23 - The Shared Airway: Management of the Patient with Airway Pathology
Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.
Title: General Thoracic Surgery, 6th Edition
Copyright 2005 Lippincott Williams & Wilkins
> Table of Contents > Volume I - The Lung, Pleura, Diaphragm, and Chest Wall > Section VII - Pulmonary Resections > Chapter 30 - Tracheal Sleeve Pneumonectomy
Chapter 30
Tracheal Sleeve Pneumonectomy
Yoh Watanabe
Tracheal sleeve pneumonectomy is an aggressive procedure for resection of bronchial carcinoma involving the tracheobronchial angle, carina, or lower trachea and lung. The airway is reconstructed by anastomosis of the opposite main-stem bronchus to the lower trachea. This procedure is a type of extended resection, a term suggested by Chamberlain and associates (1959).
In 1950, Abbott and associates first reported experience with the surgical resection of the carina, tracheal wall, and contralateral bronchial wall in patients undergoing right pneumonectomy. He also detailed the technical difficulties encountered in that procedure. In 1959, Gibbon also described a patient who underwent resection of the distal trachea during right pneumonectomy and anastomosis of the left bronchus to the residual trachea and survived for 6 months. After that, however, only a few reports of tracheal sleeve pneumonectomy were published for some years. Mathey and colleagues (1966) reported two patients with epidermoid carcinoma who had undergone right tracheal sleeve pneumonectomy and survived for 1.5 and 4.5 years, respectively, and Thompson (1966) reported a patient undergoing right tracheal sleeve pneumonectomy.
In 1972, Jensik and associates reported 17 cases of tracheal sleeve pneumonectomy. The results of tracheal sleeve pneumonectomy in a moderate number of patients have been reported subsequently by Jensik (1982) and Deslauriers (1979, 1989) and their associates as well as by Deslauriers (1985) and Faber (1987). However, operative mortality in these reports was 27% to 31%, and the 5-year survival rate was only 13% to 23%. In addition to these reports, the results of tracheal sleeve pneumonectomy were reported by Fujimura (1985), this author (1990a), Tsuchiya (1990), and Muscolino (1992) and their associates, as well as by Sharpe and Moghissi (1996). However, these series had fewer patients, and the results with respect to long-term survival remained unsatisfactory.
On the other hand, in recent years, Dartevelle (1988, 1995), Mitchell (2001), Roviaro (1994, 2001), and Mezzetti (2002) and their colleagues, as well as Mathisen and Grillo (1991) and Dartevelle and Macchiarini (1996), reported improved survival rates with lower operative mortality in a moderate number of patients.
SELECTION OF PATIENTS
Tracheal sleeve pneumonectomy may be considered in a patient in whom bronchial carcinoma is centrally located at the hilus of the lung with extension to involve the orifice of the main-stem bronchus or the lateral aspect of the lower trachea. The most favorable histologic type is squamous cell carcinoma, and the best results are achieved in patients with this type of lesion.
The initial step in identifying a possible candidate for this procedure is bronchoscopy. Faber (1987) reported that a large central tumor on the right side frequently caused thickening and erythema of the mucosa at the tracheobronchial angle and indicated the possibility that standard pneumonectomy would not be technically possible. Random samples for biopsy must be taken proximally to determine the possible line of division of the trachea. According to Deslauriers and Jacques (1995), tissue should be taken from any doubtful area and also in the trachea at 3 cm above the carina. Local invasion up to that level indicated that a tension-free and tumor-free reconstruction was unlikely. Dartevelle and Macchiarini (1996) concluded that invasion of the trachea beyond the lower 2 cm and contralateral main bronchus beyond 1.5 cm would produce excess anastomotic tension, so that the safe limit is 4 cm between the lower trachea and the contralateral main bronchus. Roviaro and associates (2001) performed tracheal sleeve pneumonectomy for tumors invading the main-stem bronchus that were less than 2 cm distal to the carina or that arose at the tracheobronchial angle and extended along no more than three cartilage rings on the distal tracheal wall.
Computed tomography (CT) and magnetic resonance (MR) imaging are also helpful in defining the extrabronchial extent of the lesions (Fig. 30-1). Correlation of the bronchoscopic
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and CT findings is important in determining the appropriate type of resection. With the aid of these examinations, precise delineation of the pulmonary artery, superior vena cava, and main bronchial involvement can be obtained along with detection of enlarged mediastinal lymph nodes. Local invasion of the superior vena cava is not a contraindication to sleeve pneumonectomy if tangential excision is possible. In the series of the author (1990a), Tsuchiya (1990), and Dartevelle (1988) and their colleagues, as well as Dartevelle and Macchiarini (1996) and Spaggiari and Pastorino (2000), some patients underwent concomitant resection of the superior vena cava (Fig. 30-2). Spaggiari and Pastorino (2000) performed this operation in six cases. Three patients (50%) had major complications (postpneumonectomy edema, early graft occlusion, and adult respiratory distress syndrome); however, four patients are still alive (two of them have no evidence of recurrence). They concluded that this aggressive surgery may be useful in highly selected patents in whom adequate local control achieves long-term survival.
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Fig. 30-1. A. Preoperative chest radiograph. B. Computed tomography scan of a 49-year-old man who underwent right tracheal sleeve pneumonectomy. |
Grillo (1982a, 1982b), who has done a large number of carinal resections for tracheal tumor, suggested that, in applying the procedure for bronchial carcinoma with carinal involvement, the patients should be restricted to those who are potentially curable on the basis of preoperative mediastinoscopy
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(i.e., absence of extranodal metastases, contralateral node metastasis, and upper mediastinal or extensive node metastases) and the exclusion of distant metastases. Mitchell and associates (2001) in Grillo's group concluded from their results that positive N2/N3 lymph nodes may be a contraindication to surgery because of poor prognosis. Deslauriers (1985) and colleagues (1979, 1989, 1995) recommended mediastinoscopy as part of the preoperative staging because neoplastic involvement of the superior mediastinal nodes (N2 disease) generally represents an absolute contraindication to tracheal sleeve pneumonectomy. Faber (1987) also recommended mediastinoscopy when the mediastinal lymph nodes were greater than 1 cm in diameter. Both of these authors believed that contraindications to resection were positive superior mediastinal nodes and positive contralateral tracheal nodes. Dartevelle and co-workers (1988, 1995), as well as Dartevelle and Macchiarini (1996), recommended mediastinoscopy for histologic verification, if the mediastinal lymph nodes were greater than 1.5 cm in diameter. They concluded that subcarinal lymph node involvement should not be regarded as a contraindication because such tumors were resectable en bloc with the carina, and long-term results were encouraging. However, N3 disease and ipsilateral paratracheal lymph node involvement were a surgical contraindication because there were no 2-year survivors. However, Roviaro and colleagues (2001) concluded that the presence of intracapsular mediastinal N2 lymphadenopathy does not represent a contraindication, just as it does not for conventional pneumonectomy. They did not perform routine mediastinoscopy except when N3 disease was suspected. Since 1993, however, they have routinely performed exploratory video-assisted thoracoscopy (VATS) as the very first step of the planned operation.
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Fig. 30-2. A. Preoperative chest radiograph. B. Intraoperative view. C. Schema of right tracheal sleeve pneumonectomy combined with superior vena cava resection in a 68-year-old man with squamous cell carcinoma. |
Carinal resection in patients with tumor recurrence in the bronchial stump after prior pneumonectomy is another possible surgical indication for tracheal sleeve resection. In these patients, either the right or left main-stem bronchus is anastomosed to the trachea after resection of the carina. I have performed such an operation in two patients, and the carinal resection series reported by Grillo (1982a), Deslauriers (1985), and Faber (1987), as well as Mathisen and Grillo (1991), Deslauriers and Jacques (1995), and Dartevelle and Macchiarini (1996), along with Jensik (1972, 1982), Deslauriers (1979, 1989), and Mitchell (2001) and their colleagues, have included a few cases of carinal resection after a previous pneumonectomy. Recently, Porhanov and associates (2002) reported 28 cases of carinal resection following pneumonectomy.
PREOPERATIVE ADJUVANT THERAPY IN PATIENTS WITH BRONCHIAL CARCINOMA
As preoperative neoadjuvant therapy, radiation therapy and induction chemotherapy are applicable. Jensik and colleagues (1972, 1982) recommended preoperative radiation therapy for sterilization of the mediastinal lymph nodes and the primary lesion. Twenty-five of the 30 patients in their group received radiation therapy administered from either a cobalt or linear accelerator source. The dose varied from 3,200 to 5,000 cGy, but most individuals received 4,000 cGy administered over a 4-week period. They experienced eight perioperative deaths, most of them related to the development of bronchial fistulae. It was difficult, they claimed, to incriminate preoperative irradiation as a causative factor for fistula. They also stated that the benefits resulting from reduction in tumor volume and the improvement of the lesion on bronchoscopic examination justify its use. Roviaro and associates (1994) recommended low-dosage preoperative radiation therapy to reduce tumor size to facilitate the anastomotic procedure. On the other hand, Dartevelle (1988) and Deslauriers (1979) and their associates emphasized that preoperative irradiation increases the risk for bronchopleural fistula. In our series, no one underwent preoperative irradiation. Some patients underwent bronchial arterial infusion therapy as reported by the author (2000) and co-workers (1990b); however, we have changed to systemic induction therapy for recent patients.
The effects of induction therapy for advanced lung cancer are still under evaluation. To date, Dartevelle and Macchiarini (1996), as well as Dartevelle (1995), Macchiarini (1994), and Roviaro (1994, 2001) and their associates, have applied induction therapy in patients who were candidates for sleeve pneumonectomy. Because Dartevelle's group experienced a few cases of operative deaths in patients receiving induction therapy, they concluded that the potential benefits of induction therapy should be regarded cautiously because it lowers the surgical security of an already technically demanding procedure. Veronesi and colleagues (2002) reported that, in their 27 patients undergoing bronchial sleeve resection after induction therapy (three cases of tracheal carinal resection were included), preoperative chemotherapy or a combination of chemotherapy and radiation therapy was not associated with additional risk for anastomotic complications in bronchoplastic and angioplastic procedures.
SURGICAL APPROACH
For a right tracheal sleeve pneumonectomy, I have always used a right posterolateral thoracotomy and believe it is the best approach. Muscolino and associates (1992), however, performed right tracheal sleeve pneumonectomy by an anterior thoracotomy through the fourth intercostal space in seven patients without any surgical mortality. They concluded that anterior thoracotomy might improve the surgical management of these patients. Pearson and colleagues (1984) preferred to use median sternotomy in patients requiring carinal resection. They pointed out that this technique has several advantages over a right posterolateral thoracotomy in selected cases because any type of pulmonary resection is possible through a median sternotomy. In addition, this incision also provides adequate exposure for an intrapericardial mobilization of the right pulmonary
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hilum, which also may be necessary to minimize tension on a tracheobronchial anastomosis.
With regard to left tracheal sleeve pneumonectomy, controversy exists regarding the best surgical approach, and it is also controversial whether this should be a one-stage or two-stage operation.
In the one-stage operation for left tracheal sleeve pneumonectomy, a left posterolateral thoracotomy, median sternotomy (with or without left anterior thoracotomy), or bilateral anterolateral thoracotomy (clamshell incision) can be used. Abbott and colleagues (1950), Grillo (1982a), and Salzer and co-workers (1987) reported a one-stage operation using a left posterolateral thoracotomy, but by this approach, proper exposure of the carina underneath the aortic arch is difficult, and this lack of exposure hinders performance of the anastomosis. Grillo (1982a) and Mathisen (1996) noted that, with flexion of the neck and with tapes placed around the lower trachea and the right main bronchus, it is possible to draw the airway up beneath the aortic arch and place appropriate traction sutures, excise the carina, and anastomose the trachea to the right main bronchus. Maeda and associates (1993) used left thoracotomy and compared two methods that is, drawing-down approach and drawing-up approach reported by Bjork (1955). They concluded that the drawing- down route was preferable to obtain a larger operative field without dividing branches of intercostal arteries.
Deslauriers (1989) and Gilbert (1984) and their associates, as well as Deslauriers and Jacques (1995), recommend a two-stage procedure. In the first stage, left proximal pneumonectomy is carried out, and the carina is resected from the right side 3 to 5 weeks later. They emphasize caution, however, in using this operative method. Because of the local inflammatory reaction and mediastinal shift that follow pneumonectomy, mobilization of the left main-stem bronchus stump is potentially dangerous, and one must be aware of the proximity of the left pulmonary artery stump and left recurrent laryngeal nerve.
I have done one-stage operations by median sternotomy combined with a left anterolateral thoracotomy in patients undergoing left tracheal sleeve pneumonectomy and those undergoing a carinal resection after a prior left pneumonectomy. This approach provides excellent exposure and access for lung resection as well as reconstruction procedures, which ultimately facilitates performance of the operation. Thus, I suggest and strongly recommend the median sternotomy approach combined with a left anterolateral thoracotomy for the performance of left tracheal sleeve pneumonectomy.
MAINTENANCE OF VENTILATION
Maintenance of adequate ventilation and oxygenation is of crucial importance in tracheobronchial surgery. In general, provision of ventilation is incompatible with an unobstructed operative field; a bulky endotracheal tube permits adequate ventilation but impedes access to the operative field for anastomosis.
A tube ventilation system coming from above or across the operative field is the most conventional method. Abbott and co-workers (1950) described the use of a long tube directed into the left main-stem bronchus to maintain ventilation with left endobronchial anesthesia during the operative procedure. Jensik and associates (1972, 1982) used this method in most of their patients, although it was modified in some instances with a supplementary sterile tube and connector, which is placed into the left main-stem bronchus after it is divided. The other end of the connecting tube is directed outward through the incision and over the anesthetic screen. After the first portion of the anastomosis is completed, the tube is withdrawn, and the original endobronchial tube is directed beyond the suture line into the left main-stem bronchus. The anastomosis is then completed over the tube. Geffin and associates (1969) showed that this method can be adapted to all types of carinal reconstructions. This system has the disadvantage, however, of requiring repeated tube manipulations with frequent interruption of airway suturing. If the tube runs across the operative field for example, an armored tube into the left main-stem bronchus it further restricts surgical access to the carina. Roviaro and co-workers (1994) recommend a long (45 cm), thin-caliber (5.0 to 6.5 mm) tube with self-inflating polyurethane cuff, which greatly facilitates all maneuvers.
Frumin (1959) and Heller (1964) and their colleagues described the technique of prolonged apneic oxygenation for carinal reconstruction. After hyperventilating the patient with 100% oxygen, 10 to 12 minutes of total apnea can often be tolerated. Deslauriers and associates (1979) used this technique in a few cases of tracheal sleeve pneumonectomy, but they commonly noted arrhythmias, acidosis, and hypercapnia for 15 minutes after the initiation of the prolonged apneic oxygenation. Thus, this technique is used rarely because the duration of safe apnea and the cardiovascular response are unpredictable in any individual patient.
McClish and colleagues (1985) described the value of the high-flow catheter technique after using it in 18 patients undergoing tracheobronchial reconstruction. This method has specific advantages with regard to the simplicity of the equipment and anesthetic technique. It involves positive-pressure ventilation with a high flow of gas and without air entrainment. Oxygen is applied from a high-pressure source capable of delivering it at a pressure of 50 psi and a flow of 100 L/min. Depending on the airway resistance and lung compliance, the inflation flow can be adjusted through a reducing valve to generate an airway pressure of 25 to 40 cm H2O. Deslauriers (1985) and associates (1989) now use this method preferentially.
High-frequency jet ventilation (HFJV) also can be used to provide good ventilation and oxygenation. Our group uses this ventilatory method in all our patients undergoing tracheobronchial reconstructive surgery (Fig. 30-3). El-Baz and colleagues (1981) first reported the use of HFJV in six patients undergoing tracheobronchoplastic surgery. I and my colleagues analyzed arterial blood gas values during HFJV in 21 patients receiving major airway reconstructive
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surgery, including 9 who underwent tracheal sleeve pneumonectomy. I emphasize the advantages of HFJV over classic intermittent positive-pressure ventilation using an endotracheal tube. In tracheal sleeve pneumonectomy, a relatively high driving gas pressure (1.5 to 2.5 kg/cm2) at 360 to 480 cycles per minute provides optimal ventilation and oxygenation. This method permits greater accuracy in placing and tying sutures and eliminates the need for intermittent withdrawal and reinsertion of the endotracheal tube into the contralateral main bronchus. Use of HFJV delivered through a small-bore catheter can facilitate performance of the anastomosis and thus directly contribute to the elimination of complications along the suture line and ultimately to improving the surgical outcome. In the series of Muscolino and co-workers (1992), HFJV was used. Dartevelle and colleagues (1988, 1995) and Dartevelle and Macchiarini (1996) once used Grillo's ventilation method, but they have switched to HFJV since 1982 because it improves surgical exposure, avoids endotracheal manipulations, and provides satisfactory gas exchanges.
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Fig. 30-3. The ventilatory method and blood gas analyses in a patient (75-year-old man) who underwent right tracheal sleeve pneumonectomy. DGP, driving gas pressure; DrO2, O2 content of driving gas; E:I, expiratory to inspiratory ratio; F, frequency; HFJV, high-frequency jet ventilation; IPPV, intermittent positive-pressure ventilation. |
Perelman and Koroleva (1980) reported the use of hyperbaric oxygenation. They performed the first four operations on the trachea that were ever done in a hyperbaric chamber. Compression was begun 10 to 15 minutes before entering the tracheobronchial tree. The air pressure in the operating room was raised to 2.5 to 3.0 atm, and it was possible to discontinue lung ventilation intermittently for 8 to 10 minutes.
OPERATIVE PROCEDURE
Right Tracheal Sleeve Pneumonectomy
The patient is placed in the left lateral position, and a right posterolateral thoracotomy is the approach. The thoracic cavity is entered through the fifth intercostal space. At thoracotomy, the posterior mediastinal pleura is longitudinally incised along the trachea, the right main-stem bronchus, and the esophagus from the apex to the base of the right hemithorax to expose the tracheobronchial tree. It is mandatory to ligate the azygos vein and to mobilize the trachea; the pericardium may be opened at this time. After careful observation from outside the tracheobronchial tree to detect tumor extension, the feasibility of tracheal sleeve pneumonectomy is finally determined in combination with the findings obtained by preoperative endoscopic examination. Once the decision to perform a tracheal sleeve pneumonectomy is made, the pericardium is opened along the phrenic nerve to expose the right main pulmonary artery and veins. These vessels are interrupted intrapericardially. The carina is then fully mobilized from its mediastinal bed, and tapes are passed around the lower trachea and the left and right main-stem bronchi.
Both the trachea and left main-stem bronchus are transected at the intercartilaginous ligament (Fig. 30-4A). The trachea is transected 1 cm proximal to the tumor, usually at the first or second distal tracheal ring, but sometimes transection must extend as high as 3 cm above the carina. The left main-stem bronchus is divided also at a level free of tumor, but it is seldom necessary to make the division more than one ring below the carina. Frozen sections are examined to confirm that the site of transection is free of tumor.
Before starting the reconstruction procedure, mobilization of the trachea and left main-stem bronchus is accomplished to lessen the tension at the anastomosis. The left main-stem bronchus is relatively fixed by the aortic arch. Gentle blunt dissection of this bronchus from the aortic arch and surrounding tissue is done, excluding the posterior, membranous portion. This maneuver is continued down to the left upper lobe bronchus. The trachea is pulled down in the same way, and maximal flexion of the neck fully reduces the tension at the anastomosis.
The suture material used in all patients is an absorbable one (I prefer 3-0 Vicryl). The anastomosis is commenced at the farthest point from the operator (see Fig. 30-4B). Cartilage-to-cartilage apposition of the left lateral wall of the trachea to the lateral wall of the left main-stem bronchus with the placement and tying of two sutures forms the basis of the anastomosis, and more sutures are then added to the cartilaginous part of the bronchus. Sutures are placed through the full thickness of the trachea and bronchus, making certain that the knots are tied outside of the lumen (see Fig. 30-4C). The
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membranous part of the bronchus is anastomosed as the last part of the procedure. Luminal disparity is equalized by expanding the membranous portion of the smaller bronchus and crimping that of the larger trachea (see Fig. 30-4D). Once the anastomotic procedures are completed, the suture line should be checked for air leaks, and the endotracheal tube should be located at sufficient distance above the suture line.
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Fig. 30-4. Operative procedure for right sleeve pneumonectomy. A. Transection lines for the trachea and bronchus. B. The first two stitches of the anastomotic procedure. Ventilation is maintained by high-frequency jet ventilation (HFJV) through a small-bore catheter inserted from the operative field. C. Anastomosis of the cartilaginous portion. HFJV is switched to a catheter inserted through an endotracheal tube for a completion of anastomosis at the anterior part of the cartilaginous and membranous portion. D. Equalization of luminal disparity by crimping the membranous part. E. Completion of the anastomosis. The suture line is covered circumferentially by pedicled parietal pleural flap. |
The anastomotic site is covered routinely by a circumferential pleural flap or pedicle fat flap to prevent suture leaks or dehiscence (see Fig. 30-4E). In a tracheal sleeve pneumonectomy for bronchial carcinoma, lymph node dissection of the hilar and mediastinal nodes is also performed as in routine lobectomy or pneumonectomy for malignant lung tumors.
Left Tracheal Sleeve Pneumonectomy
Left tracheal sleeve pneumonectomy is a relatively rare procedure in every series reported. As mentioned previously, controversy still exists regarding the best surgical approach and whether a one- or two-stage operation should be performed. Our group uses a one-stage operation involving median sternotomy combined with left anterolateral thoracotomy. The operation starts with median sternotomy. Exposure of the carina and main bronchus requires a transpericardial approach. The anterior pericardium is opened vertically from the level of the innominate vein to the bottom of the pericardium to permit circumferential mobilization of the ascending aortic arch, which is then retracted leftward. The posterior pericardium is incised vertically. The superior vena cava is displaced laterally and to the right. The right main pulmonary artery is exposed and displaced inferiorly. By these maneuvers, the entire mediastinal trachea and carina are clearly exposed (Fig. 30-5). Then, anterolateral thoracotomy at the fourth intercostal space is added to allow lung resection. By this approach, transection of the trachea and left main-stem bronchus for pneumonectomy and anastomosis of the trachea and right main-stem bronchus can be done easily in the same fashion as already described for right tracheal sleeve pneumonectomy. Division of the trachea at a point 1.5 cm above its bifurcation is sufficient for most tumors, but it is also possible to resect an additional length of distal trachea and elevate the right main-stem bronchus for primary anastomosis, if necessary.
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Fig. 30-5. Intraoperative view of left tracheal sleeve pneumonectomy through median sternotomy. A. Exposure of the trachea (Tr) and bronchus (Br) via pericardium. B. Transection of the distal trachea. C. Anastomotic procedure of the cartilaginous part. D. Completion of the anastomosis. Ao, aorta; PA, pulmonary artery. |
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Fig. 30-6. A. Chest radiograph taken 19 months after right tracheal sleeve pneumonectomy in a 54-year-old man shows the normal caliber of the airway at the anastomotic site. B. Bronchoscopic view of the anastomotic site 2 years after left sleeve pneumonectomy in a 66-year-old man shows a clear anastomotic line (arrow). |
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PERIOPERATIVE AND POSTOPERATIVE MANAGEMENT
As soon as the anastomosis is completed, intraoperative bronchoscopy is performed through an adapter while ventilation is maintained. The anastomotic site is observed, and blood clot or mucus is aspirated from the distal bronchus. Most patients are extubated within 4 to 5 hours after the operation. In my experience, almost all patients suffer from transient bronchorrhea, which is probably related to denervation, the interruption of lymphatics, and damage to the ciliary epithelium. It is recommended that patients be placed in the lateral decubitus position, resected side down, for postural drainage of bronchial secretions. Pernasal bronchoscopy is performed at the bedside on the first postoperative day to remove any secretions at the anastomosis and for infusion of antibiotics into the reconstructed lung. This procedure is repeated for several days, if necessary. Neck flexion is recommended for 7 days after the operation. During that time, oral intake is totally avoided, and nutrition is maintained by intravenous hyperalimentation. Figure 30-6 shows a chest radiograph and bronchoscopic findings after right tracheal sleeve pneumonectomy.
MORTALITY AND PROGNOSIS
In Table 30-1, the number of patients undergoing tracheal sleeve pneumonectomy, surgical mortality, long-term survivors, and 5-year survival rates are shown. Various reports have been done on tracheal sleeve pneumonectomy. However, most of them were results of a small number of patients with short-term follow-up. Several major reports included a moderate number of patients for evaluation of operative mortality and long-term survival rates after tracheal sleeve pneumonectomy. In 1982, Jensik and associates reported survival in 34 patients (30 right and 4 stump recurrences after prior pneumonectomy) undergoing tracheal sleeve pneumonectomy. The perioperative mortality was 29%, and the 5-year survival rate of the entire group was 15%. In 1991, Faber in Jensik's group reported final results of 40 patients in their group (36 tracheal sleeve pneumonectomies and 4 stump recurrences). Their overall operative mortality rate was 28%, and the 5-year survival rate was 20%, showing that the operative mortality was higher than the survival rate. Deslauriers and associates (1989) reported their results in 38 patients (33 right, 3 left, and 2 stump recurrences). The operative mortality rate was 29%, and the 5-year survival rate was 13%.
In recent years, however, the surgical outcomes of tracheal sleeve pneumonectomy were much improved in terms of operative mortality and long-term survival. Dartevelle and colleagues (1988, 1995), as well as Dartevelle and Macchiarini (1996), reported favorable outcomes. In 1988, they reported 55 tracheal sleeve pneumonectomies (53 right and 2 left). The overall operative mortality rate was 11%, and the actuarial 5-year survival rate, excluding six operative deaths, was 23%. In the report published in 1995, their operative mortality was reduced to 7%, and the 5-year survival rate including postoperative deaths was increased to 40%. In the report of 60 patients in 1996 (56 right and 4 left), the operative mortality rate was 3%, and the 5-year survival rate was 43%, showing encouraging results of tracheal sleeve pneumonectomy. Mathisen and Grillo (1991) reported an 8% operative mortality rate in 17 patients undergoing tracheal sleeve pneumonectomy, and Mitchell (2001) in the same group reported 35 cases with a 7% operative mortality and a 38% 5-year survival rate. Roviaro and associates (1994) reported 28 cases of tracheal sleeve pneumonectomy. Their operative mortality rate was 4%, and seven patients survived longer than 4 years, which projects to a 20% 5-year survival rate. In their recent report of 48 cases (2001), it was reported that the operative mortality rate was 8%, and the 5-year survival rate was 25%.
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Mezzetti and associates (2002) reported a 7% operative mortality rate and a 20% 5-year survival rate.
Table 30-1. Results of Tracheal Sleeve Pneumonectomy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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As shown in Table 30-1, it is true that only a few patients can survive for long among the group in which a curative operation is accomplished. Some controversy exists as to whether tracheal sleeve pneumonectomy is an appropriate procedure for bronchial carcinoma because the mortality rate is similar to the long-term survival rate. According to Mathisen and Grillo (1991), carinal resection of bronchial carcinoma has a justifiable role, if one can achieve a operative mortality rate under 10% and 5-year survival rates of 20% to 25%. Faber (1987), whose mortality rate and 5-year survival rate were 27% and 16%, respectively, reported that they had not performed tracheal sleeve pneumonectomy in the previous 3 years, probably because they have undertaken a more aggressive preoperative treatment program consisting of combination chemotherapy and radiation therapy. On the contrary, the results of Dartevelle (1995), Mitchell (2001), Roviaro (2001), and Mezzetti (2002) and their colleagues, as well as Dartevelle and Macchiarini (1996), are encouraging, and all these surgeons advocate performing tracheal sleeve pneumonectomy. From the results of their series, they concluded that tracheal sleeve pneumonectomy provides a fair survival rate in selected patients. The prognosis depends mainly on lymph node involvement; the tumors most commonly amenable are squamous cell carcinoma with N0 or N1 disease; spread to superior mediastinal nodes is a contraindication for the operation.
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