are mandatory. Quantitative ventilation–perfusion (V/Q) scanning, in conjunction with spirometry, is frequently useful given the obstructive nature of the lesions for which right carinal pneumonectomy would be performed. Diffusion capacity should be quantified for alveolar ventilation. A predicted postoperative FEV1 that is less than 30% of the predicted value based on the patient’s body surface area is a contraindication to surgery. Cardiac evaluation should include an echocardiogram to assess right ventricular function and estimate pulmonary arterial pressures as well as to gauge left heart function. An elevated pulmonary arterial pressure at rest is also a contraindication to surgery. A low threshold for cardiac stress testing is indicated for patients with risk factors for coronary artery disease.

Preoperative imaging should include a chest radiograph and a chest CT scan including visualization of the upper abdomen. In patients with nonsmall cell lung cancer, particular attention needs to be given to accurate staging of the tumor and the evaluation of distant metastases. This would mandate the additional use of positron emission tomography (PET) scanning and brain MRI imaging. Histologic confirmation of distant metastatic disease should be performed based on the results of these imaging studies and would preclude RCSP.

Bronchoscopy is an essential part of the preoperative evaluation. Rigid bronchoscopy allows optimal assessment of the extent of airway disease and provides the most accurate measurements of the extent of airway involvement. The assessment of resectability and planning for surgery is based on the accuracy of these measurements. Rigid bronchoscopy also allows for debulking of central tumors and potential relief of obstructive pneumonitis to optimize the patient’s preoperative status. If the possibility for mediastinal nodal disease has been identified on preoperative imaging, invasive mediastinal staging can be performed to confirm or refute the presence of mediastinal nodal disease. With the transsternal approach, preoperative mediastinoscopy does not typically compromise the ability to subsequently mobilize the trachea. However, the presence of mediastinal nodal metastases in the setting of nonsmall cell lung cancer should be considered a relative contraindication to RCSP.

SURGERY

Anesthetic Technique

Optimally, anesthesia for RCSP should allow for extubation at the end of the procedure. This requires preoperative planning and close intraoperative cooperation between the anesthesiologist and the surgeon. The goals of maintaining adequate anesthesia and gas exchange while allowing for surgical exposure are facilitated by the use of a transsternal approach. With a median sternotomy, persistent inflation of the right lung does not interfere with surgical exposure. In addition, early isolation of the right PA by this approach allows for early assessment of changes in PA pressure with trial clamping and optimization of gas exchange by eliminating the effects of V/Q mismatch in the right lung. An extralong, flexible, armored single-lumen endotracheal tube is used. This is typically placed in the trachea at the beginning of the procedure and then advanced into the left mainstem bronchus during exploration of the right pleural space. As the surgical resection proceeds, the tube can be withdrawn into the proximal trachea. After transection of the airway the patient can be ventilated across the operative field by intubation of the left mainstem bronchus. After placement of the posterior anastomotic sutures the proximal endotracheal tube can be advanced into the distal left mainstem bronchus with subsequent standard ventilation during completion of the anastomosis. Alternative techniques, such as high-frequency jet ventilation, independent lung ventilation, and extracorporeal membrane oxygenation (ECMO) are less likely to be required with a transsternal approach as compared to a right thoracotomy, but nonetheless are techniques with which both the surgeon and anesthesiologist should be familiar.

Positioning

The patient should be positioned supine with the neck extended and ideally both arms abducted. The area from the chin to the infraumbilical abdomen should be sterilely prepared. The operative field should include both hemithoraces prepared to the posterior axillary line. This extensive exposure is needed should an additional anterolateral thoracotomy be needed for dissection within the right pleural space. Rarely, a left hilar release is required for tension reduction, which may require a left anterior thoracotomy or can also be performed by an interpericardial approach. The sternotomy incision can be extended superiorly as needed for control of the brachiocephalic veins in the case of concomitant SVC resection and reconstruction. While laryngeal release is not felt to contribute significantly to tension reduction at the level of the tracheal carina, the transsternal approach does allow this to be performed if the resection is extensive. Finally, the sternotomy incision can be extended into the upper abdomen for omental flap mobilization as needed.

Surgical Technique

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