Definition & Overview
Carinal reconstruction is a medical procedure used as part of the treatment for a damaged tracheal carina. The tracheal carina is a ridge of cartilage that divides the two main bronchi of the lungs. It is located in the lower part of the trachea and is near the 5th thoracic vertebra. It tends to rise and fall as a person breathes. The carinal is quite sensitive and is responsible for triggering cough reflexes. It can, however, succumb to damage due to tracheobronchial injury or abnormal tissue growth.
Due to the location of the carina, reconstruction is considered as a demanding procedure that carries considerable risk for the patient.
Who Should Undergo and Expected Results
Carinal reconstruction can be recommended for patients who suffer from a damaged tracheal carina, which could be due to disease or traumatic injury. Most traumatic injuries to the carina are caused by tracheobronchial injury, or injury to the airways that occur close to the carina. Studies show that tracheobronchial injury affects the area within 2.5cm of the carina up to 60% of the time, making carinal reconstruction necessary. The most common type of injury is a tear in or near the carina, which can result from blunt force or penetrating trauma to the chest or neck.
Tracheal injury can also occur as a result of aspiration of liquids and foreign objects as well as inhalation of harmful smoke or chemical fumes. When not treated, tracheal injuries can cause stenosis and airway obstruction, which can result in a life-threatening condition. As such, some patients who suffer from such injuries require emergency care.
Symptoms of tracheal injury or a damaged carina include:
- Dyspnea or difficulty breathing
- Dysphonia or a hoarse, breathy voice
- Abnormal breathing sounds
- Blood-tinged sputum
Damaged tracheal carina can also be caused by tumours or lesions on the carina itself. The tumours can be centred on the carina, but this is not always the case. In the majority of cases, the tumours are related to or caused by lung cancer. In others, they occur due to adenoid cystic or squamous cancers of the trachea that spread to the carina.
Carinal tumours are quite difficult to treat, partly because of their highly complex location. Thus, the procedure used to excise the tumour and reconstruct the carina needs to be performed by skilled surgeons. The outcome of the procedure is also affected by proper patient selection, the severity of the injury, and the stage of the tumour at the time of diagnosis. In general, early detection can improve a patient’s chance of survival.
Despite the complexity of the procedure, studies show that the surgical resection of the tumour followed by carinal reconstruction is the most effective treatment for tumours in the tracheal carina. However, the procedure is not widely performed as some experts believe that its benefits are very limited compared to its risks.
How is the Procedure Performed?
Different techniques and approaches are used to perform carinal reconstruction. The specific method may vary depending on the unique circumstances surrounding the patient’s condition, such as the extent of the tumour and its location.
In some cases, the resection involves lobectomy or bilobectomy of the upper, lower, or middle lobes of the lungs, depending on the extent of the disease. In others, it is combined with pulmonary resection or pneumonectomy.
Typically, carinal reconstruction is performed following the steps outlined below:
- Prior to the procedure, the patient undergoes some tests and scans. These include x-ray, computed tomography (CT), and electrocardiography scans. CT scans of the abdomen and the brain, as well as bone scintigraphy, are also performed to rule out metastasis. Due to all these tests, patients are confined at the hospital at least 3 to 5 days before the procedure.
- Patients also undergo bronchoscopy to assess the extent of the tumour and the possibility of requiring resection.
- For the actual procedure, the patient is placed under general anaesthesia, which is administered intravenously.
- An epidural catheter is sometimes also used to provide post-operative pain relief.
- Surgeons typically use a long, flexible endotracheal tube. They usually enter the chest through the right or left fifth intercostals space through thoracotomy.
- If lung resection is necessary, the surgeon performs it first.
- The surgeon then moves on to the reconstruction. Two-thirds of the trachea and the left main bronchus are first anastomosed.
- The surgeon then trims about one ring of the cartilage from the remaining one-third of the trachea.
- The right bronchus is then anastomosed to the trimmed area. Anastomosis can be performed either end-to-side or end-to-end.
Surgeons performing carinal reconstruction have to make sure that blood supply to the trachea and bronchus is continuous. They also need to reduce tension at the anastomosis.
Possible Risks and Complications
Patients who undergo carinal reconstruction are at risk of:
- Wound dehiscence
- Respiratory tract neoplasms
- Anastomotic leakage
- Pulmonary function failure
- Anastomotic stenosis
Also, in the case of tumours and lesions, carinal resection and reconstruction does not guarantee against recurrences.
Liu XY, Liu FY, Wang Z, Chen G. “Management and surgical resection for tumors of the trachea and carina: experience with 32 patients.” World J Surg. 2009 Dec;33(12): 2593-8. http://www.ncbi.nlm.nih.gov/pubmed/19830481
Yamamoto K, Miyamoto Y, Ohsumi A, Imanishi N, Kojima F. “Surgical results of carinal reconstruction: An alternative technique for tumors involving the tracheal carina.” The Annals of Thoracic Surgery. 2007 July. 84(1):216-220. http://www.sciencedirect.com/science/article/pii/S0003497507002032