Carinal sleeve resection: last exit for bronchial insufficiency—a 17-year, single-centre experience

Abstract

OBJECTIVES Bronchopleural fistula after pneumonectomy and dehiscence of an anastomosis after sleeve lobectomy are severe complications. Several established therapeutic options are available. Conservative treatment is recommended for a small fistula without pleural infection. In patients with a bronchopleural fistula and subsequent pleural empyema, surgical management is the mainstay. Overall, the associated morbidity and mortality are high. Carinal sleeve resection is the last resort for patients with a short stump after pneumonectomy or anastomotic dehiscence after sleeve resection near the carina. METHODS All patients with bronchopleural fistula after pneumonectomy or sleeve resection who underwent secondary carinal sleeve resection between 2003 and 2019 in our institution were evaluated retrospectively. Patients with anastomotic dehiscence after sleeve lobectomy underwent a completion pneumonectomy. The surgical approach was an anterolateral thoracotomy; the anastomosis was covered with muscle flap, pericardial fat or omentum majus. In case of empyema, povidone-iodine-soaked towels were introduced into the cavity and changed at least twice. RESULTS A total of 17 patients with an initial sleeve lobectomy in 12 patients and pneumonectomy in 5 patients were treated with carinal sleeve resection in our department. Morbidity was 64.7% and 30-day survival was 82.4% (n = 14). A total of 70.6% of the patients survived 90 days (n = 12). Median hospitalization was 17 days and the median stay in the intensive care unit was 12 days. CONCLUSIONS Carinal sleeve resection is a feasible option in patients with a post-pneumonectomy fistula or anastomotic insufficiency following sleeve lobectomy in the absence of alternative therapeutic strategies. Nevertheless, postoperative morbidity is high, including prolonged intensive care unit stay.

Pneumonectomy with Carinal Sleeve Resection in Patients with Non-Small-Cell Lung Cancer

“…For patients with SP for NSCLC the 5-year OS is stated to be 25-44% [2,10,14] and our results for patients with pSP are in line with the literature. Patients with sSP are a specific subgroup and alternative treatment options are rare, as recently discussed [3]. In the emergency situation sSP was performed and a 5-year survival of 10.5% is lower than expected in early stages of NSCLC, but expected in view of the severe course of these patients.…”

“…The detailed operative technique, especially the management of additional empyema in cases of sSP, is described in further publication [3].…”

“…The detailed operative technique, especially the management of additional empyema in cases of sSP, is described in further publication. 3 In case of right-sided SP, the azygos vein was dissected to gain approach to the right main bronchus. In patients with left-sided SP, the ductus Botalli was visualized and dissected.…”

“…In cases of centrally located NSCLC invading the carina, pneumonectomy with carinal sleeve resection is an option to allow the full resection of the tumour [1,2]. Furthermore, sleeve pneumonectomy (SP) is also an approach to manage central bronchial insufficiency after pneumonectomy or anastomosis dehiscence after sleeve resection [1,2,3]. However, SP is still one of the most challenging procedures in thoracic surgery and therefore only performed in specialized centres.…”

“…1,2 Furthermore, sleeve pneumonectomy (SP) is also an approach to manage central bronchial insufficiency after pneumonectomy or anastomosis dehiscence after sleeve resection. [1][2][3] However, SP is still one of the most challenging procedures in thoracic surgery and therefore only performed in specialized centers. Even in these high-volume centers, SP only represents approximately 1% of resections for NSCLC and is the procedure with the poorest survival.…”