INDICATIONS/CONTRAINDICATIONS

Indications

The most common resection of the carina involves the entire right lung and carina because of the frequency of bronchogenic carcinoma relative to other primary tracheal neoplasms. Right carinal pneumonectomy should be considered in patients who harbor nonsmall cell lung cancer, usually originating from the right upper lobe orifice and extending to the lateral aspect of the lower trachea (Fig. 44.1). The neoplasm should not extend beyond 4 cm from the distal trachea as documented by computed tomography (CT) imaging and bronchoscopy. Primary airway tumors such as squamous cell carcinoma or adenoid cystic carcinoma may also be considered provided resection is feasible. Positive microscopic resection margins may be acceptable with adenoid cystic carcinoma since adjuvant radiation improves long-term results. The alternative indication for right carinal sleeve is a positive bronchial margin after standard pneumonectomy.

Contraindications

Absolute contraindications to right carinal pneumonectomy include insufficient pulmonary reserve, impaired cardiac function including pulmonary hypertension, and airway involvement in excess of 4 cm. Great caution should be applied in patients in whom extensive airway resection is undertaken where the trachea is to be anastomosed to the left main bronchus. The incidence of anastomotic problems significantly increases when the extent of resection is 4 cm or greater. The left main bronchus is tethered in its cephalad migration by the aortic arch and is therefore relatively immobile. With extensive resections, left-sided anastomoses are subject to excessive tension and greater potential for devascularization of the region. A history of prior mediastinal irradiation, although no longer an absolute contraindication to surgery, requires special operative considerations, including the use of an omental flap to wrap the anastomosis. Finally, in patients with NSCLC, the presence of N2 (stage IIIA) or N3 (stage IIIB) disease (American Joint Committee on Cancer 7th edition) should serve as a relative contraindication to surgery given the poor long-term outcome demonstrated in these cases. The need for superior vena cava (SVC) resection in these cases does not necessarily preclude surgery.

PREOPERATIVE PLANNING

All patients in whom carinal sleeve pneumonectomy is being considered should undergo CT chest and PET to permit proper evaluation of lung parenchyma, mediastinum, and to identify nodal or extraregional disease. Invasive mediastinal staging (endobronchial ultrasound [EBUS] or mediastinoscopy) should be performed in these patients to rule out pathologic N2/N3 disease despite a negative PET or anatomically normal lymph nodes.

This author favors the use of mediastinoscopy at the time of formal resection and reserves EBUS for diagnostic purposes in the preoperative period. Mediastinoscopy followed by a delayed carinal resection can be associated with scar tissue along the pretracheal plane that may compromise tracheal mobility at the time of resection. The degree of extraluminal tumor invasion can also be ascertained at the time of mediastinoscopy. The bronchoscopic appearance of the tumor will dictate candidacy for sleeve pneumonectomy. The degree of invasion should always be documented by biopsies to understand the limits of resection. If the tumor extends beyond 4 cm of the lower trachea or beyond 1.5 cm of the left mainstem bronchus, tension on the airway anastomosis can be expected. All patients need routine pulmonary function tests to determine adequate pulmonary reserve. A stair climb test of 2 to 3 flights (12 to 18 m) can also be used as a crude test for assessment of pulmonary and cardiac reserve. If the patient has borderline pulmonary function, one should consider a quantitative ventilation and perfusion scan and cardiopulmonary exercise testing (CPET) to measure oxygen consumption (VO₂). Echocardiogram should also be routinely obtained to assess left and right ventricular function and to rule out significant valvular heart disease or pulmonary hypertension.

SURGERY

Anesthestic Technique

Every effort is made to design an anesthetic plan that permits extubation at the end of the procedure.

This technique should include placement of an epidural catheter preoperatively and the use of total intravenous anesthesia. This strategy relies on short-acting hypnotics, narcotics, and paralytic agents to permit adequate respiratory drive upon completion of the surgery. Because of their size and inflexibility, double-lumen endotracheal tubes often present difficulties in these procedures. As such, an extra long, flexible, armored, single-lumen endotracheal tube is used, which can be advanced into the left mainstem bronchus to provide one-lung ventilation as indicated. As surgical resection proceeds, the left mainstem bronchus is intubated across the operative field. A plan of intermittent ventilation is then used to allow precise placement of anastomotic sutures. As the end-to-end tracheobronchial anastomosis is reapproximated and the sutures are tied, the original endotracheal tube is advanced into the bronchus, allowing uninterrupted ventilation. Alternative ventilatory techniques, such as high-frequency (jet) ventilation and independent lung ventilation, are options about which both surgeon and anesthesiologist should be knowledgeable. Cardiopulmonary bypass, although feasible, should be discouraged during carinal resection and reconstruction because of the incremental morbidity associated with the procedure and the potential for tumor dissemination. Autologous blood recovery systems “Cell Saver” should be avoided in this context.

Positioning

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