Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_747_Библиотеки_им_академика_М_И_Перельмана

tinue ventilation. (a) Use the existing endotracheal tube, with­drawing it temporarily whilst resecting the airway and working around it whilst undertaking the anastomosis. The bulkiness of an endobronchial double-lumen tube makes this difficult. However, if the strictured area could only accom­modate a narrow endotracheal tube, this should be left full length so that it can be advanced into the distal trachea or left main bronchus to continue ventilation during the anastomo­sis. (b) The tube, whether endobronchial or endotracheal, is withdrawn and ventilation continued using an armored, small caliber tube across the operating field into the distal trachea or left main bronchus. This prevents blood spilling into the left lung but is obtrusive and has to be removed at some stage dur­ing the anastomosis. This method is the one of choice when undertaking a Barclay reconstruction (see later). (c) The tube, endotracheal or endobronchial, is withdrawn. A nasogastric tube is inserted through the original tube into the distal tra­chea or left main bronchus and used to provide ventilation using a Venturi injector. The nasogastric tube is sutured in place to prevent it flailing around. Hemostasis is important to limit the amount of blood insufflated into the left lung. This is probably the method of choice for uncomplicated segmen­tal resection of the lower trachea or carinal reconstruction.

If the surgeon forewarns the anesthetist, pre-oxygenation

Carinal resection and reconstruction

tion by the Venturi method described above. Reconstruction is achieved by first recreating a new carina using the medial third of the circumference of both main bronchi, and anasto­mosing this double-barrelled lumen to the distal trachea as described above.

thoracotomy approach, providing continued ventila-

A variation of this technique allows resection of the

mediate bronchus and the left main bronchus to recreate the carina. If the right upper lobe bronchus can be preserved it can be subsequently anastomosed to the side of the trachea a centimeter above the main anastomosis. A small, semicircu­lar defect is created in the cartilage of the lateral wall of the trachea, at its junction with the membranous part of the tra­cheal wall.

Lung volume reduction surgery

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(residual volume greater than 180% of predicted value in my practice) that results in markedly diminished quality of life. Patient selection is as critical to a favorable outcome after LVR as the technical performance of the procedure – the lat­ter being fairly straightforward. Criteria for patient selection continue to undergo refinement, but several principles have become clear from clinical series involving the operation.

First, NETT identified a high risk group who should not be operated upon because the mortality is 16%. This group con­sists of individuals with FEV less than 20% predicted and either a diffusing capacity less than 20% predicted or homo­geneous distribution of disease.

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lobes) left with relatively preserved parenchyma, do better because in these patients resection can be targeted to the more diseased areas. In addition, patients with markedly elevated PCO2, in the opinion of the author and many others, are at higher risk after the operation. Similarly, patients with markedly elevated pulmonary artery pressures and those who are severely depleted nutritionally are not good candidates. No fixed age limit exists, but the operation should be approached with caution in patients older than 70 years. Patients who have had previous thoracotomy cannot safely undergo LVR on that side, and patients who have undergone previous sternotomy are also poor candidates due to difficulty with adhesions and subsequent prolonged air leaks.

Pulmonary complications are common after LVR, and patients should be informed preoperatively of the risks of mucous plugging requiring bronchoscopy and/or minitra­cheostomy placement, pneumonia, and prolonged air leaks. When LVR is performed by median sternotomy, imperfect sternal healing may occur because these patients have a high work of breathing, but this problem virtually always presents as only a minor ‘click’ without instability. We have had one case of frank mediastinitis in over 200 LVRs performed at our institution. The most common major morbidity of the oper­ation is respiratory failure with prolonged mechanical venti­lation, and this complication often leads ultimately to the death of the patient, if not within 30 days of the procedure. Published series of LVRs report operative mortality rates of 0–10%, with a mean of 6%. These rates may be significantly higher without careful patient selection.

The side with the more severe disease is operated on first so that single-lung ventilation is maintained for the shortest possible time on this lung. Ventilation to this side is discon­tinued as the bone incision is being made, which provides sufficient time for the slowly deflating, emphysematous lung to collapse. Usually by the time the pleural space is entered, the areas with the most perfusion are well deflated by absorp­tion atelectasis, whereas the most severely diseased areas, usu­ally at the apex, remain partially inflated.