Carinal surgery: A single-institution experience spanning 2 decades

Abstract

Objectives: Complete resection of neoplasms involving the carina are technically challenging and have high operative morbidity and mortality. This study examines the last 2 decades of clinical experience at our institution.Methods: Medical records were retrospectively reviewed between 1997 and 2017 to identify all patients who underwent carinal resection. Primary outcome measures include risk factors for complications and overall survival.Results: In total, 45 carinal resections were performed with a median follow-up of 3.4 years (interquartile range 0.8-8.5). Procedures included 21 neocarinal reconstructions (48%), 14 right carinal pneumonectomies (30%), 9 left carinal pneumonectomies (20%), and 1 carinal plus lobar resection (2%). Age ranged from 27 to 74 years, and 23 of 45 patients were female. Eight received neoadjuvant chemotherapy and 6 preoperative radiation. Extracorporeal membrane oxygenation and cardiopulmonary bypass were intraoperatively used for 4 patients with no mortality. Four patients underwent superior vena cava resection and reconstruction. Anastomotic complications occurred in 5 patients, all of which were managed conservatively: 1 required stent placement and a second underwent hyperbaric oxygen therapy. Postoperative events were observed in 26 patients (58%), including pneumonia (n ¼ 11), blood transfusion (n ¼ 8), and atrial arrhythmias (n ¼ 8). More serious complications, such as acute respiratory distress syndrome, occurred in 3 patients. Postoperative events were most closely associated with pulmonary resection (P ¼ .040). There were 3 deaths, yielding an overall operative 30-and 90-day mortality of 6.8% and 7%, respectively.Conclusions: Despite advances in perioperative management, carinal resection poses challenges for both patient and surgeon. Preoperative chemotherapy, radiation, and concomitant pulmonary resection were associated with increased risk of complications. Patient selection and meticulous surgical technique contribute to reduction in morbidity and mortality. (J Thorac Cardiovasc Surg 2019;157:2073-83)

Elucidation of clinicopathological factors associated with improved clinical outcomes for carinal pneumonectomy in T4 non-small cell lung cancer

“…These differences may have negatively impacted our operative and survival outcomes in comparison with other studies. A recent report by Costantino et al described excellent operative mortality of 6.8%; however, the mortality after CP was 12% in the same report (16). In comparison, Eichhorn et al used a patient cohort very similar to our study cohort, and our post-2000 results are equivalent or better than their reported outcomes of 3% 30-day mortality, 40% 3-year OS, and 31% of 5-year OS (12).…”

“…As numerous articles have described, patient selection, perioperative management including anesthetic technique, and surgical technique are key factors for achieving favorable short-term surgical and long-term oncologic outcomes after carinal surgery (3,4,(9)(10)(11)(12)(13)(14)(15)(16). Our outcomes showed clear improvements over the two decades of the study, and therefore analysis of these factors between the two study periods was performed.…”

“…Carinal pneumonectomy, as other EPs, continues to be a technically complex procedure with the potential for fatal surgical morbidity and mortality even in modern thoracic surgery. Since the early reports of experiences with carinal surgery including CP in the 1950s (6-8), many studies have been published originating mainly from the major thoracic centers worldwide (9)(10)(11)(12)(13)(14)(15)(16). These studies have demonstrated clear improvements over the early results, with a 0-16% decrease in postoperative mortality and a 25-66.3% increase in 5-year OS.…”

Tracheal and carinal resections in the treatment of non-small cell lung cancer: a trend to a minimally invasive approach

“…Even in 2000 decade, the rate of complications was reported with a wide variability, with a top value of 50.8% (45). In recent years and in centers with experienced surgeons, and with the advent of minimally invasive approaches, the mortality rate is lower with overall postoperative 30-day rates between 2.7% to 10.9%, but still with a wide range of morbidity (12,46,47). Also, reports of new techniques like carinal resections with lung parenchyma-sparing for NSCLC by uniportal VATS give a new perspective to this kind of complex cases.…”

A novel lung autotransplantation technique for treating central lung cancer: a case report

“…Lateral tracheal fenestration was performed above the level of carina. The tracheal opening was at least 1-1.5 cm 2 in size and created entirely on the cartilaginous wall or partly including the edge between cartilaginous and membranous wall (6,7). The anastomosis between graft bronchus and lateral wall of trachea was started using parachute principle.…”