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MMCTS
(May 7, 2007). doi:10.1510/mmcts.2006.002113 Copyright © 2007 European Association for Cardio-thoracic Surgery Procedure Sleeve pneumonectomyUnité de Chirurgie Thoracique, Hôtel-Dieu Hospital, APHP, Paris V University, Paris, France * Corresponding author: * Service de Chirurgie Thoracique, 1 Place du Parvis Notre Dame, 75004, Paris, France Tel.: +33-1-4234 8884; fax: +33-1-4234 8885. marco.alifano{at}htd.aphp.fr; marcoalifano{at}yahoo.com
Sleeve pneumonectomy remains a surgical challenge with specific problems of intraoperative surgical and anesthesiologic management. In the present chapter we expose the techniques currently employed in our institution. Sleeve pneumonectomy is associated with a non-negligible mortality, with figures ranging from 8% to 15%. This operation is able to provide microscopic free margins (R0) for the majority of the patients, which is an important prognostic factor. Results in terms of long-term survival are encouraging as overall 5-year survival rates range from 25% to 45%, which is to be considered as a satisfactory result for these patients with a locally advanced cancer. Nodal status is a relevant prognostic factor as patients with N2 disease have survival rates lower than 15%.
Key Words: Airways • Jet ventilation • Lung cancer surgery • Sleeve pneumonectomy
Lung cancers with carinal involvement are rarely resectable. Despite recent technical refinements in tracheal surgery and bronchial sleeve lobectomy, resection of tumors with involvement of the carina remains a challenge for thoracic surgeons and anesthesiologists. Technical aspects of sleeve resection and intraoperative airway management are presented herein.
Pre-operative work-up
Pulmonary function is assessed by spirometry, arterial blood gas analysis and ventilation-perfusion lung scan. Resection is considered functionally possible without further investigations if the predictive postoperative FEV1 (calculated on the basis of spirometry and isotopic scan) is
Anesthesia and airway management
Surgical approach
Right sleeve pneumonectomy Thoracic cavity is entered through the fifth intercostal's space. Serratus anterior muscle is systematically spared. In the case of pre-operative radiation therapy, it is harvested to be subsequently transposed intrathoracically for protection of tracheo-bronchial suture. Possible adhesions between lung and parietal pleura are sectioned. The thoracic cavity is inspected to rule out pleural carcinosis. Lung parenchyma and elements of hilum are palpated to ascertain the extension of primary tumor and to rule out associated lung nodules. The lateral aspect of the mediastinum is then approached. The pleura is opened circumferentially around the pulmonary hilum. Nodal stations 2, 4, and 7 are explored to check for possible nodal disease. Resectability of metastatic nodes (especially after induction treatments) should be confirmed before undertaking resection. Pulmonary veins are infrequently involved by the tumor and may be often easily dissected and encircled. Tumoral involvement of main pulmonary artery is variable. If no invasion is present it is dissected and encircled in its extra-pericardial portion (Video 1). Otherwise an intra-pericardial dissection of the main pulmonary artery may be necessary. In some instances, it is carried out in its inter-cavo-aortic portion. Invasion of superior vena cava may be associated. If resection is considered indicated, it is carried out according to the techniques published elsewhere in this collection.
The vascular elements of the hilum are now under control. The lung is then retracted upward and the sub-carinal region exposed. Full nodal dissection (station 7) is carried out (Video 2). Haemostasis is achieved by electrocoagulation and metallic clips. Dissection of the region also allows exposition of the posterior-inferior aspect of left mainstem bronchus. Its dissection is continued over the first 2–3 cm. Nodal dissection of stations 8 and 9 is also carried out.
Nodal dissection of paratracheal (stations 2 and 4) nodes is then performed. Precarinal region is also completely dissected. The right tracheo-bronchial angle is explored. In the case of pure endobronchial involvement of the carina and more distal lung cancer, dissection of this angle is easily accomplished. If a neoplastic involvement of the region (by direct tumor extension or nodal disease with extracapsular spreading) exists, dissection is often more difficult. Division of the azygos vein arch is often useful to improve exposition. In some instances, tumoral infiltration of the vein may require partial resection with en bloc exeresis with the operative specimen. Trachea is dissected and encircled with an umbilical tape cranially to its possible tumoral involvement. While trachea should be freed anteriorly to improve mobility for subsequent anastomosis, care is taken to prevent unnecessary devascularization by excessive dissection of its postero-lateral aspects. Dissection of the carinal region is continued over the anterior-superior aspect of the left mainstem bronchus, which is exposed and dissected (Video 3). This allows encircling of the left main bronchus with an umbilical tape.
Resectability has thus been verified and the resection phase will begin. The inferior pulmonary vein, the superior pulmonary vein, and the pulmonary artery (Video 4) are sutured by a mechanical stapler and divided. In the case of proximal infiltration, vascular clamping may be necessary.
At this point, the position of the endobronchial tube is checked and the tube is eventually withdrawn if needed. Two types of carinal resection are possible: partial carinal resection (wedge resection) and complete carinal resection. In the case of partial resection, the endobronchial tube may be left in place. In the case of bulky tumors, the right mainstem bronchus may be sectioned at its origin (although in a possibly infiltrated area) and the lung is put away from the operative field to facilitate further resection (Video 5). Carinal wedge resection (which is feasible in the case of carinal infiltration limited to the origin of right main bronchus) implies preservation of the left tracheo-bronchial angle with a small amount of wall of the left main bronchus. This type of carinal resection allows partial preservation of vascularization of the carinal region. Partial tracheal resection is started obliquely cranially to the right tracheo-bronchial angle, whereas partial resection of left mainstem bronchus implies an oblique section started on the medial aspect of the bronchus. These steps of carinal wedge resection may be sometimes performed with the endobronchial tube in place in the left main bronchus, as shown in Video 6, but retrieval of the tube and jet ventilation (as described in the following paragraph) is preferable because of improved visualization of both tracheal and bronchial edges as well as easier placement of stitches. Tracheo-bronchial anastomosis is carried out by separate 4-0 or 3-0 polydioxanone stitches. All the stitches are passed before starting knotting. Stitches on the membranous walls are knotted last in order to minimize traction on more fragile tissues.
If total carinal resection is carried out, the endobronchial tube is withdrawn several centimetres and positioning of its extremity in the trachea, cranially to the anticipated area of section, is checked by palpation. As for partial carinal resection, section of right bronchus at its origin facilitates further maneuvers of airway resection. The right lung is put away from the operative field, the endoluminal aspect of carinal region is inspected through the right bronchus stump and subsequent tracheal and bronchial sections are carried out during a few moments of apnea. Both trachea and left mainstem bronchus are entirely cut, the trachea transversally, the bronchus slightly obliquely to compensate size discrepancy in the subsequent anastomosis. Extent of resection on each side is guided by data of pre-operative work-up and inspection through the stump of right bronchus. The specimen of carinal resection is sent to the pathology laboratory for frozen sections. The reconstruction phase is performed under high-frequency jet ventilation. The ventilation tube is secured with a stitch passed across its distal hole to prevent accidental extubation. The jet-ventilation catheter is introduced by the anesthesiologist in the endotracheal tube and positioned by the surgeon in the left mainstem bronchus. The anastomosis between the trachea and bronchus is performed for the mediastinal part of the suture with a running suture with a resorbable polydioxanone 4-0 monofilament. The running suture is in a first step passed and secondly tied and knotted to two additional separate stitches (one for each extremity) (Video 7). Knots are placed extraluminally. For the superficial part, the suture is made by simple interrupted anastomotic sutures of 3-0 (for the cartilaginous portion) or 4-0 (for the membranous portion) polydioxanone. All the stitches are passed before starting knotting. The sutures are placed in a concentric fashion 3 to 4 mm apart from the cut edge of the airway, such that the knots will lie outside the airways when tied. If size discrepancy between the two anastomotic edges exists, suture positioning implies different distances between stitches on the two edges. After completion, anastomosis is submitted to a hydro-pneumatic test and covered by pleura and surrounding tissues (Video 8). In case of pre-operative radiation therapy, a pedicled muscular flap is used to wrap the anastomosis. A single thoracic drain (relied to a balanced chest drainage unit) is put in the pleural cavity, and thoracotomy is closed in the standard fashion.
Left sleeve pneumonectomy through thoracotomy It is even a more challenging procedure as compared to right sleeve pneumonectomy, because of anatomical differences. The presence of aortic arch is responsible for increased difficulties in surgical access to carinal region. The initial phases of exploration and dissection are similar to right sleeve pneumonectomy. Pleura is opened along the pulmonary hilum and pulmonary veins are dissected as usual. The sub-aortic window is approached. In this area, which is potentially infiltrated by the tumor, care is to be taken to identify the left recurrent laryngeal nerve which has to be protected if possible. Its resection is necessary in case of neoplastic infiltration. If the primary tumor or infiltrating metastatic nodes are present in this region, resection en bloc with the pulmonary hilum will be carried out. The pulmonary artery is dissected in its extra- or intra-pericardial (more frequently) portion according to the extent of tumoral infiltration. Division of the ligamentum arteriosum is often necessary. Dissection of subcarinal region is then started. A naso-gastric tube helps in respect of esophageal wall. Pulmonary veins and artery are then sectioned as above described for right sleeve pneumonectomy. Further dissection of the airway is strongly facilitated by retrieval back into the trachea of the endobronchial tube. Upward traction of the lung allows exposition and dissection of the subcarinal region. Station 7 nodes are removed and the origin of right mainstem bronchus entirely dissected. Downward traction of the lung facilitates dissection along to left mainstem bronchus up to its origin. The tracheo-bronchial angle is exposed and inferior paratracheal nodes dissected. Mobilization of the aortic arch may facilitate dissection of this region. Dissection is continued upwards along the trachea. Trachea and right mainstem bronchus are encircled in an umbilical tape. Further maneuvers of tracheo-bronchial resection and anastomosis follow the same rules as in right sleeve pneumonectomy, but technical difficulty is increased. The intratracheal retrieval of the ventilation tube and the use of jet ventilation are mandatory to accomplish left sleeve pneumonectomy.
Left sleeve pneumonectomy through sternotomy With respect to the dissection of airways, dissection of trachea is started at the level of the innominate artery (Video 9). Its mobilization is necessary to perform a tension-free anastomosis. Care is taken to respect the adventitial plane of the innominate artery, which is encircled with an umbilical tape and gently retracted upward. The inferior portion of trachea is exposed in the inter-aortico-caval space. At this moment of operation paratracheal nodes are removed (Video 10). While dissection is continued caudally, the precarinal region is encountered. The right pulmonary artery is pulled caudally and the origin of both mainstem bronchi exposed (Video 11). The subcarinal region is exposed and nodal dissection of this station carried out. Dissection of right mainstem bronchus is generally easier as it is free from tumoral infiltration. The origin of mainstem-bronchus is possibly involved by an extraluminal tumoral infiltration. If this is the case, resectability depends on the possibility of achieving dissection from surrounding non-resectable structures (i.e. aortic arch and esophagus). As long as dissection is continued along the bronchus, a combined transmediastinal/transpleural/transpericardial approach may be used to completely dissect the subaortic region. Opening of the pericardium and section of the ligamentum arteriosum allows control of the origin of the left pulmonary artery and, if necessary, of the superior pulmonary vein. The trachea is then encircled upward to the anticipated zone of section; the right mainstem bronchus is dissected up to origin of right upper lobe bronchus and encircled. Vascular elements of lung pedicle are also encircled. Once dissection of the tumor is almost entirely achieved, the resection phase of the operation starts. Pulmonary veins are sectioned (generally after stapling with a mechanical device). Pulmonary artery is either sectioned after stapling or after clamping, in case of very proximal involvement.
The anesthesiologist withdraws the tube in the proximal trachea. Trachea and right mainstem bronchus are sectioned circumferentially during a short period of apnea. A jet-ventilation catheter is descended along the tube, and positioned with care by the surgeon inside the sectioned right mainstem bronchus. The anastomosis is confectioned according to the same rules as previously described: a running suture for the deep aspect and separate stitches for the superficial aspect. Once the anastomosis is finished, dissection of the distal portion of the left main bronchus from esophagus and inferior aspect of aortic arch is completed, allowing removal of the operative specimen. The anastomosis is checked by a hydro-pneumatic test and covered by surrounding tissue or by a pedicled muscular flap. Drainage and wound closure are performed as usual.
Sleeve pneumonectomy is a challenging procedure associated with a non-negligible mortality, with figures ranging from 8 to 15% [1,2,3,4]. In our experience, dealing with 65 patients (58 treated by right sleeve pneumonectomy, 2 by left sleeve pneumonectomy, and 5 by isolated carinal resection), overall operative mortality was 7.7%. Mortality among patients treated by sleeve pneumonectomy was 8.5% whereas there was no death among those receiving isolated carinal resection [1]. The morbidity of procedure is also relatively high, with figures approaching 50% [2]. In our experience, postoperative pneumonia and supraventricular arrhythmias represented the most frequent complications [1]. Anastomotic complications are not infrequent in this type of surgery: Mitchell et al. [2] reported a 17.2% rate, a figure taking into account necrosis, separation, stenosis, bronchial mucosal slough, and excessive granulation tissue formation. In the series by de Perrot et al. [3], nine anastomotic dehiscence and three local necrosis were observed among the 119 patients treated by carinal resection. Anastomotic fistula is associated with a high mortality rate (approximately 45% [2]) and its management is often challenging. Chest drainage is generally mandatory in this condition in an emergent setting, but associated procedures have been proposed, including carinal re-resection [2,5], and silicone stenting [2]. Of note, carinal re-resection is associated with an extremely high mortality rate [5]. In our opinion, if the anastomotic fistula is compatible with spontaneous or mechanical ventilation (when required by patient's respiratory status), the condition is best managed by a three-step procedure including initial tube drainage, followed by open-window thoracostomy and intrathoracic flap transposition [6]. Prevention of anastomotic problems is thus mandatory: avoiding excessive de-vascularization, preparation of a tension-free suture (by using release maneuvers and avoiding resections longer than 4 cm), and meticulous technique of anastomosis, contribute to lower the incidence of this complication. Carinal resection provides microscopic free margins (R0) in the majority of patients [1,2,3], which is an important prognostic factor. Nodal status is the other relevant prognostic factor, as patients with N2 disease have survival rates lower than 15% [1,2,3]. Overall, 5-year survival rates range between 25–45% [1,2,3,4, 7, 8].
Sleeve pneumonectomy is a relatively infrequent procedure and remains a challenge for thoracic surgeons. Management of patients with tumors requiring this operation is difficult in terms of pre-operative selection and operative technical difficulties from both an anesthesiologic and a surgical point of view. In spite of this, results of this operation are especially encouraging in the case of complete resection and absence of mediastinal nodal involvement.
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Summary
Introduction
40% of predicted FEV1 and provided that no major hypoxemia (<60 mmHg) or hypercapnia (>46 mmHg) exists. Otherwise, an exercise test with determination of maximum oxygen uptake (
O2) is performed. Operative risk is considered acceptable if the maximum 
15 ml/kg/min. In the presence of values between 15 ml/kg/min and 20ml/kg/min, patients are considered at relatively high risk and definitive decision is based on a complex evaluation taking into account the predictive postoperative FEV1, PO2, PCO2, maximum 
