title: Technical innovations of carinal resection for nonsmall-cell lung cancer.
abstract: BACKGROUND
  We present our perioperative management of operable nonsmall-cell lung cancer invading the tracheobronchial bifurcation and the results obtained.
  
  
  METHODS
  Fifty consecutive patients undergoing carinal surgery with radical lymphadenectomy over a 5-year period were studied.
  
  
  RESULTS
  Eighteen patients (36%) were N2 and had chemoradiation (48 +/- 6 Gy) preoperatively. Surgery included 34 carinal pneumonectomies (24 right, 10 left), 11 carinal lobectomies (n = 6) or bilobectomies (n = 5), and 5 carinal resections, with (n = 3) and without (n = 2) reconstructions. Patients were ventilated through low tidal volume controlled techniques except during airway resection and reconstruction, during which the apneic (hyper) oxygenation techniques were used. High inspiratory oxygen concentrations, multiple collapse and reexpansions, hypoperfusion of the ipsilateral lung, and fluid overload were avoided. All patients but 1 were extubated in the operating room, 7 +/- 5 minutes after skin closure. Operative mortality (less than 30 days) and morbidity were 4% (n = 2) and 37% (n = 18), respectively. All resections but 1 (98%) R1 were complete. The number of resected nodes per patient was 9 +/- 2, and 7 (22%) of the 32 patients who had negative preoperative positron emission tomography results had micrometastatic mediastinal nodes. With a median follow-up of 38 months, actuarial 5-year and disease-free survivals were 51% and 47%, respectively. Disease-free survival was significantly affected by endobronchial extension (tracheobronchial angle invasion versus less than 0.5 cm from carina, p = 0.03) and nodal status (N0 versus N1-2, p = 0.02) in the multivariate analysis.
  
  
  CONCLUSIONS
  Preoperative chemoradiation, carinal lobectomy, or left pneumonectomy, and radical lymphadenectomy do not worsen the therapeutic index of carinal surgery. The high incidence of micrometastatic nodes in positron emission tomography-negative patients justifies routine mediastinoscopy and radical lymphadenectomy.
authors.affiliation: Department of General Thoracic Surgery, University of Barcelona, Barcelona, Spain. pmacchiarini@clinic.ub.es
authors.forename: Paolo
authors.initials: P
authors.lastname: Macchiarini
authors.forename: Matthias
authors.initials: M
authors.lastname: Altmayer
authors.forename: Tetsuhiko
authors.initials: T
authors.lastname: Go
authors.forename: Thorsten
authors.initials: T
authors.lastname: Walles
authors.forename: Karl
authors.initials: K
authors.lastname: Schulze
authors.forename: Ingeborg
authors.initials: I
authors.lastname: Wildfang
authors.forename: Axel
authors.initials: A
authors.lastname: Haverich
authors.forename: Michael
authors.initials: M
authors.lastname: Hardin
mesh_terms: D000328:Adult; D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology / Q000601:surgery*; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology / Q000601:surgery*; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D008481:Mediastinoscopy; D008875:Middle Aged; D009367:Neoplasm Staging; D011013:Pneumonectomy / Q000379:methods*; D016896:Treatment Outcome