Carinal resection and reconstruction with complete pulmonary parenchyma preservation: a single-institution analysis of 36 cases

Abstract

Background: Carinal resection, performed in only a few high-volume centers, remains one of the most complicated and technically demanding surgeries. Few studies have examined the outcomes of carinal resection and reconstruction with complete pulmonary parenchyma preservation.Methods: Patients who underwent isolated carinal resection and reconstruction at the Shanghai Chest Hospital between 2006 and 2020 were retrospectively reviewed. Clinicopathological, perioperative, and follow-up outcomes were analyzed.Results: A total of 36 patients were included, including 19 men and 17 women. The average age was 50.7±14.8 years. Right posterolateral thoracotomy (n=33, 91.7%) and cross-field intubation during anastomosis (n=31, 86.1%) were selected for the majority of the carinal surgeries. The average intraoperative blood loss was 225.0 mL, and the mean operation duration was 196.1 minutes. Postoperative complications were observed in 14 patients (38.9%), including cicatricial stenosis (n=8, 22.2%), anastomotic fistula (n=3, 8.3%), air leak (n=1, 2.8%), cardiac arrhythmia (n=4, 11.1%), pneumonia (n=2, 5.6%), respiratory failure (n=1, 2.8%), and pulmonary embolism (n=1, 2.8%). There were 2 perioperative deaths (5.6%). Multivariate analysis revealed that being overweight was an independent favorable factor for postoperative complications [P=0.042, odds ratio (OR) =0.092, 95%, confidence interval (CI): 0.009-0.922]. Pathological diagnoses included squamous cell carcinoma (SCC) (n=12, 33.3%), adenoid cystic carcinoma (ACC) (n=15, 41.7%), mucoepidermoid carcinoma (MEC) (n=2, 5.6%), stricture (n=1, 2.8%), and other rare histological types. An R0 resection was achieved in 14 patients, while 21 patients (60.0%) had microscopically positive margins.Lymph node metastasis was confirmed in 6 patients (17.1%). Overall survival (OS) was 94.4% at 1 year and 79.4% at 5 years, with 107 months as the median survival time (95% CI: 64.0-150.0 months). All patients with negative margins remained alive during the follow-up period, while those who received R1 resections had much poorer survival rates due to tumor recurrence [P=0.042, hazard ratio (HR) =4.938, 95% CI: 1.062-22.950]. Conclusions:In selected patients, carinal resection and reconstruction with complete pulmonary parenchyma preservation was a feasible option to achieve an appreciable long-term survival at the risk of acceptable operative mortality and morbidity, particularly when complete resection with negative margins could be realized.

Short‐ and medium‐term outcomes of video‐assisted thoracoscopic surgery versus thoracotomy for carinal lung resection combined with carina reconstruction in locally advanced non–small cell lung cancer patients

“…Therefore, the feasibility of VATS for carina reconstruction may require more investigation in a larger cohort. Finally, the incidence of the anastomotic fistula was 10.81% (4 of 37 patients) in our study, similar to that reported by previous research that ranged from 8.3% to as high as 20% 5,6,8,13 . However, all of the anastomotic fistula led to prolonged air leaks, pneumonia, acute respiratory distress syndrome, and even death in our study.…”

“…Finally, the incidence of the anastomotic fistula was 10.81% (4 of 37 patients) in our study, similar to that reported by previous research that ranged from 8.3% to as high as 20%. 5 , 6 , 8 , 13 However, all of the anastomotic fistula led to prolonged air leaks, pneumonia, acute respiratory distress syndrome, and even death in our study. Therefore, this common, but severe complication of carina reconstruction should be taken seriously and dealt with properly to achieve better perioperative outcomes.…”

“…Before the airway procedure, the corresponding pulmonary vessels were disconnected, and fissures were completed to prepare for lung resection. The surgical strategy related to the airway and carina was performed following the procedures described by our team previously 9,13 . The main bronchus and distal trachea should be sufficiently exposed.…”

“…The surgical strategy related to the airway and carina was performed following the procedures described by our team previously. 9 , 13 The main bronchus and distal trachea should be sufficiently exposed. The paratracheal LNs were fully removed.…”

Resektionen der Trachealbifurkation

“…Die Deckung der Bronchialanastomose durch einen gestielten, effektiv perfundierten Gewebelappen, z. B. aus Thymusrestgewebe, Interkostalmuskel oder Latissimus-dorsi-Lappen, wird von den meisten Autoren empfohlen [15,32,38,43]. Die Durchtrennung von Trachea und Bronchien führt, trotz Präservation der oberflächlichen Gefäßversorgung, zu einer passageren Ischämie der Bronchialschleimhaut distal der Anastomose.…”