Adult Chest Surgery

Chapter 66. Sleeve Resection/Bronchoplasty for Lung Cancer 

The importance of parenchymal preservation during pulmonary surgery was realized over 50 years ago when descriptions of bronchial resection and reconstruction were first published.1–3 Since then, considerable technical refinement and anatomic insight have greatly expanded indications for lung-sparing operations. Bronchoplastic resections form one category of these procedures and have a unique set of indications. There is no question that these operations are technically more demanding than standard anatomic pulmonary resections, yet, by appreciating their benefits, the additional time spent performing these procedures is justly rewarded.

The terms bronchoplasty and bronchoplastic resection have been applied to a wide variety of operations of either main or lobar bronchi. The operations usually involve concomitant parenchymal resection. Indications for resection and reconstruction of the bronchus alone are rare. Although some thoracic surgeons have interchanged right upper lobe bronchoplasty with right upper lobe sleeve resection, a lobar bronchial orifice (e.g., right upper lobe) occasionally can be reconstructed without resecting a sleeve of main bronchus.

INDICATIONS

The standard indication for bronchoplastic resection is an intrabronchial lesion emanating from either the main bronchus itself or a lobar bronchus with main bronchus encroachment. The extent of the diseased area must allow for reconstruction after the resection. Etiology is often a low-grade neoplasm such as typical carcinoid or mucoepidermoid4 or, rarely, isolated bronchial stenosis secondary to granulomatous disease, trauma, foreign body, or benign neoplasm.5,6 Bronchoplastic resections can be applied to more invasive cancers (non-small cell lung cancer (NSCLC) or metastases), but oncologic principles, namely, achieving a complete resection (including a negative margin), must be followed.7 The naive mind-set that a positive margin simply can be radiated postoperatively must be avoided. Regardless of operation, if an incomplete resection could be predicted preoperatively, the patient likely would benefit greater from chemoradiation therapy as definitive therapy or, at least, as induction therapy (i.e., administered preoperatively).

The issue of N1/N2 lymph node involvement clearly complicates the decision to proceed with a lung-sparing bronchoplastic resection versus pneumonectomy or bilobectomy. To date, there are no data to suggest that larger parenchymal resections provide a higher cure rate for stage II or stage III lung cancer. In fact, pneumonectomy appears to be a risk for mortality after induction therapy for resectable stage IIIA lung cancer.8Consequently, there is no compelling reason to avoid bronchoplasty for stage II or stage III lung cancer as long as a complete resection can be obtained. In addition, data from several European studies using neoadjuvant chemotherapy or radiation have permitted a bronchoplasty to be performed without additional morbidity.

Few definitive contraindications exist to bronchoplasty aside from those just discussed or the general fitness of any patient undergoing pulmonary resection of any type. Although bronchoplastic resections appear to be safe when performed after induction chemoradiation therapy (at least up to 4500 cGy), radiation therapy delivered more than 3 months before the resection should be considered a risk.

PREPARATION

Bronchoscopy is universally required for operative planning. Succeeding the classically entailed rigid instrument, flexible video bronchoscopy offers a less morbid alternative for diagnosis and initial palliative therapy. For patients presenting with obstructing pneumonia, airway patency is temporarily restored using endobronchial techniques (i.e., laser, cautery, pneumatic dilation, etc.); any infection should be effectively drained and treated before proceeding with a planned resection.

Noninvasive imaging includes a chest CT scan and, for non-small cell lung cancer or metastases, a PET scan. To complete the staging process, a mediastinoscopy (see Chap. 61) should be performed for all lung cancers. It is also helpful in bronchoplastic resections for anterior mobilization of the main stem bronchi and trachea. If N2 lymph node involvement is found (for patients with lung cancer), the patient is usually offered induction therapy before the resection or treated solely with chemoradiation.

Because epidural analgesia is an important adjunct for recovery, catheters are placed before the induction of anesthesia. Ipsilateral lung isolation usually is obtained with a contralateral double-lumen tube.

TECHNIQUES

All bronchoplastic procedures include reconstruction of the airway. (The techniques of airway surgery are reviewed.) Familiarity with the parenchymal anatomy is a necessity. Although there are standards regarding the conduct of these operations, consensus is lacking regarding the specific suture technique or type of suture one should use, and personal preference prevails with regard to these details.

Finally, my personal preference is to buttress all bronchoplasty sites. Transposed tissue pedicles include thymic (epicardial) fat pad, pleura, pericardium, and occasionally, muscle flap. The most common muscle pedicle is the intercostals. Although some do not recommend wrapping the flap circumferentially around the anastomosis out of concern for heterotopic ossification from retained periosteum, a recent series did not find this to be a problem. The serratus anterior can be used as a buttress for reconstructions after induction chemoradiation therapy.

Bronchotomy Closure

The most basic bronchoplastic technique is hand-sewn closure of a bronchial stump divided close to its takeoff from the mainstem bronchus or trachea. Often, a flap of membranous airway can be turned back over the open stump and sewn in place with interrupted 4-0 monofilament suture (Fig. 66-1). This maneuver is predicated on having enough uninvolved membranous airway to allow the repair. As with most of these procedures, accurate intraoperative margin pathology must be available. Some short bronchial stumps can be closed by simple anteroposterior reapproximation (Fig. 66-2). The surgeon must assess the quality of the tissue and have a sense of the tension under which the bronchus is plicated. Closely spacing the interrupted sutures helps to distribute tension but will not compensate for a gross error in judgment. Airway compliance should be assessed carefully before considering a bronchotomy closure. In older patients, calcium within the anterior bronchial rings can make simple closure of a very tight bronchial stump more risky, and surprisingly, the more complex sleeve resection is often the safer operation. Conversely, in younger patients, even if a small amount of the mainstem bronchus is plicated during the closure, results are excellent. Rarely should a primary closure be attempted after wedge bronchotomy (Fig. 66-3). Although this type of reconstruction often can be performed with minimal tension, the resulting kink in the airway can become a mechanical and functional obstruction postoperatively.

Figure 66-1.

 

Bronchoplastic removal (A) and closure (B) of a bronchial stump using a flap of the membranous airway.

 

Figure 66-2.

 

Alternative technique for bronchoplastic removal (A) and closure (B) of a short bronchial stump involving simple suture reapproximation.

 

Figure 66-3.

 

Primary closure of a wedge bronchotomy (A) can result in severe angulation of the airway and mechanical obstruction (B).

Bronchial Sleeve Resection

Most bronchial sleeve resections occur in the context of parenchymal (lobar) resection. Rarely, pathology isolated to the left mainstem bronchus or bronchus intermedius mandates a true resection and reconstruction of the bronchus itself. Regardless, the technique of airway surgery is similar.

Important factors to consider specific to these operations are (1) will the planned operation result in a complete resection, (2) can the repair be constructed tension-free, and (3) if not, what are the fallback options? To this end, the etiology of the disease becomes important. Specifically, for lung cancer, accurate staging is mandatory. Also, a history of prior chest surgery makes complete mobilization of the lung more difficult, and a previous coronary artery bypass may complicate a hilar release. Finally, can the patient tolerate a bilobectomy or pneumonectomy if the planned bronchoplastic resection cannot be completed safely, as would be the case if the pulmonary artery or mainstem bronchus were irreparably injured?

Any lobar resection can be accompanied by a sleeve of resected bronchus. Left-sided resections are more challenging because the aortic arch and heart tend to limit exposure. Mediastinoscopy is useful not only from a cancer staging standpoint but also in mobilizing the proximal left and right main stem bronchi and carina. Unfortunately, mediastinal adhesions that form after a remote mediastinoscopy will complicate airway mobilization. Intraoperative flexible bronchoscopy after induction of anesthesia is mandatory in every patient to confirm the location and extent of the pathology.

Right Upper Lobe Sleeve Resection

The right upper lobe sleeve resection is the most common and straightforward sleeve resection one can perform. A left-sided double-lumen tube is placed during induction of anesthesia, and the patient is positioned for a posterolateral thoracotomy. Muscle-sparing techniques can be used to enter the hemithorax at the fourth or fifth interspace. Some trapezius and posterior latissimus muscles may require division if the fourth interspace is entered. An intercostal muscle pedicle can be harvested for later use.

The lung must be fully mobilized. The anterior and posterior pleural reflections over the hilum are divided. The inferior pulmonary ligament is divided back to the inferior pulmonary vein. The chest should be surveyed carefully to ensure that no obvious contraindications for the procedure exist (e.g., pleural metastases, interlobar spread, etc.). Separation of the pulmonary arterial and venous supplies to the upper lobe and completion of the horizontal fissure and cephalad aspect of the major fissure follow.

Once the lobe is isolated, the subcarinal space is dissected until the pericardium and carina are easily visualized. This entails mobilizing the esophagus from the airway. The subcarinal lymph node packet is removed. The anterior aspect of the right mainstem bronchus and bronchus intermedius then are freed from loose fibroareolar attachments to the pulmonary artery. The ongoing pulmonary artery is distracted from the airway with gentle traction inferiorly and anteriorly.

Umbilical tapes are passed around the proximal right mainstem bronchus and the bronchus intermedius, and the proximal airway should be completely mobile (Fig. 66-4). Unless disease extends close to the carina, the proximal right mainstem bronchus should not be skeletonized, and the azygos vein seldom needs to be divided. The airway is transected in a perpendicular fashion proximally and distally (Fig. 66-4, inset). The specimen is sent for margin analysis. Determining the exact location for airway division can be aided by bronchoscopy. To reduce tension on the bronchial anastomosis, proximal and distal release maneuvers are performed. Standard proximal release maneuvers involve dissection of the anterior and, if necessary, posterior mainstem bronchus and trachea from investing fibroalveolar tissues. Since most of the proximal airway vascular supply is segmental and delivered through lateral pedicles, the airway is mobilized circumferentially above and below these lateral attachments without compromising the blood supply. Extensive, complete circumferential dissection results in ischemia at the anastomosis. For right-sided bronchoplastic resections, the left mainstem bronchus is easily mobilized by adhering to the same principle. The right mainstem bronchus, however, cannot be easily dissected for left-sided resections. Little is gained by extended (5 cm) anterior and posterior mobilization because the proximal airway still will be tethered by its lateral vascular attachments.

Figure 66-4.

 

Right upper lobe sleeve resection. After the anterior aspect of the right mainstem bronchus and bronchus intermedius are mobilized from the pulmonary artery, the artery is distracted with gentle traction inferiorly and anteriorly. Umbilical tapes are passed around the proximal right mainstem bronchus and the bronchus intermedius. (Inset) The airway is transected proximally and distally.

 

If the resection margins are free of disease, a few choices for reconstructing the airway can be considered. Interrupted suture technique has been demonstrated to be effective and reliable. For anastomoses of well-matched bronchi, a continuous suture technique simplifies the reconstruction primarily by avoiding the complex array of multiple untied sutures used for the interrupted anastomosis. Before beginning the anastomosis, the cut ends of the airway are oriented properly and tested for a tension-free coaptation. Stay sutures placed at the membranous-cartilaginous junctions facilitate coaptation (Fig. 66-5). Because of the posterolateral view, it is easy to become disoriented because the airway will be rotated almost perpendicular to its native position during the reconstruction. Palpation permits immediate identification of the membranous airway and should be repeated frequently if orientation becomes unclear during the anastomosis. Once proper alignment is established, a running suture (usually 4-0 polypropylene) is begun at the medial membranous-cartilaginous junction (which will project as the most posterior aspect of the anastomosis from the posterolateral thoracotomy vantage). The anastomosis proceeds in a mediolateral fashion in both directions. The entire membranous airway is reapproximated with this running suture and tied to a second anchoring suture placed at the lateral cartilaginous-membranous junction. The lateral (corner) stitch then is run medially (to reapproximate the cartilaginous airway) toward the apex of the airway, where it is tied to the running suture sewn in the other direction. Alternatively, the cartilaginous portion is closed with a running suture first from medial to lateral; this avoids injury to the pulmonary artery. Thereafter, the posterior membranous portion can be closed as well.

Figure 66-5.

 

Running anastomosis technique. A. Stay sutures are placed at the membranous-cartilaginous junctions of both proximal and distal airways for orientation purposes. B. Running suture technique is begun on the medial aspect of the anastomosis and proceeds laterally (in both directions) to coapt the entire membranous component and the medial half of the cartilaginous airway. C. The membranous suture is secured to a lateral anchor stitch, and this second suture is run medially toward the apex of the cartilaginous airway.

Interrupted suture technique is also an option (particularly for a size mismatch), but again, the organization of the multiple sutures becomes cumbersome. When there is a size discrepancy between the right mainstem bronchus and the bronchus intermedius, a telescoping anastomosis is performed with the membranous portion run and the anterior cartilaginous airway interrupted.

Once the bronchoplasty is completed, the anastomosis is leak tested at 25–30 cm H2O of pressure. No air leak can be tolerated from the reconstructed airway. It is customary to buttress the anastomosis with a pedicled flap of autologous tissue (e.g., thymic fat pad, pleura, or intercostal muscle), although this is of no proven benefit to airway healing. Importantly, buttressing is not the solution for lack of pneumostasis of the bronchoplasty and will not salvage a poorly constructed anastomosis. Buttressing does, however, separate the anastomosis from the pulmonary artery. This is especially important if bronchial and arterial sleeve resections are performed concomitantly.

Most patients should be extubated in the OR. The effectiveness of steroids postoperatively is unproved, but I favor an induction dose.9

Early postoperative bronchoscopy is recommended only for symptoms or air leak not explained by a parenchymal source. Mild pulmonary dysfunction from ipsilateral pulmonary edema is common. Chest tube management is identical to that in nonbronchoplastic resections. Bronchoscopy is performed at 6 weeks to assess airway healing. Unless abnormal findings are encountered, bronchoscopies are scheduled at yearly intervals, up to 5 years, for cancer surveillance.

Other Sleeve Resections

Resection of any other lobe can be combined with a bronchoplastic procedure (Fig. 66-6). While the principles of reconstruction are the same for all, there are slight differences in the anatomic concerns of each.

Figure 66-6.

 

Diagrams demonstrating other possible bronchoplastic resections.

 

For tumors of the right middle lobe bronchus (usually carcinoid), the position of the involved bronchus and tumor in relation to the superior segmental and composite basilar bronchi becomes important. It can become a very tedious, often treacherous, undertaking to attempt reconstruction if the lower lobe bronchus is cut back to the orifices of the segmental bronchi. Scalloping the distal airway in an attempt to save the superior segment complicates and jeopardizes the repair (Fig. 66-7). Because this maneuver produces a patulous membranous airway, reanastomosis can result in stenosis of the superior segment orifice and chronic atelectasis of the associated lung. In these instances, it is often better to resect the superior segment and create a more linear sewing margin.

Figure 66-7.

 

A. Technical problems can arise when the airway is scalloped to accommodate an inferior takeoff of the right middle lobe during a sleeve resection of the lobe. B. Sacrifice of the superior segment may be a better alternative.

 

A right lower lobe sleeve resection is complicated primarily by the size discrepancy between the remaining middle bronchus and the bronchus intermedius. Depending on tumor location, a flange of tissue around the middle lobe orifice can be saved and will be a much better size match for reconstruction (Fig. 66-8). When a size mismatch cannot be avoided, a telescoping technique of interrupted sutures can be used. Occasionally, the membranous portion of the bronchus intermedius can be plicated to improve sizing issues (Fig. 66-9).

Figure 66-8.

 

If possible, leaving a flange of airway around the middle lobe orifice of intermediate size is a better match and simplifies reconstruction after right lower lobe sleeve resection.

 

Figure 66-9.

 

Plication of the membranous airway also can reduce a size mismatch.

Left-sided resections are more rare and more difficult. The problem lies with exposure. The left pulmonary artery (anteriorly) and the aortic arch (posteriorly) limit access to the left mainstem bronchus from the left posterolateral approach. Extensive mobilization of the aorta often is required, and because of the difficult exposure, interrupted suture technique is the best option for reconstruction. For resection and reconstruction of the left mainstem bronchus, these issues are most critical. For an isolated proximal left main stem tumor, the bronchoplastic procedure also can be performed through a sternotomy, with or without cardiopulmonary bypass. The left mainstem bronchus is located from this exposure through the posterior pericardium just cephalad to the main pulmonary artery and to the left of the ascending aorta. Injury of the left recurrent nerve can complicateany left-sided bronchoplastic procedure. Alternatively, an isolated left main stem bronchial tumor can be approached from a right thoracotomy with good exposure posterior to the carina.

SUMMARY

Although more complex than standard parenchymal resections, bronchoplastic procedures provide lung-sparing alternatives to pneumonectomy or bilobectomy. Patient selection is critical, but in appropriately screened patient populations, excellent outcomes can be achieved.

EDITOR'S COMMENT

Any cancer operation can be accompanied by a sleeve resection of the adjacent bronchus. The main goal of this procedure is to avoid pneumonectomy and spare as much lung as possible. Dissection should proceed carefully around the bronchus but with care not to devascularize the bronchus. Although a running stitch is described, we routinely use interrupted figure of eight sutures on the cartilage side of the anastomosis. Likewise an intercostal muscle flap is routinely interposed between the bronchoplasty and the adjacent pulmonary artery.

–MJK

REFERENCES

1. D'Abreu AL, Mac HS: Bronchial "adenoma" treated by local resection and reconstruction of the left main bronchus. Br J Surg 39:355–7, 1952. 

2. Paulson DL, Shaw RR: Bronchial anastomosis and bronchoplastic procedures in the interest of preservation of lung tissue. J Thorac Surg 29:238–59, 1955.[PubMed: 14354774]

3. Paulson DL, Shaw RR: Preservation of lung tissue by means of bronchoplastic procedures. Am J Surg 89:347–55, 1955.[PubMed: 13228786]

4. Bueno R, Wain JC, Wright CD, et al: Bronchoplasty in the management of low-grade airway neoplasms and benign bronchial stenoses. Ann Thorac Surg 62:824–8; discussion 828–9, 1996. 

5. Gebauer PW: Bronchial resection and anastomosis. J Thorac Surg 26:241–60, 1953.[PubMed: 13097580]

6. Farray D, Mirkovic N, Albain KS: Multimodality therapy for stage III non-small cell lung cancer. J Clin Oncol 23:3257–69, 2005.[PubMed: 15886313]

7. Deslauriers J, Gaulin P, Beaulieu M, et al: Long-term clinical and functional results of sleeve lobectomy for primary lung cancer. J Thorac Cardiovasc Surg 92:871–9, 1986.[PubMed: 3773543]

8. Albain K, Scott C, Rusch VR: Phase III comparison of concurrent chemotherapy plus radiotherapy (CT/radiotherapy) and CT/radiotherapy followed by surgical resection for stage IIIA (pN2) non-small cell lung cancer (NSCLC): Initial results from Intergroup trial 0139 (RTOG93-09) (Abstract 2497). Proc Am Soc Clin Oncol 22:621, 2003. 

9. Rendina EA, Venuta F, Ricci C: Effects of low-dose steroids on bronchial healing after sleeve resection: A clinical study. J Thorac Cardiovasc Surg 104:888–91, 1992.[PubMed: 1405686]



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!