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He devised the operation as a lung-sparing technique for the resection of centrally located pulmonary tumors. Paulson and Shaw are credited with popularizing the technique in the United States in the 1950s.
Currently, sleeve lobectomy is accepted as the standard of care for lung tumors extending into the central airways. Since the tumor tends to obstruct the lobar bronchus, leading to postobstructive atelectasis, patients have functionally lost the affected lobe’s contribution to overall pulmonary function. Sleeve lobectomies tend to be well tolerated because they remove only the affected lobe and a small portion of the attached airway.
With the exception of tumors that affect all lobar orifices or have extensive longitudinal main pulmonary artery involvement, a sleeve lobectomy is feasible for all tumors invading the main bronchus or any lobar bronchi. Although a right upper lobe sleeve is the most common and straightforward procedure, a sleeve lobectomy can be performed on any lobe, including the right lower lobe with preservation of the right middle lobe. Even extensive main bronchial involvement is amenable to sleeve resection by extending the airway resection to involve the entire mainstem bronchus. The remaining lobe(s) is reimplanted into the carinal opening and airway diameter mismatches are reconciled with bronchoplastic techniques. Limited pulmonary artery involvement can be treated with a combined bronchial and pulmonary artery sleeve resection. Finally, it is our practice to perform a sleeve lobectomy whenever the tumor is visible as a fungating mass emanating from a segmental airway. Although these tumors may sometimes be successfully resected utilizing a standard lobectomy, we feel the additional margin obtained with a sleeve lobectomy may reduce the risk of local recurrence.
Before performing a sleeve resection, patients undergo a metastatic workup with a brain magnetic resonance imaging and a positron emission tomography scan to rule out distant disease. A contrast-enhanced chest computed tomography (CT) with reformatted two- and three-dimensional airway images provide detailed information of the longitudinal extent of airway involvement, while a flexible bronchoscopy further assesses the extent of endobronchial involvement. The information gleaned from these two studies is used to determine the feasibility of a sleeve lobectomy. Given the central location of these tumors, a mediastinoscopy is performed. Patients found to have regional nodal involvement are treated with neoadjuvant chemoradiotherapy and are then restaged with a chest CT scan to determine if they are candidates for sleeve resection.
We prefer to perform a sleeve lobectomy through a posterolateral thoracotomy. Shingling of the fifth rib may allow for improved access to enable secure, airtight knots. Intercostal muscle flaps are harvested and used to wrap airway anastomoses to reduce the risk of bronchopleural and bronchovascular fistula. The periosteum should be removed to prevent possibility of extrinsic anastomotic compression from bone regeneration. Dissection of the main bronchus is limited to a few millimeters to either side of the segment to be resected and the pleural incisions are likewise limited. Limiting the extent of dissection helps preserve the blood supply along the bronchus as well as from the pleural and surrounding tissues, helping to reduce the risk of anastomotic dehiscence.
Centrally located lung tumors, which invade the lobar or main bronchus, can be treated with either a pneumonectomy or a sleeve lobectomy. There are no randomized prospective studies comparing the two treatment modalities. However, six large retrospective series consistently demonstrate that sleeve resection is associated with at least equivalent and possibly improved 5-year survival.
The largest series published to date compared 1250 consecutive patients from a single institution who underwent either a sleeve lobectomy (n = 184) or a pneumonectomy (n = 1046). Sleeve lobectomies were always performed when technically feasible. Compared with the pneumonectomy group, the sleeve lobectomy group was associated with reduced operative mortality (1.6% versus 5.3%) and improved 5-year survival (52% versus 31%, P < 0.0001). The survival improvement was statistically significant for early-stage disease, but not for stage III disease. Local recurrence rates were lower in the sleeve group compared with the pneumonectomy group (22% versus 35%).
When technically possible, a sleeve lobectomy is preferred over a pneumonectomy. It preserves lung parenchyma and is associated with reduced morbidity and mortality when compared with pneumonectomy. As such, sleeve lobectomy is currently considered the standard of care.