Management

The technique for carinal resection (tracheal sleeve pneumonectomy) for bronchogenic carcinoma is described in Chapter 29, "Carinal Reconstruction," and anesthesia in Chapter 18, "Anesthesia for Tracheal Surgery." Resection of a carina and a bronchial stump for residual tumor or for strictly localized recurrence may be indicated, but only after rigorous preoperative and intraoperative assessment. Dartevelle and Macchiarini additionally recommend introducing latissimus dorsi and serratus anterior muscles to buttress the anastomosis, and performing a tailoring thoracoplasty to obliterate the pleural space for infection control.43 We have not done this in a "clean" operation.

Initial experience with carinal resection for bronchogenic carcinoma was discouraging, with mortality rates of nearly 30% reported by Jensik, Deslauriers, and their teams.33,34 Our initial early postoperative mortality rate was 8%, but delayed mortality was 11%, due principally to anastomotic complications from tracheal reimplantation of the residual right lung, hence totalling a mortality rate of 19%.36 This contrasted with an 8 to 12% mortality rate for carinal resections for primary tracheal tumors.44 Nonetheless, inclusive of the unfavorable early cases noted, our total mortality rate dropped to 15.5% by 1998.42 The mortality rate of 11% reported by Dartevelle and colleagues in 1988 is assuring.37 Our surgical mortality dropped to 10% in the second half of our series, varying with type of resection.45 A very significant part of early postoperative mortality was due to a particularly aggressive and rapidly moving adult respiratory distress syndrome (ARDS), which has been labelled postpneumonectomy pulmonary edema or noncardiogenic pulmonary edema. The operation may go smoothly, and the patient who was extubated early will appear to be in fine

figure 8-16 A, Adenocarcinoma (arrows) of the right upper lobe invading the carina in a 40-year-old patient with insufficient pulmonary reserve to tolerate pneumonectomy. B, Reconstruction with end-to-side anastomosis of the bronchus intermedius to lower trachea (open arrow) just above the end-to-end joining of distal trachea and left main bronchus (arrow). Eight years later, an adrenal metastasis appeared. More often the bronchus intermedius is implanted into the medial side of the left main bronchus.

figure 8-16 A, Adenocarcinoma (arrows) of the right upper lobe invading the carina in a 40-year-old patient with insufficient pulmonary reserve to tolerate pneumonectomy. B, Reconstruction with end-to-side anastomosis of the bronchus intermedius to lower trachea (open arrow) just above the end-to-end joining of distal trachea and left main bronchus (arrow). Eight years later, an adrenal metastasis appeared. More often the bronchus intermedius is implanted into the medial side of the left main bronchus.

condition for 24 hours. At 36 to 48 hours, a diffuse infiltrate appears in the remaining lung. This progresses almost relentlessly to opacification of the residual left lung, and ultimately to death (see Figure 21-1 in Chapter 21, "Complications of Tracheal Reconstruction"). At postmortem examination, the lung is wet and heavy but only nonspecific bacteria, if any, are cultured. This does not support a postmortem diagnosis of broncho-pneumonia. The syndrome also follows conventional right pneumonectomy less often, and left pneu-monectomy or lobectomy even less frequently. Initially, it was attributed to perioperative intravenous fluid overload.46 We and others have not found any correlation between the amount of perioperative fluid administered and the occurrence of this dreaded complication.47 Nonetheless, it seems prudent to manage pneu-monectomy patients with minimum fluid administration. Interference with pulmonary lymphatics may impair the ability of the remaining lung to clear interstitial fluid. Barotrauma is likely implicated. The low incidence of ARDS in the series of Dartevelle and Macchiarini suggested a difference in anesthesiologic techniques.43 The declining incidence of this complication is likely due to adjustment of intraoperative airway ventilatory pressure and tidal volumes to avoid pulmonary barotrauma.

Until recently, the syndrome was nearly uniformly fatal. Addition of inhaled nitric oxide to the therapeutic regimen of fluid restriction, diuresis, ventilatory support, and steroids give promise of better results.47 Ten consecutive patients with severe ARDS (ARDS score 3.1), treated with inhaled nitric oxide at 10 to 20 ppm, showed immediate improvement in the mean ratio of partial pressure of arterial oxygen to fraction of inspired oxygen from 95 to 128 mm Hg (32% improvement), with further improvement there after. Chest x-rays improved in 8 patients, and 7 patients survived. The 3 who died were late deaths related to sepsis after recovery from initial ARDS.

Early in my experience, I tried to save the right lower or middle and lower lobes by bronchial implantation, after intrapericardial hilar mobilization, into either the side of the trachea above the end-to-end trachea to left main bronchus anastomosis, or into the medial side of the left main bronchus. Although the right main bronchus may be quite easily anastomosed in this way, excessive tension results if the right lower lobe bronchus or bronchus intermedius is pulled up to the trachea. Stenosis or separation resulted in a number of instances, with some fatal anastomotic complications.42 Clearly, this should not be done. If it is essential to save parenchyma because of borderline function, anastomosis of the bronchus intermedius or right lower lobe bronchus should be made to the medial side of the left main bronchus. Ishihara and colleagues also reattached the bronchus intermedius and left main bronchus to the trachea side-by-side, in 2 patients.40 Where functional status permits, pneumonectomy is probably preferable for safety.

Unilateral node dissection does not seem to affect anastomotic healing. Excessive bronchial stripping is best avoided. As in all airway surgery in the thorax, a second tissue layer is advised over the anastomosis. If irradiation has been given remotely, omental coverage will help to provide healing elements to the inert bronchial tissues (see Chapter 42, "The Omentum in Airway Surgery and Tracheal Reconstruction after Irradiation"). Since these tumors are so central, resection will often be made intrapericardially, and portions of esophageal wall or superior vena cava may also have to be excised. Extensive surgery, including our earlier adverse techniques described, produced an operative morbidity of 47% compared with 27% for carinal reconstruction without pneumonectomy.42

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