Carinal Resection and Sleeve Pneumonectomy - Indications, Procedure, and Complications

Introduction

Patients with lung cancer that has spread to a part of the windpipe are carefully chosen and treated with surgery. The long-term results of this treatment are appreciable. Many surgical approaches are followed conventionally. Due to the advancing revolution in minimally invasive surgeries and the expertise of surgeons, many complex surgeries have been performed to treat lung cancer with highly positive outcomes. One such complex surgery is carinal resection and sleeve pneumonectomy. It is rarely performed and always under the expertise of a multidisciplinary team.

What Is Carina?

Carina is a structure at the base of the trachea (windpipe) at the point of its division into right and left bronchi (branches).

What Are Carinal Resection and Sleeve Pneumonectomy?

Carinal resection and sleeve pneumonectomy are surgical procedures for managing tumors (cancer) in the lower trachea. The procedure involves removing the lung, its main stem (bronchi), a part of the trachea, and the carina. Then, the remaining lung is re-implanted in the trachea. It is a technically challenging procedure. Carinal resection and sleeve pneumonectomy were earlier performed through a conventional open thoracotomy, but advancements in minimally invasive thoracoscopic surgeries have proven to be advantageous over conventional procedures.

Carinal Resection and Sleeve Pneumonectomy Indications:

• Presenting with symptoms such as worsened cough and blood sputum from one year.

• Benign or inflammatory strictures.

• Common tumors like squamous cell carcinoma (cancer when lung cells abnormally multiply, forming a tumor), adenoid cystic carcinoma (tumor arising from bronchial glands), and bronchogenic carcinoma (a subtype of lung cancer).

• Geographic tumors likefibroma (a disease that occurs when lung tissue is damaged or scarred), lipoma (a rare tumor due to the accumulation of fat), and chondroma (cartilaginous tumor in the lungs).

When Are Carinal Resection and Sleeve Pneumonectomy Contraindicated?

This surgery is not indicated in patients with the mediastinal nodal disease (a disease in the area of the chest that separates the lungs).

What Are the Preoperative Evaluations done Before Carinal Resection and Sleeve Pneumonectomy?

• Preoperative medical evaluation is done along with cardiopulmonary evaluation.

• Complete pulmonary function tests are performed for evaluation.

• Steroid dependency or inflammatory conditions of the windpipe should be corrected.

• Previous high-dose radiation therapy should also be considered.

• Airway assessment is done with proper imaging techniques and endoscopy.

• MRI (magnetic resonance imaging) may be advised to check for vascular (blood vessel) abnormalities.

• Mediastinoscopy can also be performed to rule out mediastinal nodal disease before dealing with primary lung cancer.

• All tracheostomy tubes and stents should be removed before the surgery.

• Radiotherapy can also be advised before the surgery. In such cases, the surgery is performed after the healing period.

What Are the Different Approaches in Which the Surgery Can Be Performed?

• Right thoracotomy is mainly preferred.

• For small tumors, the transsternal approach is preferred. The transsternal approach is performed using total sternotomy.

• A bilateral clamshell incision with transverse sternotomy can also be performed similarly.

How Are Carinal Resection and Sleeve Pneumonectomy Surgery Performed?

Before the beginning of the surgery, anesthetic considerations and airway maintenance are checked. Then, the anesthesiologist and the surgeon perform the surgery in a coordinated manner. Under general anesthesia, the transsternal approach is best carried out for diseases of the lower trachea. The ultimate goal of the surgery is to remove the tumor involving the carinal area and a part of the bronchi.

• Proper visual access is achieved by an incision made in the middle of the sternum.

• After the incision, the underlying fat and thymus are mobilized to achieve clear visibility of the veins beneath the structures.

• All the essential blood vessels are retracted carefully, and access is gained.

• The blood supply of the trachea should not interfere at any point.

• The trachea and bronchi portions are dissected without disturbing the underlying food pipe (esophagus).

• Then the lung involved is removed from the pleural cavity inside a retrieval bag without enlarging the skin incision.

• Fiber optic bronchoscopy is done intraoperatively to assess the total resection.

• One lung ventilation is maintained with an endoscope.

• Sutures are used to join the open ends of the trachea and bronchi.

What Are the Steps to Follow After Carinal Resection and Sleeve Pneumonectomy?

• Patients require maximum attention after surgery.

• Postoperative pain control is achieved with anesthesia and pain-relieving medications.

• Antibiotics are prescribed for at least seven days.

• An X-ray is taken to assess the condition of the remaining part of the lung, and the patient is discharged.

• Follow up bronchoscopy (technique of visualizing air passages with a small-sized camera and light fixed to a tube for therapeutic purposes) is performed six months after the surgery to monitor the recovery.

What Risks Are Involved in Carinal Resection and Sleeve Pneumonectomy?

• Early complications:

  • Pulmonary edema or this complication can arise due to fluid overload.

  • ARDS, or acute respiratory distress syndrome, is a serious condition where the lungs cannot supply enough oxygen required for the body.

  • Cardiac arrhythmias or irregular pumping of the heart.

  • Vocal cord paralysis or uncontrolled movement of muscles that control voice.

  • Mild necrosis (death of tissue) or infection (accumulation of pus).

  • Mediastinitis or swelling or irritation of the chest area between the lungs.

• Late complications:

  • Tumor recurrence.

  • Anastomotic strictures (narrowing of the new connection formed due to sutures).

How Are the Complications Managed?

• Pulmonary edema can be managed with proper supportive care, oxygen supplementation, and fluid restriction.

• Cardiac arrhythmias are controlled using medications such as beta-blockers and calcium channel blockers.

• Bilateral vocal cord paralysis needs permanent tracheostomy (surgically created channel in the windpipe providing an alternative way for breathing).

• Tumor recurrence is managed with brachytherapy and stenting. Systemic therapy and radiation can also be used.

Conclusion

Carinal resection and sleeve pneumonectomy are complex surgeries to treat lung cancers. The success of the surgery is determined by the patient's clinical condition, the surgeon's expertise, and the anesthesiologist. Unlike traditional surgery, mortality rates for carinal resection and sleeve pneumonectomy procedures have increased by three to four times. Carinal resection can also be performed without pneumonectomy when the lung is not involved. However, carefully selecting patients for this procedure, using advanced anesthetic and surgical techniques, and improving postoperative care have improved success rates