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Free Oral Sessions: Thoracic Anaesthesia and Surgery

Carinal resection: anaesthetic management and results after two years' experience: O-45

Jiménez, M J.ª; Martínez, E.; Caro, A. G.; Fita, G.; Rovira, I.; Matute, P.; Gomar, C.; Gimferrer, J. Mª; Macchiarini, P.

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European Journal of Anaesthesiology: June 2007 - Volume 24 - Issue - p 14

Introduction: Carinectomy is considered the treatment of choice in lesions of the tracheal carina or tracheobronchial angle. Its usefulness for carcinoma is still controversial and represents a challenge for surgeons and anaesthesiologists [1,2]. The aim is to present our two years of surgery experience.

Method: Between April 2005 and November 2006, fourteen patients with non-small cell lung cancer underwent carinal resection and mediastinal dissection. Clinical notes were reviewed retrospectively: age, sex, length of stay, tumour staging, histopathological diagnosis, complementary treatment (chemotherapy, radiotherapy), type of surgery, approach, anaesthetic management (TIVA technique), monitoring of cerebral activity by BIS and Somanetics® (SrO2 cerebral), protective ventilation with very low tidal volumes (TV) and apnoeic hyperoxygenation as a ventilation technique during the tracheobronchial anastomosis), postoperative complications, mortality and length of hospital stay.

Results: Twelve males and 2 females (mean age 55 ± 8.6 years), underwent carinal resection. Five had received neo-adjuvant chemotherapy; 9 underwent sleeve pneumonectomy, 4 right lobectomy with carinal resection and one, only carinal resection. The approach was median sternotomy in 6 patients and right thoracotomy in 8. Hypercapnia secondary to low TV and apnoeic oxygenation was the main anaesthetic management problem; hypoxaemia occasionally needed cross surgical field ventilation. Fluid overload, repetitive pulmonary atelectasis and high oxygen blood concentration were avoided. All patients were extubated within 24 hours after surgery. Mortality was 7% (1 patient in the first year) and morbidity rate was 64% (9 patients). Purulent tracheobronchitis, haemodynamic instability and pneumothorax, being the main complications. Suture dehiscence occurred in one case (7%). Length of hospital stay was 17 ± 21 days and survival was 79% after a follow-up (4-24 months).

Conclusions: Carinal resection is a feasible procedure despite previous neo-adjuvant treatment. The anaesthetic management is particularly difficult and requires a learning curve for intraoperative and postoperative events. However in centres with expertise these procedures show a low rate of pitfalls and complications.

References:

1 de Perrot M, Fadel E, Mercier O, et al. Long term results after carinal resection for carcinoma: does the benefit warrant the risk? J Thorac Cardiovasc Surg 2006; 131: 81-89.
2 Mitchell JD, Mathisen DJ, Wright CD, et al. Resection for bronchogenic carcinoma involving the carina: long-term results and effect of nodal status on outcome. J Thorac Cardiovasc Surg 2001; 121: 465-471.
© 2007 European Society of Anaesthesiology