carinal pneumonectomy cameron wright, md thoracic surgery mgh 2012 focus on thoracic surgery: lung...

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Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

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Page 1: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Carinal Pneumonectomy

Cameron Wright, MDThoracic Surgery

MGH2012 Focus on Thoracic Surgery:

Lung Cancer

Page 2: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Disclosures

None

Page 3: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Sleeve Pneumonectomy

• Can be performed on either side but right side much more common

• Typical case is a NSCLC involving the right tracheobronchial angle

• Careful bronchoscopy by the surgeon crucial to delineate the extent of endobronchial disease

• 4 cm of trachea is the most that can be resected in the average case

Page 4: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Squamous Cell RMB

Page 5: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Adenocarcinoma RMB and Trachea

Page 6: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Submucosal Spread in RMB

Page 7: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Adenocarcinoma RMB with Subcarinal Nodal Invasion

Page 8: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Evaluation and Treatment

• Chest CT with IV contrast

• Metastatic survey (CT/PET for nodes, distant disease)

• Consider EBUS-FNA as preferred technique to stage the mediastinum

• Delay mediastinoscopy to day of resection so as to not limit tracheal mobility

• Ensure POP-FEV1 is adequate (Quantitative V/Q to accurately predict)

• Use CT/RT induction with particular caution-would favor induction chemotherapy alone if needed

Page 9: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Technique of Right Sleeve Pneumonectomy

• Bronchoscopy to ensure enough LMB and trachea are present for reconstruction

• Mediastinoscopy to sample nodes and free up anterior trachea (blood supply is lateral)

• Use long wire reinforced ETT (not DL ETT) to intubate LMB for thoracotomy

• Thoracotomy in 4th interspace, or median sternotomy

Page 10: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Technique of Sleeve Pneumonectomy

• Explore chest, confirm resectability

• Decide about SVC involvement

• Measure extent of tracheal involvement

• Divide vessels first

• Bring sterile ETT and airway circuit onto field (rarely need jet ventilation)

Page 11: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Technique of Sleeve Pneumonectomy

• Encircle trachea and LMB at proposed division sites (avoid L RLN!)

• Free up anterior LMB to enhance mobility

• Divide LMB after pulling back indwelling ETT

• Ventilate LMB from the field ETT

• Divide trachea and check margins

Page 12: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Technique of Anastomosis

• Place 2-0 Vicryl stay sutures 2 rings deep at 3 and 9 o’clock around 1 ring with knot outside

• Place circumferential 4-0 Vicryl sutures about 4 mm deep and 4 mm apart while adjusting for size discrepancy

Page 13: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Anastomotic Sutures

Page 14: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Technique of Sleeve Pneumonectomy

• Flex chin and tie stay sutures first (left wall will have least tension)

• Tie 4-0 sutures next-cartilage first, then membraneous wall

• Check for airleaks

• Wrap anastomosis with fat pad or other tissue buttress

• Extubate patient at end of case

Page 15: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Right Sleeve Pneumonectomy

Page 16: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Left Sleeve Pneumonectomy

Page 17: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Left Sleeve Pneumonectomy-Use of Tracheal and Aortic Sling

Page 18: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Sternotomy Exposure

Page 19: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Results of Sleeve Pneunonectomy

• Operative mortality usually 7-10% (was 25%)

• Post-pneumonectomy ARDS most common cause of early mortality

• Anastomotic complications uncommon but life-threatening

• Five year survival 20 to 40%

• Prognostic factors: nodal status, FEV1

Page 20: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Results of Sleeve Pneumonectomy

Author # Cases Mortality 5Y Survival

Mitchell

1999

35 10% 42%

Roviaro

2000

49 8% 25%

Mezzetti

2002

27 7% 20%

Porhanov

2002

166 16% 25%

7% if N2

Jiang

2009

11 10% 27%

7% if N2

Page 21: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Survival According to Nodal Status at the MGH

Page 22: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Tracheal Closure of Jack-A Way to Resect Up To The Carina

Page 23: Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

Sleeve Pneunonectomy-Conclusion

• Rare subset of pulmonary resections

• Avoid N2 disease and induction chemoradiotherapy

• Avoid lengthy resections of trachea

• Mobilize airway to reduce tension

• Careful anastomotic technique

• Wrap anastomosis