Postoperative airway stenosis and stent therapy in carinal reconstruction for lung cancer.

A 48-year-old male had adenocarcinoma of the right upper lung lobe that invaded the lower trachea. The right upper lobe, the carina, and 5 rings of the lower trachea were resected. The carina was reconstructed using end-to-end anastomosis between the trachea and right intermediate bronchus, with the left main bronchus anastomosed to the side wall of the intermediate bronchus. Two months after surgery, the right intermediate bronchus developed bronchomalacia and the tracheal anastomosis granulatory stenosis. Bronchomalacia was treated with 2 expandable metallic stents, and granulatory stenosis with a Dumon stent. Although the silicone stent successfully dilated the granulatory stenosis, the metallic stents caused delayed glanulatory stenosis. We concluded that a metallic stent is not desirable for treating postreconstructive airway stenosis including bronchomalacia, whereas a Dumon stent may be effective.     

Postoperative airway stenosis and stent therapy in carinal reconstruction for lung cancer

A 48-year-old male had adenocarcinoma of the right upper lung lobe that invaded the lower trachea. The right upper lobe, the carina, and 5 rings of the lower trachea were resected. The carina was reconstructed using end-to-end anastomosis between the trachea and right intermediate bronchus, with the left main bronchus anastomosed to the side wall of the intermediate bronchus. Two months after surgery, the right intermediate bronchus developed bronchomalacia and the tracheal anastomosis granulatory stenosis. Bronchomalacia was treated with 2 expandable metallic stents, and granulatory stenosis with a Dumon stent. Although the silicone stent successfully dilated the granulatory stenosis, the metallic stents caused delayed glanulatory stenosis. We concluded that a metallic stent is not desirable for treating postreconstructive airway stenosis including bronchomalacia, whereas a Dumon stent may be effective.     

Carinal reconstruction with wide airway resection by a new technique

Carinal reconstruction with wide airway resection by a new technique was conducted in two cases. A 61-year man with tracheal stenosis by tracheal cancer, 6 tracheal rings, 2 left bronchial rings, total right main bronchus, for which carina was resected and reconstructed by a new technique and for a 69 year man with lung cancer in right upper lobe, for which right upper-middle bilobectomy, S6 segmental resection and circumferential pulmonary artery resection were performed. The tracea, left main bronchus, and right basal segment bronchus were anastomosed by new technique and the right main pulmonary artery and basal segment artery was anastomosed subsequent to chemotherapy. Both patients discharged within seventeen postoperative days in consideration of the absence of postoperative complication. Bronchoscopic findings after reconstruction indicated neither stenosis nor dehiscence at the site of anastomosis. The new reconstructive method of carina permits simple anastomosis, the possibility of carina reconstruction even in the case of wide airway resection and loss tension at the site of anastomosis.     

Partial sleeve right pneumonectomy with carinal flap closure

We describe a technique used in 2 patients for resection of carcinoid tumor arising from the right main bronchus and extending along the lateral wall of the lower trachea. A flap was mobilized from the non-involved membranous posterior wall of the right main bronchus, which was left attached to the carina. This was used to close the defect in the lower trachea. Both patients did well after surgery and were followed-up for 10 to 17 years with no evidence of recurrence.     

Congenital absence of cartilaginous tracheal rings associated with esophageal atresia and trifurcated carina: a novel anomaly?

Tracheomalacia associated with esophageal atresia (EA) is a well-known condition. However, complete absence of tracheal rings (TRs) is extremely rare. Our aim is to describe a novel triad of conditions and to discuss the best treatment. An expremature male operated for EA presented with severe respiratory distress. The diagnosis of absent cartilage rings, suspected on bronchoscopy, was confirmed by optical coherence tomography. The absence of TRs was localized to a short tracheal segment, and the carina trifurcated into right upper lobe, right intermediate, and left main bronchus. The patient was treated with resection and anastomosis with a completely satisfactory course. Absence of TRs was previously reported by us in 2 other cases, both with associated EA and trifurcation of the carina. One child was treated with tracheostomy and the other with a stent, but the outcome was far from optimal. The patient with tracheostomy eventually underwent resection and anastomosis with tracheostomy closure. Congenital absence of TRs is extremely rare. Although localized, it is responsible for severe symptoms owing to complete tracheal collapse and may be misdiagnosed as tracheomalacia. In our experience, it has been associated with EA and trifurcated carina. Our limited experience suggests resection of the abnormal segment and tracheal anastomosis as the best treatment.     

Therapeutic strategy for a patient suffering from a peripheral pulmonary tumor in the right upper lobe and an endotracheal tumor in the carina

A 64-year-old male, who had received successful radiotherapy for the previous laryngeal cancer, was admitted to our department for the treatment of a peripheral pulmonary tumor in the right upper lobe and an endotracheal tumor in the carina. The endotracheal biopsy of the carinal tumor demonstrated squamous cell carcinoma, though preoperative examination of the intrapulmonary tumor was unable to clarify it's pathological type. The intrapulmonary tumor required right upper lobectomy and R2 lymph node dissection as a measure against the possibility of primary lung cancer. Since the endotracheal cancer was diagnosed as an intra mucosal tumor by the preoperative computed tomography (CT) scans and the bronchoscopic examination, laser abrasion therapy to the endotracheal tumor was performed 4 days before the lobectomy of the intrapulmonary tumor. After the pulmonary operation, the intrapulmonary tumor was diagnosed as squamous cell carcinoma without lymph node metastasis, and it was suggested to be a metastatic tumor of the previous laryngeal cancer. Both radiotherapy to the carina and general chemotherapy with docetaxel hydrate and carboplatin were used as adjuvant therapies 36 days after the lobectomy. One year after the pulmonary surgery, there is no recurrence of the tumor in the lung or carina. Laser abrasion therapy to the endotracheal tumor is very useful and safe for the patient, who should then receive pulmonary resection soon after the therapy.     

Anaesthesia for carinal resection

A case of adenocystic carcinoma (cylindroma) of the trachea is reported. Ventilation was successfully maintained for long periods by use of the venturi technique during resection of the carina, and during a later operation for relief of tracheal stenosis.     

气管隆突切除及重建术治疗中心型支气管肺癌

本文报告１０例侵及气管隆突或距隆突０．３ｃｍ以内的中心型支气管肺癌行气管隆突切除及重建术，其中右上叶及隆突切除重建术３例，右全肺及隆突切除２例，左全肺及隆突切除４例，左上叶及隆突切除重建术１例，加部分左心房切除术３例。本组根治切除９例。姑息切除１例。术后并发症３例（３０％）。术后无癌生存６年１例，３年１例，２年１０月１例，２年６月３例，１年２例，半年１例；另１例于术后８月死于脑转移。重点讨论了手术适应证、手术方法、围手术期监护和处理。     

A case of adenoid cystic carcinoma of the left main bronchus, which was performed carinal resection and reconstruction while the aortic arch is pulled down

A 55-year-old woman, who had treated as bronchial asthma for eight months, was admitted to our hospital. Chest CT scan showed a mass in the left main bronchus. Bronchoscopic examination revealed a tumor obstructing the left main bronchus and invading the left lower portion of the trachea. The pathologic diagnosis was adenoid cystic carcinoma. Primary resection of the left main bronchus and the carina with the objective and one-stoma-type carinal reconstruction were performed by the left thoracotomy. We pulled down the aortic arch to obtain an operative field, and carried out the operative procedure at the upper side of the aortic arch. As the resection margin contained residual tumor, the postoperative irradiation (50 Gy) was added.     

Complete surgical resection of inflammatory myofibroblastic tumor with carinal reconstruction in a 4-year-old boy

Inflammatory myofibroblastic tumor of the carina and the main bronchus is a rare tumor. The authors report here on a case of a 4-year-old boy with an inflammatory myofibroblastic tumor at the carina and extending to the left main bronchus. He presented with fever and a cough of 2 months' duration. Preoperative assessment of the tumor revealed an intraluminal round mass arising from the carina and extending into the left main bronchus, and this caused near-total obstruction of the left main bronchus and the subsequent total collapse of the entire left lung. The complete resection of the mass with carinal reconstruction was successful. The tumor was a round mass measuring 1.5 × 1 cm. It had characteristic features of an inflammatory myofibroblastic tumor, namely, the proliferation of spindle-shaped fibroblasts and myofibroblasts.     

Partial median sternotomy: anterior approach to the upper thoracic esophagus

Based upon experience with cervicothoracic esophageal carcinomas in which resection of the manubrium, adjacent clavicles, and ribs has facilitated exposure of the tumor, it has been found that a partial upper sternal split (without resection) provides access to the upper thoracic esophagus to the level of the carina. With a knowledge of the anatomic relationships of the esophagus in this area, this direct anterior approach has been used for both benign and selected malignant diseases involving the upper thoracic esophagus. A partial median sternotomy has been used in 11 patients with the following esophageal pathology: upper- and/or middle-third malignancy (six), benign upper-third stricture (three), perforation of upper-third esophagogastric anastomotic stricture (one), and cricopharyngeal achalasia in association with a chronic cervical compression fracture that prevented extension of the neck (one). The following operations were performed: blunt esophagectomy with cervical esophagogastric anastomosis (six), segmental esophageal resection with primary anastomosis (three), drainage of perforation (one), and extended cervical esophagomyotomy (one). A chylothorax developed in one patient with carcinoma, the only major postoperative complication in this group. Transient hoarseness occurred in two patients. Careful evaluation of the patient with upper thoracic esophageal pathology, focusing on the type, extent, and location of the abnormality relative to the level of the carina, as well as the habitus of the patient, often indicates that a partial sternotomy can be utilized to facilitate the operation.     

Tracheobronchoplasty for functional restoration

We have experienced 10 cases of terminal mediastinal tracheostomy (TMT), 7 cases of laryngotracheal anastomosis with subtotal resection of cricoid cartilage (LTT), 5 cases of sleeve or wedge segmentectomy (SS, WS) for lung cancer with low pulmonary function, and 5 cases of carinal reconstructions (CR) with one stomal anastomosis between left lobar bronchus and trachea after partial resection of carina for tuberculous stenosis of left main bronchus. Modified TMT which stomaplasty was constructed with cervical and anterior chest skin flap different from primary procedure by Grillo was performed in 3 cases without innominate artery rupture nor cicatricial stomal stenosis. LTT by Pearson's procedure caused telescoped anastomosis. Pulmonary function was reserved in all 5 cases of SS and WS. Salvaged left lung by single stomal CR in the cases of tuberculous stenosis functioned well. Two different approaches for subaortic arch anastomosis, namely Pull-down and Pull-up, were proposed in single stomal CR. Pull-down provided excellent exposure of the carina without sacrifice of intercostal arteries. Indication of plasty was extended by TMT and LTT for upper limits of airway resection, SS and WS for limited operation against lung cancer, and single stomal CR for tuberculous stenosis of left main bronchus.     

A bronchial glomus tumor surgically treated with segmental resection

Extracutaneous glomus tumors are unusual and their occurrence in bronchus has been recognized with rarity. We present the clinical and pathological features of a case with bronchial glomus tumor. A 67-year-old man was admitted with a symptom of cough, and his chest CT scan and fiberoptic bronchoscopy demonstrated a localized polypoid tumor in the right superior bronchial trunk. Histology of the biopsy specimen by bronchoscopy was demonstrated as a typical carcinoid tumor. The tumor was surgically resected by a segmental resection of the right superior bronchial trunk and end-to-end anastomosis was followed to reconstruct the airway tract through a standard right side thoracotomy approach. The pathological and immunohistochemical findings resulted in the diagnosis of the tumor as a bronchial glomus tumor.     

Carinal Reconstruction and Sleeve Right Upper Lobectomy Assisted with Extracorporeal Membrane Oxygenator for Non-small Cell Lung Cancer - A case report -

Bronchogenic carcinoma involving the carina has remained a challenging problem for thoracic surgeons. Carinal resection and reconstruction is limitedly indicated because this aggressive surgical approach has been reported to be associated with significant morbidity and mortality while long-term outcome has not been determined. Wesuccessfully performed carinal reconstruction and sleeve right upper lobectomy assisted with ECMO for a 60-year-old male with squamous cell carcinoma in the right upper lobe extending to the carina.     

Carinal resection of bronchogenic carcinoma

Carinal resection was performed in 10 cases of bronchogenic carcinoma during 12 year-period. The mean age of patients was 58 years, with a range of 42 to 68 years. There were 7 male and 3 female. The tumor was located on the right side in 7 cases, on the left side in 1 case on the carina in 2 cases. The histological examination showed squamous cell carcinoma in 5 cases, adenocarcinoma in 4 cases and adenoid cystic carcinoma in 1 case. The staging revealed T3N2 M0 Stage IIIA in 2 cases, T4N0M0 Stage IIIB in 1 case, T4N1M0 Stage IIIB in 1 case, T4N2M0 Stage IIIB in 5 cases and T4N3M0 Stage IIIB in 1 case. The surgical methods were as follows; sleeve pneumonectomy in 5 cases, wedge carinal resection with pulmonary resection in 3 cases (right sleeve upper lobectomy in 2 cases and right pneumonectomy in 1 case), carinal resection in 2 cases. The site of bronchial anastomosis was overlapped by thymus in 6 cases. The 30-day mortality rate in tracheo-carinal resection was 10% (one patient). Eight patients died and remaining 2 patients are still alive without any evidence of recurrence. 5-year survival rate was 36%. These outcomes were almost equal to those of surgical case in the same stage.     

局部晚期非小细胞肺癌气管隆凸切除气道重建的临床分析

目的探讨局部晚期非小细胞肺癌患者隆凸切除气道重建术的适应证,分析其临床特征和预后。方法回顾性分析我院15例气管隆凸切除气道重建肺癌手术患者的临床资料,其中单纯气管隆凸完全切除重建术1例,右全肺切除加隆凸切除重建术6例,右肺上叶切除加隆凸完全切除重建术3例,左全肺切除加隆凸切除气道重建术5例。采用Kaplan Meier法计算生存率,采用Log-rank检验比较生存期。结果手术时间155～410min（261．3±81．6min）,术中清扫纵隔淋巴结10．8±3．7枚。全部患者无围术期死亡;术后并发肺部感染2例,经呼吸机辅助通气加抗感染治疗后出院;乳糜胸1例,保守治疗后康复出院;1例患者因胸管持续Ⅱ度漏气而行开胸探查,术中发现是余肺而非气管吻合口漏气,缝扎肺组织漏气处痊愈。全组患者中位生存期为39个月,3年生存率52．5％,5年生存率22．5％。右全肺切除加隆凸重建患者中位生存期12个月,非右全肺切除患者中位生存期40个月。结论对侵犯主支气管近端及隆凸的局部晚期肺癌患者,肺切除加隆凸切除重建术可取得较为理想的治疗效果,但其中需行右全肺切除患者预后较差,采用手术治疗应慎重。     

Human papillomavirus and squamous cell carcinoma in a solitary tracheal papilloma

We report the case of a 52-year-old woman suffering from breathlessness on exertion. A chest radiograph identified a lesion in the intrathoracic trachea. A tumor 0.4 × 0.5 × 0.7 cm in size causing an approximately 80% reduction in the cross-sectional area of the trachea 3 cm above the carina was removed, and histology showed moderately differentiated squamous cell carcinoma. Intrathoracic resection of the tumor and anastomosis was performed through a right lateral thoracotomy. The final histology examination showed atypical papilloma. Polymerase chain reaction–restriction fragment length polymorphism confirmed human papillomavirus-6b in the tumor. The patient remained well 18 months after surgical intervention without recurrence.     

Delayed bronchial stenosis after blunt chest trauma with right aortic arch

We report a case of delayed bronchial stenosis after blunt chest trauma with right aortic arch. A 21-year-old male passenger was involved in a traffic accident. He was brought to an emergency hospital with severe chest pain and dyspnea, and diagnosed with multiple rib fractures, right hemopneumothorax and chylothorax. He was treated with chest tube drainage and the symptoms subsided. About 9 weeks later, he complained of exertional dyspnea and was referred to our hospital. Bronchoscopy demonstrated circumferential stenosis of the right main bronchus approximately 1 cm distal to the carina. Thoracic computed tomography and magnetic resonance imaging revealed the right aortic arch. Successful resection of the bronchial stenotic lesion was performed followed by end-to-end anastomosis through midsternotomy due to the associated right aortic arch. Postoperative bronchoscopy revealed that the site of the anastomosis was patent and his symptoms were relieved.     

Bronchoplastic lobectomy with wide wedge resection for lung cancer with long-term steroid medication

A 57-year-old man with erythrodermia, who was given 5-10 mg/day of prednisolone for 2.5 years, was admitted to our hospital for squamous cell lung carcinoma of the right upper lobe. A bronchoscopy revealed a tumor nearly obstructing the right upper lobe bronchus. A bronchoplastic lobectomy was performed with wide wedge resection of the main bronchus and truncus intermedius. A postoperative bronchoscopy revealed good healing of the anastomosis and a 3-dimensional construction of the bronchus with chest computed tomography demonstrated no stenotic change and no kinking change in the anastomosis. One year and 6 months after surgery, no local recurrence was seen in the region of bronchoplasty. Bronchoplastic lobectomy with wide wedge resection is a useful procedure in cases with risk factors of anastomotic dehiscence, such as after induction therapy or during long-term administration of adrenal cortical steroids.     

A case of carcinoma of the esophagus involving the trachea undergoing anterior mediastinal tracheostomy with pedicled omental wrapping

A 62-year-old male who complained of dysphagia, body weight loss and hoarseness was admitted to our hospital. Chest x-ray film disclosed right superior mediastinal mass compressing membranous portion of trachea. Esophageal fiberscope revealed carcinoma of cervical esophagus. Bronchofiberscope revealed the paralysis of right recurrent laryngeal nerve and the invasion of esophageal cancer to tracheal membranous portion from the 5th tracheal ring to the 12th. The cancer also invaded the right lobe of thyroid which was shown by echogram. Operation was performed. On dissecting the cervical region, it was found that the tumor invaded both sides of the trachea so that tracheal reconstruction could not be done without injuring left recurrent laryngeal nerve. Sternotomy was added. Anterior mediastinal tracheostomy was done after laryngeal resection with total thoracic esophagectomy and tracheal resection leaving 5 rings long cartilage from carina. The trachea was wrapped with pedicled omentum. Post-operative course was uneventful. This procedure helps to increase blood supply to the tracheal anastomosis and turns to advantage in preventing infectious extension around trachea to mediastinum as well as tracheal compression to major vessels.