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Carinal Resection - Indications, Contraindications, and Surgical Management

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Carinal resection removes the tracheobronchial bifurcation without removing the lung parenchyma. Read the article below to know more.

Medically reviewed by

Dr. Kumar Sonal

Published At January 27, 2023
Reviewed AtDecember 1, 2023

Introduction:

The trachea is a cartilaginous and membranous tube. It begins as a continuation of the larynx at the lower border of the cricoid cartilage of the larynx at the level of the sixth cervical vertebra, to the level of the angle of Louis (T4/5) thoracic vertebra, where it divides into two principal bronchi, at the level of the sternal angle, one for each lung.

Carina is a cartilaginous ridge on the internal aspect of the last tracheal cartilage, present just at the tracheal bifurcation site. Therefore, carinal resection is the resection or removal of the tracheobronchial bifurcation, with or without the removal of the lung parenchyma. It can often be confused with carinal pneumonectomy, which involves the removal of the lung parenchyma or lung as a whole entity.

Under any situation, the major purpose of carinal resection is to restore the continuity of the airways. The most prevalent finding is the primary tracheal tumors involving the metastatic extension of nearby structures such as the lungs, larynx, and thyroid. The most common primary tracheal tumors are squamous cell carcinoma and adenoid cystic carcinoma. Carinal resection is most commonly used for bronchogenic malignancies. Benign tumors of the trachea and bronchus are rarely resected.

What Are the Indications of Carinal Resection?

The most common indications of carinal resection are:

  • Non-small cell lung cancer.

  • Primary tumors of the carina or distal trachea.

  • Bronchogenic carcinomas.

  • Benign or inflammatory structures.

What Are the Contraindications of Carinal Resection?

The most common contraindications are:

  • Insufficient cardiopulmonary reserve.

  • Pulmonary hypertension.

  • Lesions involving the airway of a size more than 4 cm (centimeter) in diameter.

What Are the Signs and Symptoms of the Tracheobronchial Tumors?

The most common signs and symptoms are:

  • Chronic persistent non-productive cough.

  • Sputum production is most commonly associated with post-obstructive pneumonia and tracheobronchial inflammation.

  • Hemoptysis is a rare finding.

  • Stridor with severe airway obstruction.

What Are the Diagnostic Tests to Be Carried Out?

The diagnostic tests that can be carried out are as follows:

  • Computed Tomography (CT) Scan: It is usually the first test to locate the lesion at the distal trachea and the principal bronchi. It also allows the assessment of the tumor extent, involvement of mediastinal lymph nodes, condition of the pulmonary parenchyma, and presence of pleural or pericardial effusion.

  • Bronchoscopy: It is one of the initial diagnostic tests to be carried out and acts as a potential therapeutic intervention. It allows direct visualization of the tumor, assessment of tumor extent, and tissues can be removed for further investigations. Endoluminal palliative therapy is usually carried out for lumen restoration in obstructive lesions. For mechanical debulking of tumors, cryoablation with cryospray can be used. Temporary stenting can often be used to re-establish the airway lumen, but stents may cause mucosal irritation and granulation tissue formation and may cause peribronchitis or inflammation of the peribronchial tissue; thereby, resection becomes more challenging.

  • Positive Emission Tomography (PET) Scan: It is an important diagnostic tool that helps evaluate the primary tracheal malignancy, mediastinal and distant metastasis, and the presence of such lesions would require further investigations of the tissues.

  • Magnetic Resonance Imaging (MRI): It can be used to delineate the extension of the tracheal tumor into the surrounding peritracheal tissues and vascular anatomy.

  • Endobronchial Ultrasound: It is one of the most important diagnostic tools. If mediastinal lymph nodes are involved, it is a significant predictor of poor survival after complete carinal resection. To evaluate involved mediastinal lymph nodes, invasive mediastinal staging can be done. In addition, endobronchial ultrasound allows adequate sample collection of the mediastinal lymph nodes for further pathological investigations. During a mediastinoscopy, there are high chances of disruption of the anterior pre-tracheal plane leading to scarring, increased tension, and decreased tracheal mobility. It also increases the anastomotic complications and limits the extent of the resection. Therefore, mediastinoscopy is not used now.

  • Pulmonary Function Tests: This is a valuable tool in the assessment of the pulmonary reserve of the patient.

  • Ventilation-Perfusion Scan: If carinal pneumonectomy is considered, a further ventilation-perfusion scan should be performed to better delineate the predicted postoperative pulmonary function. Nowadays, an imaging modality that has gained popularity is single photon emission computed tomography ventilation-perfusion (SPECT/VQ) imaging which allows precise delineation of the functional lung anatomy. It may be helpful in these cases. It has higher sensitivity, specificity, and accuracy than a conventional ventilation-perfusion scan.

  • Echocardiography: It is useful in identifying high-risk groups of patients with pulmonary hypertension.

  • Six Minutes' Walk Test: It is a useful tool to assess the physiologic status of individuals. Further, formal cardiopulmonary exercise tests may be required to select the patients that would be an ideal candidate for chest resection.

What Is the Surgical Management of Tracheal Tumors?

Surgical interventions for tracheal tumors are:

  • Bronchoscopy: It is the first and foremost step before resection. It allows direct visualization of the tracheal anatomy and decision on the resectability. Usually, a four and a half cm in diameter can be resected safely without complications.

  • Mediastinoscopy: It is usually performed just before resection because it helps develop the paratracheal plane, allowing tracheal mobilization.

  • Right Thoracotomy: Most carinal resections can be performed by right posterior lateral thoracotomy. Through the fourth intercostal space, the pleural cavity is reached. The lung is retracted anteriorly and inferiorly, and the azygos vein is ligated. The mediastinal pleura anterior to the esophagus is reached, and the trachea with the right principal bronchus is exposed.

  • Left Thoracotomy: Usually, the arch of the aorta and the left principal bronchus limit the carina and trachea exposure. Therefore, mobilization of the arch of the aorta and the left pulmonary artery may improve the exposure of the carina.

  • Median Sternotomy: It is an anterior approach to sternotomy. The sternum is divided, and the carina and the distal trachea are exposed.

  • Video-assisted Thoracoscopic Surgery: It is a minimally invasive technique for carinal resection. An incision is made on the fourth intercostal space. Dissection is made to mobilize the distal trachea and carina.

  • Tracheobronchial Anastomosis: Anastomosis is performed with simple interrupted sutures. A transmural finder needle probe is used to identify the proximal level of dissection. Identification of a wrong level results in more extended defects and high tension on the anastomosis. The trachea is transected just above the tumor, the distal end of the trachea is transected, and the specimen is sent for frozen section analysis.

Only the trachea is removed in carinal resection, and both lungs are preserved. A large variety of reconstruction options are available to recreate the bifurcation of the trachea. In carinal pneumonectomy, the trachea and the involved lung are removed. Reconstruction is performed with single anastomosis between the distal of the trachea and the proximal end of the principal bronchus.

Conclusion:

Carinal resection is most commonly used for bronchogenic malignancies, primary tracheal tumors, and non-small cell lung cancer. A patient may present with hemoptysis, non-productive cough, and stridor. Proper diagnosis and early intervention can reduce the progression of the lesion. Anastomotic dehiscence is the most common complication of carinal resection, associated with high mortality and morbidity. It may result in mediastinitis and potential loss of the airway. So, to avoid anastomotic dehiscence, vascularized flaps such as pleural, pericardial, and thymic fat are used.

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Dr. Kumar Sonal
Dr. Kumar Sonal

General Surgery

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