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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

Gross resected specimen (case 2) which shows left endobronchial growth with extra-luminal component
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Figure 3: Gross resected specimen (case 2) which shows left endobronchial growth with extra-luminal component

Mentions: A 50-year-old gentleman presented with cough, hemoptysis and progressive dyspnea of 4 years duration. Fibreoptic bronchoscopy showed an endobronchial polypoidal lesion in left main bronchus; the lesion was completely occluding the bronchial lumen and was extending 1 cm above carina. Right main bronchus and lobar bronchi were normal on bronchoscopy. CECT of chest with virtual bronchoscopy revealed a well-defined homogenously enhancing soft tissue mass measuring 3.6 × 3.1 cm seen in left peri-bronchial location; the mass had intraluminal component in left main bronchus and was extending into the tracheal bifurcation. There were fibro-bronchiectatic changes in the left lung with volume loss; however, right lung was normal [Figure 2]. Pulmonary function test showed FEV1 of 1.58 l (52% of predicted), FVC of 2.44 l (66% of predicted) and FEV1/FVC of 64.55%. Bronchoscopy-guided biopsy confirmed adenoid cystic carcinoma. He was planned for left carinal pneumonectomy through median sternotomy. He was intubated with single-lumen endotracheal tube. After median sternotomy, anterior and posterior pericardium was opened; SVC was isolated and retracted toward 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. He was placed on CPB; ventilation was switched off. Trachea was divided 2.5 cm above the carina and right bronchus was divided 1.5-cm beyond carina; 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 reinserted and CPB was reversed. The left lung was adherent densely to the parieties and heart was also deviated to the left side. In order to facilitate the delivery of specimen underneath the arch of aorta and to completely mobilize the left lung, a transverse anterior thoracotomy was made through 4th inter-costal space. After the left carinal pneumonectomy specimen was delivered, thoracotomy and median sternotomy wounds were closed over left thoracic tube drainage. 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 4 hours later after hemodynamic stabilization. His postoperative period was uneventful. Figure 3 displays the gross resected specimen which shows left endobronchial growth with extra-luminal component. Microscopic examination confirmed adenoid cystic 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)

Gross resected specimen (case 2) which shows left endobronchial growth with extra-luminal component
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 3: Gross resected specimen (case 2) which shows left endobronchial growth with extra-luminal component
Mentions: A 50-year-old gentleman presented with cough, hemoptysis and progressive dyspnea of 4 years duration. Fibreoptic bronchoscopy showed an endobronchial polypoidal lesion in left main bronchus; the lesion was completely occluding the bronchial lumen and was extending 1 cm above carina. Right main bronchus and lobar bronchi were normal on bronchoscopy. CECT of chest with virtual bronchoscopy revealed a well-defined homogenously enhancing soft tissue mass measuring 3.6 × 3.1 cm seen in left peri-bronchial location; the mass had intraluminal component in left main bronchus and was extending into the tracheal bifurcation. There were fibro-bronchiectatic changes in the left lung with volume loss; however, right lung was normal [Figure 2]. Pulmonary function test showed FEV1 of 1.58 l (52% of predicted), FVC of 2.44 l (66% of predicted) and FEV1/FVC of 64.55%. Bronchoscopy-guided biopsy confirmed adenoid cystic carcinoma. He was planned for left carinal pneumonectomy through median sternotomy. He was intubated with single-lumen endotracheal tube. After median sternotomy, anterior and posterior pericardium was opened; SVC was isolated and retracted toward 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. He was placed on CPB; ventilation was switched off. Trachea was divided 2.5 cm above the carina and right bronchus was divided 1.5-cm beyond carina; 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 reinserted and CPB was reversed. The left lung was adherent densely to the parieties and heart was also deviated to the left side. In order to facilitate the delivery of specimen underneath the arch of aorta and to completely mobilize the left lung, a transverse anterior thoracotomy was made through 4th inter-costal space. After the left carinal pneumonectomy specimen was delivered, thoracotomy and median sternotomy wounds were closed over left thoracic tube drainage. 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 4 hours later after hemodynamic stabilization. His postoperative period was uneventful. Figure 3 displays the gross resected specimen which shows left endobronchial growth with extra-luminal component. Microscopic examination confirmed adenoid cystic 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