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Ann Thorac Surg 1998;66:1865-1866
© 1998 The Society of Thoracic Surgeons

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Correspondences

Cardiopulmonary bypass for tracheal tumor resection: revival of an old technique?

^a Department of Cardiothoracic Surgery, University Hospital, S-58185 Linköping, Sweden

To the Editor

It was highly stimulating to read the recent article of Refaely and Weissberg [1] as well as invited commentary of Perelman, one of the pioneers of tracheal surgery. The article is very timely and addresses the crucial issue of minimizing surgical trauma during resection of tracheal tumors. We agree that low-grade malignant tumors should be resected conservatively with preservation of lung parenchyma, which was beautifully illustrated by the authors.

The access to the lower trachea and the carina may be very difficult and forceful retraction of the lung may contribute to the adult respiratory distress syndrome and death, as it was in the case described by the authors. It was suggested that the use of cardiopulmonary bypass (CPB) would be helpful by obviating the need for ventilation of the right lung and rendering the anastomosis easier to perform. We could not agree with this more. We recently presented our initial experience with distal tracheal and carinal tumors resection aided by CPB and discussed its place among various approaches [2]. Cardiopulmonary bypass was successfully used in tracheal and carinal reconstruction in the 1960s and 1970s [3–7]. However, because of the high risk and complexity of CPB at that time, it was eventually abandoned. Today CPB is a well-established, safe, and simple procedure. This makes it an attractive technique to facilitate surgery of the lower trachea and the carina. Herein we briefly describe one of our cases to demonstrate usefulness of CPB. A 63-year-old woman was admitted with symptoms of airway obstruction and pneumonia. Bronchoscopy revealed a tumor at the level of the carina, obstructing the left main bronchus, and carcinoid tumor was diagnosed at biopsy. The patient was scheduled for an elective operation. Right posterolateral thoracotomy was performed. The ascending aorta and the right atrium were cannulated and CPB was instituted. The carina was widely opened (Fig 1). The pars membranacea and the part of the carina had to be resected with the tumor. The median walls of both main bronchi were sutured together, thereby creating a new carina at the lower level. The duration of CPB was 40 minutes. Recovery was uneventful, with no bleeding problems or other CPB-related complications. The patient was discharged on postoperative day 10 and is well at 2 years follow-up, without evidence of carcinoid tumor recurrence.

View larger version (47K): [in this window] [in a new window]   Fig 1. The carina with tumor is resected. The median walls of both main bronchi are sutured together, creating a new carina at the lower level.

Although our experience with resection of distal tracheal and carinal tumors with CPB is very limited, we believe that CPB may significantly facilitate resection in these cases. This option should always be considered for resection of the major airways when adequate oxygenation can not be accomplished by conventional techniques, especially in patients with acute respiratory distress. Further reports are necessary to demonstrate the safety and effectiveness of the technique.

References

1. Refaely Y., Weissberg D. Surgical management of tracheal tumors. Ann Thorac Surg 1997;64:1429-1433.[Abstract/Free Full Text]
2. Peterffy A., Konstantinov I.E. Resection of distal tracheal and carinal tumors with the aid of cardiopulmonary bypass. Scand Cardiovasc J 1998;32:109-112.[Medline]
3. Woods F.M., Neptune W.B., Palatchi A. Resection of the carina and main stem bronchi with the use of extracorporeal circulation. New Engl J Med 1961;264:492-494.[Medline]
4. Adkins P.C., Izawa E.M. Reconstruction of tracheal cylindroma using cardiopulmonary bypass. Arch Surg 1964;88:405-409.[Medline]
5. Neville W.E., Langston H.T., Correll N., Maben H. Cardiopulmonary bypass during pulmonary surgery. J Thorac Cardiovasc Surg 1965;55:265-276.
6. Neville W.E., Thomason R.D., Peacock H., Colby C. Cardiopulmonary bypass during noncardiac surgery. Arch Surg 1966;92:576-587.[Medline]
7. Bricker D.L., Parker T.M., Dalton M.L. Cardiopulmonary bypass in anesthetic management of resection. Its use for severe tracheal stenosis. Arch Surg 1979;114:847-849.[Medline]

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