1. Carinal Pneumonectomy Cameron Wright, MD Thoracic Surgery MGH 2012 Focus on Thoracic Surgery: Lung Cancer

2. Disclosures None

3. Sleeve Pneumonectomy Can be performed on either side but right side much more common Typical case is a NSCLC involving the right tracheobronchial angle Careful bronchoscopy by the surgeon crucial to delineate the extent of endobronchial disease 4 cm of trachea is the most that can be resected in the average case

4. Squamous Cell RMB

5. Adenocarcinoma RMB and Trachea

6. Submucosal Spread in RMB

7. Adenocarcinoma RMB with Subcarinal Nodal Invasion

8. Evaluation and Treatment Chest CT with IV contrast Metastatic survey (CT/PET for nodes, distant disease) Consider EBUS-FNA as preferred technique to stage the mediastinum Delay mediastinoscopy to day of resection so as to not limit tracheal mobility Ensure POP-FEV1 is adequate (Quantitative V/Q to accurately predict) Use CT/RT induction with particular caution-would favor induction chemotherapy alone if needed

9. Technique of Right Sleeve Pneumonectomy Bronchoscopy to ensure enough LMB and trachea are present for reconstruction Mediastinoscopy to sample nodes and free up anterior trachea (blood supply is lateral) Use long wire reinforced ETT (not DL ETT) to intubate LMB for thoracotomy Thoracotomy in 4th interspace, or median sternotomy

10. Technique of Sleeve Pneumonectomy Explore chest, confirm resectability Decide about SVC involvement Measure extent of tracheal involvement Divide vessels first Bring sterile ETT and airway circuit onto field (rarely need jet ventilation)

11. Technique of Sleeve Pneumonectomy Encircle trachea and LMB at proposed division sites (avoid L RLN!) Free up anterior LMB to enhance mobility Divide LMB after pulling back indwelling ETT Ventilate LMB from the field ETT Divide trachea and check margins

12. Technique of Anastomosis Place 2-0 Vicryl stay sutures 2 rings deep at 3 and 9 oclock around 1 ring with knot outside Place circumferential 4-0 Vicryl sutures about 4 mm deep and 4 mm apart while adjusting for size discrepancy

13. Anastomotic Sutures

14. Technique of Sleeve Pneumonectomy Flex chin and tie stay sutures first (left wall will have least tension) Tie 4-0 sutures next-cartilage first, then membraneous wall Check for airleaks Wrap anastomosis with fat pad or other tissue buttress Extubate patient at end of case

15. Right Sleeve Pneumonectomy

16. Left Sleeve Pneumonectomy

17. Left Sleeve Pneumonectomy-Use of Tracheal and Aortic Sling

18. Sternotomy Exposure

19. Results of Sleeve Pneunonectomy Operative mortality usually 7-10% (was 25%) Post-pneumonectomy ARDS most common cause of early mortality Anastomotic complications uncommon but life-threatening Five year survival 20 to 40% Prognostic factors: nodal status, FEV1

20. Results of Sleeve Pneumonectomy Author# CasesMortality5Y Survival Mitchell 1999 3510%42% Roviaro 2000 498%25% Mezzetti 2002 277%20% Porhanov 2002 16616%25% 7% if N2 Jiang 2009 1110%27% 7% if N2

21. Survival According to Nodal Status at the MGH

22. Tracheal Closure of Jack-A Way to Resect Up To The Carina

23. Sleeve Pneunonectomy-Conclusion Rare subset of pulmonary resections Avoid N2 disease and induction chemoradiotherapy Avoid lengthy resections of trachea Mobilize airway to reduce tension Careful anastomotic technique Wrap anastomosis