Objective: Carinal resection is the most complicated procedure in tracheobronchial surgery. The main aspects of the technique are still debated at the present time. We present our experience of 231 carinal resections with analysis of operative techniques, complications and long-term survival. Methods: Since 1979 we have performed 231 carinal resections. Indications for surgery included lung cancer in 151 cases (65.4%), non-bronchogenic carcinoma in 45 (19.4%), main bronchus fistula with short stump in 25 (10.8%), stenosis of tuberculous and nonspecific etiology in nine (4%), and trauma in one case (0.4%). We have performed 156 right-sided resections (67.5%) and 75 left-sided (32.5%). In 162 cases carinal pneumonectomy was undertaken, carinal resection following pneumonectomy was performed in 28 cases, isolated resection of bronchial bifurcation was performed in 25 cases, and in 15 cases we combined lobectomy and resection of bifurcation. The length of resection extended from one to nine tracheal rings. The operative approach was lateral thoracotomy in 102 cases (44.2%), and sternotomy in 129 (55.8%). Results: Thirty-seven patients died postoperatively (16%). Complications were observed in 82 patients (35.4%), dominated by anastomotic problems which occurred in 58 cases (25.1%). The most frequent causes of death were respiratory distress syndrome and anastomotic dehiscence (P < 0.05). Mortality and the incidence of complications were significantly correlated to length of resection, laryngeal nerves injury, and mode of intraoperative ventilation. Conclusions: The feasibility of carinal resection is limited by the patient's functional status and extension of tumor growth. Thorough selection of patients may improve immediate and long-term results.

/pdf/indications-and-results-of-sleeve-carinal-resection-3p96i8wpga.pdf

Indications and results of sleeve carinal resection

Surgery remains the best curative option in patients with early stage lung cancer (stage I and II). Developments in minimally invasive techniques now allow surgeons to perform lung resections on elderly patients, patients with poor pulmonary function or significant cardiopulmonary comorbidities. New techniques, such as stereotactic radiotherapy and ablative procedures, are being evaluated in early-stage lung cancer and may represent an alternative to surgery in patients unfit for lung resection. Perioperative mortality rates have dropped significantly at most institutions in the past two decades and complications are managed more efficiently. Progress in imaging and staging techniques have helped cut futile thoracotomy rates and offer patients the most adequate treatment options. Large randomised trials have helped clarify the role of neoadjuvant, induction and adjuvant chemotherapy, as well as radiotherapy. Surgery remains an essential step in the multimodality therapy of selected patients with advanced-stage lung cancer (stage III and IV). Interventional and endoscopic techniques have reduced the role of surgery in the diagnosis and staging of nonsmall cell lung cancer, but surgery remains an important tool in the palliation of advanced-stage lung cancer. Large national/international surgical databases have been developed and predictive risk-models for surgical mortality/morbidity published by learned surgical societies. Nonetheless, lung cancer overall survival rates remain deceptively low and it is hoped that early detection/screening, better understanding of tumour biology and development of biomarkers, and development of efficient targeted therapies will help improve the prognosis of lung cancer patients in the next decade.

https://err.ersjournals.com/content/errev/22/129/382.full.pdf

Surgery for nonsmall cell lung cancer.

OBJECTIVES: Lobectomy with an en-bloc chest wall resection is an effective but potentially morbid treatment of lung cancer invading the chest wall. Minimally invasive approaches to lobectomy have reduced morbidity compared with thoracotomy for early stage lung cancer, but there is insufficient evidence regarding the feasibility of hybrid thoracoscopic lobectomy chest wall resection. We reviewed our experience with an en-bloc chest wall resection and lobectomy to evaluate the outcomes of a hybrid approach using thoracoscopic lobectomy combined with the chest wall resection where rib spreading is avoided. METHODS: All patients who underwent lobectomy and en-bloc chest wall resection with ribs for primary non-small cell lung cancer from January 2000 to July 2010 were reviewed. Starting in April 2003, a hybrid approach was introduced where thoracoscopic techniques were utilized to accomplish the pulmonary resection and a limited counter incision was used to perform the en-bloc resection of the chest wall, avoiding scapular mobilization and rib spreading. Preoperative, perioperative and outcome variables were assessed using the standard descriptive statistics. RESULTS: During the study period, 105 patients underwent en-bloc lobectomy and chest wall resection, including 93 patients with resection via thoracotomy and 12 patients with resection via the hybrid thoracoscopic approach. Complete resection was achieved in all patients in both groups. Tumour size and the extent of resection were similar in the two groups. There were no conversions and no perioperative mortality in the hybrid group. Post-operative outcomes were similar, although patients who underwent the hybrid approach had a shorter length of stay (P= 0.03). CONCLUSIONS: A hybrid approach that combines thoracoscopic lobectomy and chest wall resection is feasible and effective in selected patients. The use of a limited counter incision without rib spreading does not compromise oncologic efficacy. Further experience is needed to determine if this approach provides any advantage in outcomes, including post-operative morbidity.

/pdf/feasibility-of-hybrid-thoracoscopic-lobectomy-and-en-bloc-7od1zhdxme.pdf

Feasibility of hybrid thoracoscopic lobectomy and en-bloc chest wall resection †

Our findings indicate that arch distance-to-maximum tumor diameter ratios can be a supportive tool used by radiologists and surgeons to determine pleural invasion category and surgical indications for T3 and T4 invasion.

https://pubs.rsna.org/doi/pdf/10.1148/radiol.12120864

Use of CT to Evaluate Pleural Invasion in Non–Small Cell Lung Cancer: Measurement of the Ratio of the Interface between Tumor and Neighboring Structures to Maximum Tumor Diameter

Recognizing that surgical treatment is still the best option for controlling lung cancer, surgeons want an operation to be performed when the benefits clearly outweigh the possible risks, and when it has been determined that cancer resection is the most appropriate course of management. The necessity for a compulsive attitude toward preoperative assessment is therefore to be emphasized. Approximately 45% of all lung cancers are limited to the chest, where surgical resection is the most effective method of controlling the disease. Patients with tumour (T) 1, node (N) 0 and T2N0 tumours have early lung cancer, and most are curable by resection, with 5‐yr survival rates in the range 75–80% for patients with T1N0 status. The “gold standard” of surgery remains lobectomy. Stage T1N1 and T2N1 carcinomas represent a group of patients in whom the disease involves hilar and bronchopulmonary nodes. This group is best treated by complete resection and mediastinal lymphadenectomy. Survival data following surgical resection of T3 tumours clearly show better survival in patients with T3N0 disease than in those with T3N1–2 disease. Five-year survival rates for completely resected T3N0 lesions are in the range 30–50%. Once N1 disease is present, survival decreases to 15–20%. Incomplete resections fail to cure and surgery is not indicated if N2 disease is documented preoperatively. On occasion, T4 tumours involving the carina or vertebral body can be completely resected but T4N1–2 lesions are virtually incurable by surgery. The presence of mediastinal lymph node metastasis (N2/N3 disease) is an ominous prognostic sign and stage III‐b disease, by virtue of metastatic contralateral nodes, is an absolute contraindication to surgical resection. Induction treatments with chemoradiation have shown prolongation of survival and three randomized trials have demonstrated a survival advantage over surgery alone.

https://erj.ersjournals.com/content/erj/19/35_suppl/61s.full.pdf

Current surgical treatment of nonsmall cell lung cancer 2001

Complications of tracheal sleeve pneumonectomy: Personal experience and overview of the literature

Non-small Cell Lung Cancer With Chest Wall Invasion* Evolution of Surgical Treatment and Prognosis in the Last 3 Decades

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Complications of tracheal sleeve pneumonectomy: Personal experience and overview of the literature

Non-small Cell Lung Cancer With Chest Wall Invasion* Evolution of Surgical Treatment and Prognosis in the Last 3 Decades