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Carina involvement & management of satellite nodule

Carina involvement & management of satellite nodule. Indications. Primary NSCLC (95%) Post-pneumonectomy stump recurrences or fistulas Primary carinal tumors. Eligibility. NSCLC tumors approaching (<0.5 cm) or invading the tracheobronchial bifurcation

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Carina involvement & management of satellite nodule

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  1. Carina involvement & management of satellite nodule

  2. Indications • Primary NSCLC (95%) • Post-pneumonectomy stump recurrences or fistulas • Primary carinal tumors

  3. Eligibility • NSCLC tumors approaching (<0.5 cm) or invading the tracheobronchial bifurcation • ≤ 4 cm of airway resection to make a R0 • No multiple (>2) N2 levels or +N3 nodes • No distant metastasis • Normal CP, liver and renal function • No contraindications: previous operation, asymptomatic SVC or muscular esophageal wall invasion, chronic steroid intake (< 5 mg/day)

  4. No-Redo mediastinoscopy

  5. Intraoperative Managemnt • Total iv anesthesia (75 min) with ↓TV controlled ventilation techniques • ↑ FiO2, multiple collapse and re-expansions, HPV & hypoperfusion of the ipsilateral lung, & fluid overload were avoided • Standard ET tube for initial intubation • Apneic hyperoxygenation technique with permissive hypercapnia

  6. Technical Advantages Size Undisturbed & Uninterrupted anastomosis Increases flexibility

  7. Right posterolateral thoracotomy Right carinal pneumonectomy Right post-pneumonectomy stump recurrence Carinal (bi)lobectomy Median Sternotomy Left Carina pneumonectomy Carina resection Left post-pneumonectomy stump recurrence Incisions

  8. Advances in left carinal resections Maximal inter-aorticocaval exposure Safer left hilus manipulation

  9. Pericardiophrenic release

  10. Primary end-to-end anastomosis (Right)

  11. Right carinal pneumonectomy

  12. Primary end-to-end anastomosis (Left)

  13. Carinal Lobectomy(ies)

  14. Secondary end-to-side anastomosis

  15. Controversies • Is a carinal pneumonectomy a better operation? • Where to do the secondary anastomosis? • Residual left main bronchus or trachea • Leave a long or short residual stump?

  16. Carinal Pneumonectomy (n=10) Simple pneumonectomy (n=10) Postoperative management • Avoid hyperinflation residual lung • Intrathoracic fluid volumes monitoring • NO/Iloprost inhalation & CPAP ventilation • Aggressive control of secretions or temporary open tracheotomy • Intrapulmonary percussive ventilation • NGT (24 to 36 hrs)

  17. Surgical Results

  18. Anastomotic Complications

  19. Oncological outcome • All but 1 had a R0 resection; • 39% of pretreated N2 pts were pathologically downstaged to N1 or N0; • PET scan was false negative in 7 (32%); • 5-years actuarial survival and DFS, 51 and 47%; • Multivariate DFS analysis: endobronchial extension (<0.5 cm from carina vs. tracheobronchial angle) and N status (N0 vs. N1 & N2)

  20. Conclusions • Surgery of the carina is very challenging • Must always respect golden rules (Grillo HC) • Carinal lobectomy is technical & oncological feasible • Technical advances have ↓mortality but not morbidity • Anastomotic complications remain lethal • Post-carinal ARDS or ALI benefit from extracorporeal respiratory support

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