Carinal resection for bronchogenic cancer

Traditionally, high technical morbidity and mortality and uncertain long-term survival have been associated with carinal surgery for bronchogenic carcinoma. However, growing evidence exists that judicious indications, meticulous surgery, and also perioperative management can decrease surgical mortality. Contraindications include patients whose tumors are so extensive that reconstruction would be under tension and those with involved precarinal and paratracheal nodes. Patients with diseased subcarinal nodes might benefit from surgery. Right carinal pneumonectomy is the most common carinal procedure, and the safe limit of resection is approximately 4 cm between the lower trachea and contralateral main bronchus. Small lesions involving the carina only may be resected without pulmonary resection with somewhat greater resectional limits. Right upper lobe tumors involving the carina may also be completely resected by saving the right middle and lower lobes and fashioning a new carina. Fatal early (noncardiogenic pulmonary edema) and late (anastomotic dehiscence or separation) complications after carinal pneumonectomy may be preventable by limiting mediastinal lymphatic dissection and perioperative intravascular fluid overload. A limited tailored thoracoplasty and transposition of the latissimus and serratus muscles into the postpneumonectomy pleural space can mitigate anastomotic complications. If these recommendations are respected, the technical mortality rates of carinal pneumonectomy can equal those observed after conventional pneumonectomy, and 5-year survival rates in excess of 40% can be expected for NO-1 patients. Invasion of the carina by bronchogenic carcinoma should not be considered by itself a surgical contraindication because the potential for cure is not elusive.