Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass.
Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
J Thorac Cardiovasc Surg. 2019 May;157(5):2073-2083.e1. doi: 10.1016/j.jtcvs.2018.11.130. Epub 2018 Dec 15.
Complete resection of neoplasms involving the carina are technically challenging and have high operative morbidity and mortality. This study examines the last 2 decades of clinical experience at our institution.
Medical records were retrospectively reviewed between 1997 and 2017 to identify all patients who underwent carinal resection. Primary outcome measures include risk factors for complications and overall survival.
In total, 45 carinal resections were performed with a median follow-up of 3.4 years (interquartile range 0.8-8.5). Procedures included 21 neocarinal reconstructions (48%), 14 right carinal pneumonectomies (30%), 9 left carinal pneumonectomies (20%), and 1 carinal plus lobar resection (2%). Age ranged from 27 to 74 years, and 23 of 45 patients were female. Eight received neoadjuvant chemotherapy and 6 preoperative radiation. Extracorporeal membrane oxygenation and cardiopulmonary bypass were intraoperatively used for 4 patients with no mortality. Four patients underwent superior vena cava resection and reconstruction. Anastomotic complications occurred in 5 patients, all of which were managed conservatively: 1 required stent placement and a second underwent hyperbaric oxygen therapy. Postoperative events were observed in 26 patients (58%), including pneumonia (n = 11), blood transfusion (n = 8), and atrial arrhythmias (n = 8). More serious complications, such as acute respiratory distress syndrome, occurred in 3 patients. Postoperative events were most closely associated with pulmonary resection (P = .040). There were 3 deaths, yielding an overall operative 30- and 90-day mortality of 6.8% and 7%, respectively.
Despite advances in perioperative management, carinal resection poses challenges for both patient and surgeon. Preoperative chemotherapy, radiation, and concomitant pulmonary resection were associated with increased risk of complications. Patient selection and meticulous surgical technique contribute to reduction in morbidity and mortality.
肿瘤累及隆突的完全切除术在技术上具有挑战性，且手术发病率和死亡率较高。本研究回顾了我院过去 20 年的临床经验。
1997 年至 2017 年间对病历进行回顾性分析，以确定所有接受隆突切除术的患者。主要研究终点为并发症和总生存率的危险因素。
共进行了 45 例隆突切除术，中位随访时间为 3.4 年（四分位距 0.8-8.5）。手术方式包括 21 例新隆突重建术（48%）、14 例右隆突全肺切除术（30%）、9 例左隆突全肺切除术（20%）和 1 例隆突加肺叶切除术（2%）。年龄 27-74 岁，45 例患者中有 23 例为女性。8 例接受新辅助化疗，6 例接受术前放疗。4 例患者术中使用体外膜肺氧合和心肺转流，无死亡。4 例患者行上腔静脉切除术和重建术。5 例患者出现吻合口并发症，均经保守治疗：1 例需支架置入，1 例需高压氧治疗。26 例（58%）患者术后出现并发症，包括肺炎（n=11）、输血（n=8）和房性心律失常（n=8）。3 例患者出现更严重的并发症，如急性呼吸窘迫综合征。术后事件与肺切除术最密切相关（P=0.040）。共有 3 例死亡，总手术 30 天和 90 天死亡率分别为 6.8%和 7%。
尽管围手术期管理有所进步，但隆突切除术对患者和外科医生都具有挑战性。术前化疗、放疗和同时行肺切除术与并发症风险增加相关。患者选择和精细的手术技术有助于降低发病率和死亡率。
