Tracheal Sleeve Pneumonectomy
Marc de Perrot
Tracheal sleeve pneumonectomy is an extended resection for tumors involving the tracheobronchial angle, carina or lower trachea, and lung. The most common indication is non small-cell lung carcinoma, but tracheal sleeve pneumonectomy can occasionally be required for other types of malignancies such as carcinoid tumor or adenoid cystic carcinoma. Over the past two decades, refinement in techniques of tracheal surgery and bronchial sleeve lobectomy has allowed tracheal sleeve pneumonectomy to become a safe procedure in experienced centers. Careful patient selection and detailed evaluation are important components to good surgical results.
In 1946, Belsey2 described a successful case of lateral wedge resection of the distal trachea and carina combined with the use of prosthetic material for reconstruction. In 1950, Abbott1 presented four patients undergoing right pneumonectomy associated with lateral resection of the tracheal wall and transverse closure above the right main bronchus. All four patients survived the operation but had problems with kinking and obstruction of the trachea that were related to excessive mediastinal shift, according to the authors. Chamberlain and colleagues,4 Gibbon,11 and Hardin and Fitzpatrick,13 in 1959, described successful resection of primary bronchogenic carcinoma involving the carina, and Grillo,12 in 1963, presented the first comprehensive approach to carinal resection and reconstruction. In 1966, Thompson and colleagues23 reported a left carinal pneumonectomy with anastomosis between the right main bronchus and the distal trachea using catgut sutures as well as a carinal resection after right pneumonectomy with anastomosis between the left lung and trachea.24 In 1966, Mathey and colleagues16 also presented their experience on tracheal sleeve pneumonectomy and suggested that circumferential carinal resection should be preferred to noncircumferential excision. Other significant reports of tracheal sleeve pneumonectomy included those from Eschapasse and colleagues,10 Perelman and colleagues,21 Jensik and colleagues,14 Deslauriers and colleagues,8 Dartevelle and colleagues5,6 and Tsuchiya and colleagues.25 Although the operative mortality was about 30% in early series, Dartevelle and colleagues in 19885 and Mathisen and Grillo in 199117 were the first to demonstrate that tracheal sleeve pneumonectomy could be performed with acceptable risk in large series of patients with bronchogenic carcinoma (Table 31-1).
Careful patient selection and detailed evaluation of the lesion are key components to good surgical results in tracheal sleeve pneumonectomy. All patients should be evaluated to ascertain that they can tolerate the operation and withstand the necessary removal of pulmonary parenchyma. The preoperative workup consists of chest radiography, chest computed tomography (CT), pulmonary function tests, arterial blood gas, ventilation/perfusion scan, electrocardiography, and echocardiography (Fig. 31-1). Stress thallium studies, maximum oxygen uptake, and exercise testing are used when indicated. The operation is an elective procedure and efforts should be made to prepare the patients for surgery with chest physiotherapy, deep breathing, and cessation of smoking. Airway obstruction, bronchospasm, and intercurrent pulmonary infection should be reversed. Steroids should be discontinued before surgery.
Flexible and/or rigid bronchoscopy is crucial to evaluate the overall length of the tumor, the adequacy of the remaining airway, and the feasibility of a tension-free anastomosis (Fig. 31-2). Besides routine investigation to rule out extrathoracic metastasis, routine mediastinoscopy should be performed at the time of surgery in patients presenting with bronchogenic carcinoma to exclude N2 or N3 disease.
Superior cavography and pulmonary angiography can be performed for carinal tumors arising from the anterior segment of the right upper lobe, because invasion of right upper lobe (mediastinal) artery usually indirectly reveals invasion of the posterior aspect of the superior vena cava (SVC) (Fig. 31-3). Transesophageal echography is occasionally performed to evaluate tumor extension to the posterior mediastinum, especially the esophagus or the left atrium.
Indications and Contraindications
In patients with bronchogenic carcinoma, carinal resection should be considered for tumors invading the first centimeter of the ipsilateral main bronchus, the lateral aspect of the lower trachea, the carina, or the contralateral main bronchus. This applies usually for right-sided tumor, since left-sided tumor rarely extends up to the carina without massively invading structures situated in the subaortic space. The safe limit of resection between the lower trachea and the left main bronchus is usually considered to be 4 cm. Upward mobilization of the left mainstem bronchus is limited because of the aortic arch and can result in excessive anastomotic tension.
Table 31-1 Results of Tracheal Sleeve Pneumonectomy in Large Selected Series
The long-term results of carinal resection for patients with bronchogenic carcinoma and N2 or N3 disease is poor; therefore the findings of positive mediastinal nodes at the time of mediastinoscopy is usually considered a contraindication to surgery7,20. Induction therapy may be offered for these patients, but this can increase the technical difficulty of the operation and may be associated with greater operative mortality and morbidity in patients undergoing tracheal sleeve pneumo- nectomy.