Clinical experience with carinal resection

Objective: Pathologic processes that involve the carina pose a tremendous c hallenge to thoracic surgeons. Although techniques have been developed to a llow primary resection and reconstruction, few institutions have accumulate d sufficient experience to allow meaningful conclusions about the indicatio ns and the morbidity and mortality rates for this type of surgery. Methods: Since 1962, 135 patients have undergone 143 carinal resections (134 primar y resection, 9 re-resection) at our institution. Indications for carinal re section included bronchogenic cancer (58 patients), other airway neoplasms (60 patients), and benign or inflammatory strictures (16 patients). Thirty- seven patients (28%) had a history of prior lung or airway surgery not invo lving the carina, Carinal resection without pulmonary resection was accompl ished in 52 patients; 57 patients had carinal pneumonectomy (44 right, 13 l eft); 14 patients had carinal plus lobar resection, and 11 patients had car inal resection after pneumonectomy (9 left, 2 right). There were 15 differe nt modes of reconstruction, based on the type and extent of resection, Tech niques were used to reduce anastomotic tension. Results: The operative mort ality rate in the 134 patients after primary carinal resection was 12.7%, A dult respiratory distress syndrome was responsible for 9 early deaths. Pred ominant predictors of operative death included postoperative mechanical ven tilation (P = .001), length of resected airway (P = .03), and development o f anastomotic complications (P = .04), Mortality rates varied by the type o f procedure and the indication for resection, Left carinal pneumonectomy wa s associated with a high operative mortality rate (31%), Complications were noted in 52 patients (39%), including atrial arrhythmias (20 patients) and pneumonia (11 patients). Anastomotic complications, both early and late, w ere seen in a total of 23 patients (17%) and resulted in death or surgical reintervention in 21 patients (91%). The operative mortality rate for carin al re-resection was 11.1%. Conclusions: Carinal resection with primary reco nstruction may be accomplished with acceptable mortality rates, but the und erlying pathologic process and chance for long-term survival must be carefu lly considered before the operation is recommended, especially in the case of left carinal pneumonectomy, Anastomotic complications exact a heavy toll on involved patients, Careful patient selection and meticulous anesthetic and surgical technique remain the key to minimizing morbidity and mortality rates.