P7. Left carinal pneumonectomy with right bronchoplastic reconstruction via left thoracotomy

Objectives: Surgery for lung cancer involving the carina requires special surgical techniques and airway management. Left carinal pneumonectomy is challenging surgery; therefore, it has been associated with relevant controversy as to the type of surgical approach.

Methods: The authors refer technical aspects of a left carinal pneumonectomy with right main bronchus resection, which required complex tracheo-bronchial reconstruction. Pretreatment staging was cT3N1MO. Anesthesia was administered by long, armored endotracheal tube into the right main bronchus under bronchoscopic control. Through a left thoracotomy, the left lung was resected with pericardectomy and partial excision of the muscular wall of the esophagus, but with positive margins on the left tracheo-bronchial orifice. Therefore, the carina was resected; unfortunately, the first tumor-free frozen sections were confirmed on the trachea over the bifurcation and on the intermediate bronchus on the right side. The opposite intermediate bronchus was intubated through the operative field with sterile tube, the right upper and intermediate bronchi were anastomosed, and this bronchial neo-orifice was sutured to the trachea. After the posterior part of the trachea and bronchial neo-orifice were anastomosed, the cross-field tube was withdrawn, and the patient was ventilated through the endotracheal tube left in place under the anastomosis. This suture was completed by the knotting of the anterior stitches. The pericardium was reconstructed by bovine patch, autologous pericardium was used for the extramucosal esophagoplasty. Definitive staging was yT4N2M0.

Results: The patient had an uneventful postoperative course. Postoperative radiotherapy of 45 Gy was administered due to malignant lymphadenopathy in 3 of 11 nodes. A suspect hipbone metastasis diagnosed 13 months postoperatively was treated by cyber-knife without the possibility of histological confirmation. After 30 months after diagnosis, multiple skeletal metastases were observed. Despite a systemic treatment, the patient died 36 months after diagnosis due to brain metastases.

Conclusions: This operation was indicated with curative intent, we believe that ultimately had a good palliative effect. Extended resections of T4 carcinomas can be undertaken in highly selected patients with acceptable morbidity and mortality, but the long-term results of such burdensome surgery still remain unclear. Nevertheless, the final success of any oncological therapy has not as yet been achievable without adequate local control.

Keywords: Non-small cell lung cancer (NSCLC); pneumonectomy; thoracotomy; bronchoplastic reconstruction