Limits...
Left carinal pneumonectomy through median sternotomy: Surgical experience of two patients.

Garg PK, Chandrashekhara SH, Keshri VK, Pandey D - Lung India (2015 Nov-Dec)

Bottom Line: Endobronchial tumors infiltrating the carina is a formidable challenge to surgeons in view of difficult surgical access to the carina, especially on the left side, problems of securing the airway intra-operatively, technically challenging anastomosis due to anatomical location, and high post-operative morbidity and mortality.We present our surgical experience of two cases of left carinal pneumonectomy which was undertaken for resectable primary salivary gland type tumors of lung.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgical Oncology, Dr. BRA Institute Rotary Cancer Hospital, New Delhi, India ; Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India.

ABSTRACT
Endobronchial tumors infiltrating the carina is a formidable challenge to surgeons in view of difficult surgical access to the carina, especially on the left side, problems of securing the airway intra-operatively, technically challenging anastomosis due to anatomical location, and high post-operative morbidity and mortality. We present our surgical experience of two cases of left carinal pneumonectomy which was undertaken for resectable primary salivary gland type tumors of lung.

No MeSH data available.


Related in: MedlinePlus

Case 1 (a) Axial CT section of chest shows the intraluminal mass (white arrow) at the origin of the left main bronchus (b) Minimal intensity projection reconstructed coronal image depicts the mass (black arrow) obstructing the left main bronchus with resultant volume loss of left lung (c) CT virtual bronchoscopy image reveals the mass projecting in the left main bronchus
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4663872&req=5

Figure 1: Case 1 (a) Axial CT section of chest shows the intraluminal mass (white arrow) at the origin of the left main bronchus (b) Minimal intensity projection reconstructed coronal image depicts the mass (black arrow) obstructing the left main bronchus with resultant volume loss of left lung (c) CT virtual bronchoscopy image reveals the mass projecting in the left main bronchus

Mentions: A 45-year-old gentleman presented with left-sided chest pain, cough, hemoptysis and progressive dyspnea of 2-years duration. Fibreoptic bronchoscopy showed an endobronchial lesion in left main bronchus extending 1 cm proximal to carina, the lesion was 2 cm proximal to left secondary carina; right main bronchus and lobar bronchi were normal. Contrast-enhanced computed tomography (CECT) of chest with virtual bronchoscopy revealed a polypoidal growth measuring 1.8 × 1.5 × 1.2 cm in the left main bronchus extending into carina, the secondary division was 2.8 cm distal to the mass [Figure 1]. Pulmonary function test showed FEV1 of 1.43 liters (49% of predicted), FVC of 1.63 litres (47% of predicted) and FEV1/FVC of 88.02%. Bronchoscopic-guided biopsy confirmed low-grade muco-epidermoid carcinoma. He was planned for carinal resection through median sternotomy. He was intubated with single-lumen endotracheal tube. After median sternotomy, anterior and posterior pericardium was opened; superior vena cava (SVC) was isolated and retracted towards right side, aortic arch was looped and retracted toward left while right pulmonary artery was pulled down. Carina was gently dissected and both right and left bronchi were also looped. The tumor was palpable till 2 cm proximal to secondary division; in order to achieve R’0’ resection and inability to achieve tension-free anastomosis between left bronchus and trachea, surgical plan was changed to left carinal pneumonectomy. We planned to resect the carina followed by intubation of the left main bronchus while anastomosis between right main bronchus and trachea was completed. We divided the carina and left main bronchus keeping 1-cm tumor-free margin. We tried to intubate the remaining left bronchus with a sterile flexo-metallic endotracheal tube through surgical field; however, the length of the remaining left bronchus was too small to accommodate the tube. We, then, ventilated the patient through right main bronchus. Patient was placed on cardio-pulmonary bypass (CPB); ventilation was switched off and anastomosis between the right main bronchus and trachea was completed with PDS 4-0 interrupted sutures. Once the anastomosis was completed, a conventional flexo-metallic single lumen endotracheal tube was re-inserted and CPB was reversed. Left pneumonectomy was completed through the same sternotomy wound. To avoid any untoward tension on the anastomotic site the chin of the patient was sutured to the anterior chest wall ensuring a slight flexion at the neck. The patient was extubated 2 hours later after hemodynamic stabilization. On first postoperative day, he had high pericardial drain bleeding, tachycardia, and hypotension. He was explored; there was pericardial margin bleeder that was controlled. Post re-exploration, he developed pneumonia that gradually worsened. He succumbed to sepsis and multi-organ failure on 7th post-operative day. Histopathological examination of the resected specimen confirmed low-grade muco-epidermoid carcinoma; all the margins were tumor-free.


Left carinal pneumonectomy through median sternotomy: Surgical experience of two patients.

Garg PK, Chandrashekhara SH, Keshri VK, Pandey D - Lung India (2015 Nov-Dec)

Case 1 (a) Axial CT section of chest shows the intraluminal mass (white arrow) at the origin of the left main bronchus (b) Minimal intensity projection reconstructed coronal image depicts the mass (black arrow) obstructing the left main bronchus with resultant volume loss of left lung (c) CT virtual bronchoscopy image reveals the mass projecting in the left main bronchus
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4663872&req=5

Figure 1: Case 1 (a) Axial CT section of chest shows the intraluminal mass (white arrow) at the origin of the left main bronchus (b) Minimal intensity projection reconstructed coronal image depicts the mass (black arrow) obstructing the left main bronchus with resultant volume loss of left lung (c) CT virtual bronchoscopy image reveals the mass projecting in the left main bronchus
Mentions: A 45-year-old gentleman presented with left-sided chest pain, cough, hemoptysis and progressive dyspnea of 2-years duration. Fibreoptic bronchoscopy showed an endobronchial lesion in left main bronchus extending 1 cm proximal to carina, the lesion was 2 cm proximal to left secondary carina; right main bronchus and lobar bronchi were normal. Contrast-enhanced computed tomography (CECT) of chest with virtual bronchoscopy revealed a polypoidal growth measuring 1.8 × 1.5 × 1.2 cm in the left main bronchus extending into carina, the secondary division was 2.8 cm distal to the mass [Figure 1]. Pulmonary function test showed FEV1 of 1.43 liters (49% of predicted), FVC of 1.63 litres (47% of predicted) and FEV1/FVC of 88.02%. Bronchoscopic-guided biopsy confirmed low-grade muco-epidermoid carcinoma. He was planned for carinal resection through median sternotomy. He was intubated with single-lumen endotracheal tube. After median sternotomy, anterior and posterior pericardium was opened; superior vena cava (SVC) was isolated and retracted towards right side, aortic arch was looped and retracted toward left while right pulmonary artery was pulled down. Carina was gently dissected and both right and left bronchi were also looped. The tumor was palpable till 2 cm proximal to secondary division; in order to achieve R’0’ resection and inability to achieve tension-free anastomosis between left bronchus and trachea, surgical plan was changed to left carinal pneumonectomy. We planned to resect the carina followed by intubation of the left main bronchus while anastomosis between right main bronchus and trachea was completed. We divided the carina and left main bronchus keeping 1-cm tumor-free margin. We tried to intubate the remaining left bronchus with a sterile flexo-metallic endotracheal tube through surgical field; however, the length of the remaining left bronchus was too small to accommodate the tube. We, then, ventilated the patient through right main bronchus. Patient was placed on cardio-pulmonary bypass (CPB); ventilation was switched off and anastomosis between the right main bronchus and trachea was completed with PDS 4-0 interrupted sutures. Once the anastomosis was completed, a conventional flexo-metallic single lumen endotracheal tube was re-inserted and CPB was reversed. Left pneumonectomy was completed through the same sternotomy wound. To avoid any untoward tension on the anastomotic site the chin of the patient was sutured to the anterior chest wall ensuring a slight flexion at the neck. The patient was extubated 2 hours later after hemodynamic stabilization. On first postoperative day, he had high pericardial drain bleeding, tachycardia, and hypotension. He was explored; there was pericardial margin bleeder that was controlled. Post re-exploration, he developed pneumonia that gradually worsened. He succumbed to sepsis and multi-organ failure on 7th post-operative day. Histopathological examination of the resected specimen confirmed low-grade muco-epidermoid carcinoma; all the margins were tumor-free.

Bottom Line: Endobronchial tumors infiltrating the carina is a formidable challenge to surgeons in view of difficult surgical access to the carina, especially on the left side, problems of securing the airway intra-operatively, technically challenging anastomosis due to anatomical location, and high post-operative morbidity and mortality.We present our surgical experience of two cases of left carinal pneumonectomy which was undertaken for resectable primary salivary gland type tumors of lung.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgical Oncology, Dr. BRA Institute Rotary Cancer Hospital, New Delhi, India ; Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India.

ABSTRACT
Endobronchial tumors infiltrating the carina is a formidable challenge to surgeons in view of difficult surgical access to the carina, especially on the left side, problems of securing the airway intra-operatively, technically challenging anastomosis due to anatomical location, and high post-operative morbidity and mortality. We present our surgical experience of two cases of left carinal pneumonectomy which was undertaken for resectable primary salivary gland type tumors of lung.

No MeSH data available.


Related in: MedlinePlus