Ann Thorac Surg 2006;82:355-356
© 2006 The Society of Thoracic Surgeons
How to do it
Partial Sleeve Right Pneumonectomy With Carinal Flap Closure
Kamal A. Mansour, MD
a
,
*
,
Joseph I. Miller, MD
a
,
Amro R. Serag, MD
b
a Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
b Cardiothoracic Surgery Unit, Tanta University, Tanta, Egypt
Accepted for publication June 17, 2005.
* Address correspondence to Dr Mansour, The Emory Clinic, 1365 Clifton Rd, NE, Atlanta, GA 30322 (Email: kamal_mansour{at}emoryhealthcare.org).
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Abstract
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We describe a technique used in 2 patients for resection of carcinoid tumor arising from the right main bronchus and extending along the lateral wall of the lower trachea. A flap was mobilized from the non-involved membranous posterior wall of the right main bronchus, which was left attached to the carina. This was used to close the defect in the lower trachea. Both patients did well after surgery and were followed-up for 10 to 17 years with no evidence of recurrence.
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Introduction
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Pulmonary resections for management of lung tumors have become frequent and standard procedures. Tumors arising at the tracheobronchial angle, carina, or lower trachea present a surgical challenge, and tracheal sleeve pneumonectomy is considered the operation of choice in these situations [1]. Since Gibbon's [2] report in 1959, this operation has proven to be a technically demanding procedure with high risk of fearsome complications and a high mortality rate of 7% to 29% [3]. Modifications of the technique were reported sporadically in the literature.
We describe a technique of partial sleeve right pneumonectomy with carinal flap closure that carries potential advantages over the routine tracheal sleeve pneumonectomy. We performed this technique in 2 patients with carcinoid tumor arising at the right tracheobronchial angle without carinal invasion. The first patient was a 27-year-old man with carcinoid tumor of the right main bronchus with extension along the lower lateral tracheal wall for ± 2 centimeters. The other was a 35-year-old woman with recurrent carcinoid tumor at the same location after laser therapy. The surgery was uneventful in both patients and they were followed-up for 17 and 10 years, respectively, with no evidence of recurrent disease.
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Technique
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General anesthesia was administered with a double lumen endotracheal tube. A right posterolateral thoracotomy incision was used. Once the thoracic cavity was entered, the hilum of the lung was dissected systematically, dividing the azygos major vein with exposure of the lower trachea and the carina, which were then mobilized. Two umbilical tapes were placed around the trachea and the left main bronchus. The anterior aspect of the trachea was then isolated for a distance of 4 to 5 cm. Ligation of the pulmonary vessels was then performed in the usual fashion. Because the posterior wall of the right main bronchus was free of tumor on bronchoscopic examination, the incision in the trachea was beveled appropriately so that a portion of the posterior membranous wall of the right main bronchus was retained (Fig 1). This gave us a well vascularized flap of bronchial tissue, which we were then able to incorporate in the bronchoplasty. An extended right pneumonectomy including the right lateral wall of the lower trachea was completed. Clear frozen section margin was confirmed. Interrupted absorbable sutures of 3-0 Vicryl (Ethicon, Somerville, NJ) were used for this purpose. The sutures started from below at the level of the carina and continued upward with the knots tied on the outside until the whole tracheal defect was closed. The bronchoplasty was tension free. Incorporation of the flap prevented any narrowing of the carina or the left main bronchus. Hydro-pneumatic testing was then carried out to confirm the integrity of reconstruction. A large flap of parietal pleura was then buttressed over the closure with interrupted 3-0 silk sutures. Mediastinal node sampling was also obtained and the chest was closed in the usual fashion. At the end of the procedure, fiberoptic bronchoscopy was done to check the stump closure. The patient was extubated in the operating room.
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Comment
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Tracheal sleeve pneumonectomy can be functionally defined as a pneumonectomy characterized by the presence of an anastomosis instead of suturing the bronchial stump. This operation has been associated with several dangerous complications such as anastomotic leaks and empyema. The incidence of empyema after tracheal sleeve pneumonectomy is 5% to 8 % [3]. It can occur with or without a bronchopleural fistula. Bronchopleural fistula was reported in the literature to occur at the rate of 5% to 10% after tracheal sleeve pneumonectomy [3] compared with the slightly lower rate of 1% to 4% reported after conventional pneumonectomy [4]. Factors implicated in the development of a fistula are inflammation or malignant infiltration of the stump, inaccurate suturing technique, preoperative radiotherapy, excessive length of the stump, and tension of the suture line. Other factors critical to healing are avoidance of tissue trauma and maintenance of blood supply to the area of anastomosis [5]. It appears that the tracheobronchial anastomosis carries a higher risk of fistula formation. This is attributed to a greater risk of compromising the blood supply as determined by tracheal mobilization and dissection maneuvers [3]. We believe that the technique described in this report carries potential advantages in decreasing this complication as it avoids excessive dissection and tissue trauma, and at the same time maintains good blood supply by using the well vascularized membranous portion of the bronchus to close the tracheal defect. However, with our experience of only 2 patients, time will tell whether the incidence of bronchopleural fistula will be lower with this technique when compared with the standard, circumferential carinal sleeve resections.
This article describes a simplified method of extended right pneumonectomy as an alternative to a right sleeve tracheal pneumonectomy. The tumor extension is more than can be simply resected with primary closure of the tracheal defect. The carinal flap is fashioned according to the size of the defect in the trachea with no major mobilization or tension on the suture line; however, the length of the flap should not exceed twice its width in order to keep adequate vascularity.
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References
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- Dartevelle PG, Macchiarini P, Chapelier A. Tracheal sleeve pneumonectomy Ann Thorac Surg 1995;60:1854-1855.[Abstract/Free Full Text]
- Gibbon JH. Discussion of Chamberlain JM, McNeill TM, Parnassa P, Edsall JR. Bronchogenic carcinoma: an aggressive surgical attitude J Thor Cardiovasc Surg 1959;38:727.[Medline]
- Roviaro G, Varoli F, Romanelli A, et al. Complications of tracheal sleeve pneumonectomypersonal experience and overview of the literature. J Thorac Cardiovasc Surg 2001;121:234-240.[Medline]
- Dartevelle PG, Khalife J, Chapelier A, et al. Tracheal sleeve pneumonectomy for bronchogenic carcinomareport of 55 cases. Ann Thorac Surg 1988;46:68.[Abstract/Free Full Text]
- McGovern EM, Trastek VF, Pairolero PC, Payne WS. Completion pneumonectomyindications, complications and results. Ann Thorac Surg 1988;46:141-146.[Abstract/Free Full Text]
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Abstract
Introduction
