Ann Thorac Surg 2007;84:216-220
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Surgical Results of Carinal Reconstruction: An Alterative Technique for Tumors Involving the Tracheal Carina
Kazumichi Yamamoto, MDa,*,
Yoshihiro Miyamoto, MDa,
Akihiro Ohsumi, MDb,
Naoko Imanishi, MDa,
Fumitsugu Kojima, MDa
a Department of Thoracic Surgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
b Department of Thoracic Surgery, Tenri Hospital, Tenri, Japan
Accepted for publication January 22, 2007.
* Address correspondence to Dr Yamamoto, Department of Thoracic Surgery, National Hospital Organization, Himeji Medical Center, Honmachi 68, Himeji, Hyogo, 670-8520, Japan (Email: granada{at}d3.dion.ne.jp).
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Abstract
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Background: We developed a novel technique for carinal reconstruction, one of the most challenging procedures and associated with high morbidity and mortality. Here, we review the results of a surgical study utilizing our technique.
Methods: Between 1989 and 1999, we performed carinal resection and reconstruction on 14 patients using a technique we developed originally. With this method, two thirds of the circumference of the trachea and the left main bronchus are anastomosed first. After one ring of cartilage is trimmed from the remaining one third of the circumference, the right bronchus is anastomosed end to side to this trimmed site.
Results: Carinal resection plus right upper lobectomy was performed in 12 patients and carinal resection plus right upper-middle bilobectomy was performed in 2 patients. Superior vena cava resection was combined in 4 patients. One patient (7.1%) died postoperatively of dehiscence and bronchoarterial fistula. Major anastomotic complications occurred in 4 patients (dehiscence in 1 and stenosis in 3 [28.5%]). One of three stenoses resolved with ballooning, and this patient survived 5 years; however, the remaining 2 patients died of respiratory problems caused by stenosis. Early and late anastomosis-related death occurred in 3 patients (21%). Overall survival was 57.1% at 2 years and 28.5% at 5 years. Survival was better in patients with N0 disease (n = 9) than those with N2 disease (n = 5; 44.4% versus 0% at 5 years, respectively).
Conclusions: Our technique for carinal reconstruction can be an alternative to other methods if patients are carefully selected. Anastomotic complications are related to high mortality. Positive N2 disease should be considered a potential contraindication to this technique.
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Introduction
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Despite an improvement in surgical and anesthetic technique since an initial report by Abbott [1] in 1950, surgical resection of bronchogenic carcinoma involving tracheal carina is still a challenge for thoracic surgeons because of technical difficulties and perioperative complications. Some authors have reported using techniques for this procedure with acceptable morbidity and mortality [2–7]; however, most of these cases underwent tracheal sleeve pneumonectomy, which utilizes the unproven method of "neocarina" reconstruction. Barclay’s method and the "double-barrel" method are two major techniques for carinal reconstruction; however, these methods are technically demanding and associated with relatively high morbidity and mortality compared with tracheal sleeve pneumonectomy.
We developed a novel technique for reconstruction of tracheal carina in 1989 and applied this technique to several patients who required carinal resection and reconstruction. The purpose of this article is to review the results of a surgical study using this technique, focusing on surgical technique and postoperative complication.
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Material and Methods
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This retrospective study is approved by our Institutional Ethics Committee. Individual consent of patients is waved because individual patients are not identified. All patients who underwent resection and reconstruction of the carina for bronchogenic carcinoma at our hospital between 1989 and 1999 were included in this study. Information and follow-up data were obtained from hospital charts and referring physicians.
Preoperative Evaluation
Preoperative evaluation consists of chest radiography, chest computed tomography (CT), pulmonary function testing, and electrocardiography. Computed tomography scanning or echosonography of the abdomen, CT or magnetic resonance imaging of the brain, and bone scintigraphy are routinely performed to exclude distant metastases. Bronchoscopy is always performed preoperatively to assess resectability and the extent of tumor involvement. Mediastinoscopy was performed in no cases in this series.
Anesthesia
An epidural catheter is placed before initiation of the procedure to provide postoperative analgesia. A standard double-lumen tube is used until the trachea and bronchus are secured. After resection of the trachea and bronchus, the left main bronchus is intubated across the operative field with a spiral tube, and the double-lumen tube is withdrawn into the proximal trachea. After two thirds of the anastomosis between the trachea and the left main bronchus has been completed, the double-lumen tube is advanced into the left main bronchus. At the end of all anastomoses, the double-lumen tube is withdrawn until the tracheal side of the anastomosis.
Surgical Technique
Our technique of carinal reconstruction is described in detail elsewhere [8–10]. The technical differences between our method and other methods are presented herein (Fig 1). The chest is entered through a right posterolateral thoracotomy through the fifth intercostal space. The fifth intercostal muscle is routinely raised as a pedicled flap at the time of thoracotomy to cover the anastomosis. Once the chest is entered, lung resection is performed first. We usually perform systematic lymph node dissection before the trachea and bronchus are secured, partly because this facilitates movement of the trachea and bronchus and also to avoid further dissection after the anastomosis is completed.
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Fig 1. A novel carinal reconstruction technique. (1) After the tracheal carina is resected, two thirds of the circumference of the trachea and the left main bronchus are anastomosed. (2) The remaining one third of the circumference is trimmed to create an oval-shape orifice to which the right bronchus is anastomosed. (3) The right bronchus is anastomosed to this trimmed orifice in end-to-side fashion.
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All efforts should be made to reduce tension at the anastomosis because the outcome depends on the tension at this site. A pretracheal plane is developed to the inferior border of the cricoid cartilage. The same maneuver is applied to the left main bronchus. The membranous portion is not dissected, to avoid interrupting the blood supply. An inferior hilar release is also performed routinely. This is achieved by creating a U-shaped incision in the pericardium beneath the hilum after division of the pulmonary ligament.
Once the lung resection is complete, anastomosis between the trachea and left main bronchus begins. First, two thirds of the circumference receives end-to-end anastomosis by simple interrupted sutures (3-0 Vicryl; Ethicon, Somerville, New Jersey). Each suture is placed through all layers of the mucosa and tied outside the airway. From the remaining one third of circumference, one ring of cartilage is additionally trimmed to create the oval hole that is anastomosed with the right bronchus. This oval hole should be a little larger than the end of the right bronchus, even if some of the tied sutures are cut. The membranous portion of the trachea should be involved in this trimming to maintain rigidity. Then, the right bronchus is anastomosed end-to-side to this trimmed site using the same method. Since the first anastomosis has a slight angle, this end-to-side anastomosis is slightly easier to perform than a normal end-to-side one.
After confirmation of air tightness at the anastomostic site, a pedicled intercostal muscle flap is routinely used to cover the anastomosis.
Statistical Analysis
Follow-up was completed up to February 2006 or to the date of death. The survival curve, including postoperative death, was calculated by the Kaplan-Meier method.
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Results
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Patients’ detailed characteristics and outcomes are provided in Tables 1 and 2.
Thirteen men and 1 woman with a mean age of 61 ± 2 years (range, 45 to 73) were included in the study. Eleven patients had a squamous cell carcinoma, whereas the remaining 3 patients had an adenocarcinoma. Five patients received preoperative induction chemotherapy. Carinal resection plus right upper lobectomy was performed in 12 patients and carinal resection plus right upper-middle bilobectomy was performed in 2. Superior vena cava resection was combined in 4 patients. Partial resection of the esophageal wall was performed in 1, and sleeve resection of the pulmonary artery was performed in 1. The length of resection between the trachea and the left main bronchus was 3.6 ± 1.3 rings (range, 2 to 6). Complete resection was achieved in all 14 patients. Pathologic nodal status was classified as N0 in 9 and N2 in 5 patients.
Postoperative death occurred in 1 patient (7.1%). This patient died of partial dehiscence of anastomosis and bronchoarterial fistula on the seventh postoperative day. The tracheobronchial wall of this patient was very fragile, and it was hard to perform anastomosis because of cutting of the wall during the surgical procedure.
Major complications occurred in 7 patients (50%). Of these, 4 patients presented with anastomotic complications: 1 dehiscence and 3 anastomotic stenoses (28.5%; Table 1). One of these 3 anastomotic stenosis patients (case 7) continued to smoke during the postoperative period and anastomotic healing was poor. Finally, the anastomotic site where the right bronchus was anastomosed was strictured, and this patient died of respiratory failure caused by pneumothorax. Another patient (case 12) had anastomotic stenosis where the right bronchus was anastomosed 3 months after the operation. This was resolved by a single attempt of ballooning without further recurrence of stenosis; this patient survived more than 5 years. The third patient (case 13) experienced stenosis at the entire circumference of the anastomotic site 6 months after surgery. Several interventions were performed, including ballooning, steroid injections and prosthetic stent insertion; however, this anastomotic site was finally strictured. This patient died of obstructive pneumonia caused by stenosis without tumor recurrence. Then a total of 3 patients died from anastomostic complication postoperatively or later (21%). All 3 patients with anastomotic stenosis had received induction chemotherapy. Three of 5 patients who received induction chemotherapy experienced anastomostic stenosis, whereas none of 7 patients who did not receive induction chemotherapy had anastomostic stenosis.
Follow-up was complete on all but 1 patient who was lost from follow-up 5 years after the operation without tumor recurrence, with a mean follow-up time of 36 months. The overall actuarial survival was 57.1% at 2 years and 28.5% at 5 years (Fig 2). Analysis of survival with respect to nodal status is shown in Figure 3. Patients without nodal involvement (N0) had a 2-year and 5-year survival of 77.7% and 44.4%, respectively, compared with 20% and 0%, for patients with mediastinal nodal involvement (N2). There were no patients with N1 disease. Statistical comparisons between survival curves were not performed because of the small number of cases, but there was a better trend of survival for patients without nodal involvement (N0).
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Fig 2. Overall survival curve. The actuarial survival was 57.1% at 2 years and 28.5% at 5 years. (Cum = cumulative.)
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Fig 3. Survival curve grouped by nodal status. More positive trends are observed among patients without nodal involvement (N0 disease: n = 9, 5-year survival 44.4%) compared with patients with nodal involvement (N2 disease: n = 5, 5-year survival 0%). (Cum = cumulative.)
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Comment
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Surgical resection of bronchogenic carcinoma involving tracheal carina is still a challenge for thoracic surgeons because of technical difficulties and perioperative complications. Several authors have reported on this topic since an initial report by Abbott [1] in 1950, but most patients with this condition underwent tracheal sleeve pneumonectomy.
Carinal reconstruction to create "neocarina" was first reported by Barclay and associates [11] in 1957. At present, Barclay’s method and the double-barrel method [12] are the principal techniques used for carinal reconstruction. However, there has been no report documenting a large number of cases with surgical outcomes, and morbidity and mortality resulting from these methods are still unclear.
In the double-barrel method, the side-to-side anastomosis of the right and left bronchi is anastomosed end to end with the trachea. This anastomosis causes high tension, especially at the side-to-side anastomosis. In addition, adjusting the difference of the caliber between the trachea and the anastomosed bronchi is technically difficult. This method, therefore, is used mainly for the resection of a small segment of the airway and especially for simple resection of carina without lung resection, which does not cause high anastomostic tension.
In Barclay’s method, the bronchus is anastomosed end to side with the lateral wall of the trachea or the bronchus after end-to-end anastomosis between the trachea and the contralateral bronchus. This method allows one to reduce tension at the anastomosis, and therefore is applicable for resection of longer segments of airway. This method, however, may cause impairment of blood flow at the lateral wall of the trachea or the bronchus and end-to-side anastomosis is technically demanding. Also, anastomosis on the trachea causes high tension if concomitant lung resection is performed because it is necessary to pull up the remaining bronchus until the level of the trachea. To avoid this tension, the remaining bronchus is sometimes anastomosed to the left main bronchus. This anastomosis, however, technically highly demanding, and places more risk on the left lung.
We developed a new method of carinal reconstruction and applied this method to 14 patients who required resection of the tracheal carina. In this method, the right bronchus is anastomosed end to side at the trimmed hole made at the anastomosis between the trachea and the left main bronchus. In case of right tracheal sleeve pneumonectomy, the right lateral aspect of the anastomosis is the site where anastomotic tension is highest. In this method, this site does not need to be anastomosed, and it is possible to avoid creating a new hole on the lateral wall of the trachea or the bronchus, which interrupts blood flow to the anastomosis. Because this site has a slight angle, it is technically easier than simple end-to side anastomosis. And also, because the remaining bronchus is anastomosed just on the anastomosis between the trachea and the left main bronchus, this anastomosis causes less tension compared with Barclay’s method and does not damage the left main bronchus.
Postoperative death occurred in 1 patient (7.1%). This result is comparable with previous reports [2–7]. This patient died of partial dehiscence followed by bronchoarterial fistula on the seventh postoperative day. Because the bronchial wall of this patient was very fragile and it was difficult to anastomose the bronchus, we now believe that tracheal sleeve pneumonectomy should have been performed to reduce the number of anastomoses to avoid possible postoperative bronchial fistula. Late anastomostic stenosis occurred in 3 patients between 3 and 6 months after surgery. One of these patients recovered after a single attempt at ballooning, but the remaining 2 patients died of respiratory problems. In total, 3 of these 4 patients with anastomostic complications died postoperatively or later (21%). This anastomosis-related mortality is not low, although carinal reconstruction with concomitant lobectomy or bilobectomy, the most complex type of carinal reconstruction, is performed in all cases in this study. Not many previous reports deal with this type of carinal reconstruction because tracheal sleeve pneumonectomy is the routine procedure for these conditions, and there are few report focusing on mortality and morbidity of carinal resection with concomitant lung resection. Mitchell and coworkers [2] reported that this type of procedure was performed in 14 patients, and 1 postoperative death and 5 anastomostic complications were observed. In this sense, our technique is comparable with this report.
In addition, 3 of 5 patients who received induction chemotherapy experienced anastomotic stenosis, whereas all 9 patients who were not treated with induction chemotherapy did not experience anastomotic stenosis. Marc de Perrot and coworkers [7] pointed out that there was an trend for higher mortality and morbidity in patients with induction chemotherapy. Anastomostic stenosis is highly related to excessive anastomostic tension, but our results may imply that induction chemotherapy also can have a negative effect on anastomosis and, based on this finding, carinal reconstruction might be avoided in patients after induction chemotherapy just in case. Our current indication for carinal resection after induction chemotherapy is tracheal sleeve pneumonectomy, a simpler procedure for this condition.
The overall actuarial survivals of 57.1% at 2 years and 28.5% at 5 years are comparable with previous reports [2–7]. More positive trends are observed in patients without nodal involvement (N0 disease: n = 9, 5-year survival of 44.4%) compared with patients with nodal involvement (N2 disease: n = 5, 5-year survival of 0%). This outcome has been observed by other authors [2–7], and thus N2 disease may be a potential contraindication to surgical resection and reconstruction of tracheal carina. Mediastinoscopy was not performed in this series; however, based on these findings, preoperative mediastinoscopy should be done routinely to exclude N2 disease preoperatively. Our current indication for preoperative N2 disease is tracheal sleeve pneumonectomy after induction chemotherapy, but only when downstaging is achieved.
In conclusion, our technique for carinal reconstruction can be an alternative to other methods for suitable patients. Special attention should be paid to patient selection, especially for those who require induction chemotherapy, including patients with N2 disease.
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Acknowledgments
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This study is sponsored in part by the Fund of Cancer Research from the Hyogo Prefecture Health Promotion Association.
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References
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Abstract
Introduction
