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Right Upper Lobe Sleeve Resection

  • Thomas A. D'Amico
    Correspondence
    Address reprint requests to Thomas A. D'Amico, MD, Assistant Professor of Surgery, Duke University Medical Center, Box 3496, Durham, NC 27710
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    From Duke University Medical Center, Durham, NC
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      The indications for right upper-lobe sleeve resection include an endobronchial malignancy originating in the right main bronchus adjacent to the upper lobe orifice, within the upper lobe orifice, or at the bifurcation of one of the upper-lobe segmental orifices with proximal extension into the right main bronchus. The decision to perform a sleeve resection instead of a standard upper lobectomy or a right pneumonectomy is based on anatomic and physiological considerations. If a complete resection is accomplished with a standard right upper lobectomy, a sleeve resection is not indicated. If the surgeon suspects that a positive bronchial margin will result, or if an intraoperative frozen section confirms a positive margin, a sleeve resection is the procedure of choice when it affords a complete resection. Lesions that significantly involve the right main bronchus or bronchus intermedius are best managed with pneumonectomy, if the pulmonary reserve is adequate.
      The preoperative assessment includes determination of the extent of resection necessary to achieve a complete resection and estimation of pulmonary reserve. The chest computed tomographic (CT) scan often confirms the presence of an endobronchial lesion and may show hilar and mediastinal adenopathy. Extensive hilar adenopathy precludes successful sleeve resection and implies that pneumonectomy is required to achieve complete resection.
      Bronchoscopy shows endobronchial involvement, and preoperative biopsies are performed to confirm the histology of the lesion and to determine the local extent of disease. The most common malignancy requiring sleeve resection is squamous cell carcinoma; however, sleeve resection may also be performed in patients with endobronchial adenoid cystic carcinoma, carcinoids, or bronchial adenomas. The bronchoscopic appearance that is most amenable to sleeve resection is a tumor emanating from a segmental orifice (apical, posterior, or anterior), with extension into the right main bronchus that would preclude standard lobectomy. Involvement of the right main bronchus with tumor usually requires pneumonectomy. Biopsy of the adjacent bronchial mucosa is performed to assess the extent of mucosal extension.
      Preoperative pulmonary function testing is considered in determining the extent of resection. In most patients with endobronchial lesions in the right upper lobe, the obstructed lobe contributes little to pulmonary function and sleeve resection results in minimal loss of pulmonary reserve. Pulmonary function testing remains important in predicting complications and is essential in considering whether a pneumonectomy would be tolerated. Quantitative ventilation and perfusion scans may be required to assess the expected loss of pulmonary function after resection in patients with proximal endobronchial lesions.

      SURGICAL TECHNIQUE

      Standard methods of airway management are employed for sleeve resections, and a right upper-lobe sleeve resection is best accomplished if a left-sided dual-lumen endotracheal tube is properly placed. Posterolateral thoracotomy provides for adequate exposure of the hilum, carina, and mediastinal lymph nodes. The thorax may be entered in the fourth or fifth intercostal space, or, alternatively, through the bed of the resected fifth rib.
      Figure thumbnail fx1
      1The conduct of the sleeve resection requires wider exposure than is usually required for standard lobectomy or pneumonectomy. When entering the chest, thorough exploration is performed to confirm the location of the primary tumor, to assess the hilar and mediastinal lymph nodes, and to exclude both secondary lesions and pleural dissemination. A complete hilar and mediastinal lymph node dissection is performed first, and frozen section analysis of mediastinal lymph nodes performed when appropriate. Extensive bronchial lymphadenopathy is a contraindication to bronchoplasty. The inferior pulmonary ligament is divided and the horizontal and oblique fissures are completely developed. Control of the pulmonary arteries and veins is obtained. The apical anterior trunk and the ascending posterior segmental arteries are ligated and divided. The segmental tributaries of the superior pulmonary vein are ligated and divided, excluding the middle lobe vein. The azygos vein is ligated and divided. Dissection of the anterior surface of the right main bronchus and bronchus intermedius, including bronchial and interlobar lymph nodes, is performed. The right lateral surface of the trachea and carina are exposed.
      Figure thumbnail fx2
      2The bronchus intermedius is transected distal to the tumor, at the orifice of the middle lobe bronchus. At this point, the tumor may be visualized for final assessment of resectability. The right main bronchus is then transected near the carina, in order to optimize the proximal margin and blood supply. These lines of transection minimize size discrepancy. The upper lobe and bronchial sleeve are submitted for frozen section analysis of the margins before completing the anastomosis. A stay suture is placed in the right lateral wall of the main bronchial stump and in the bronchus intermedius, and the cuffs are assessed for size discrepancy.
      The anastomosis is begun by placing a row of sutures in the cartilaginous portions of the bronchus; the proximal and distal cuffs are then drawn together with care, using the stay sutures to minimize tissue trauma. Any tension in the anastomosis can not be tolerated. An inferior hilar release maneuver may be performed at this point, if necessary. If the bronchial cuffs can be approximated without tension, the row of sutures are secured.
      Figure thumbnail fx3
      3A second row of sutures may then be placed in the membranous portion, and secured. Compensation for size discrepancy is accomplished by one of various methods. By using a larger interval between the proximal than on the distal bronchus, the discrepancy is minimized equally over the circumference of the anastomosis. Alternatively, the discrepancy may be compensated entirely within the membranous portion. After completion, the anastomosis is examined for air leakage under water. The anastomosis may be wrapped with a pedicled intercostal muscle or pericardial fat pad, in order to minimize the risk of bronchovascular fistula. Hemostasis is ascertained prior to closure, which is performed in routine manner, and the patient is extubated immediately, if possible.

      COMMEOTS

      The primary goal of right upper-lobe sleeve resection is to preserve pulmonary function without compromising survival.
      • Cerfolio RJ
      • Deschamps C
      • Allen MS
      • et al.
      Mainstem bronchial sleeve resection with pulmonary preservation.
      Careful patient selection is extremely important in determining the success of the procedure, and preoperative CT scan and bronchoscopy may be used to evaluate hilar and mediastinal adenopathy and to define the extent of resection.
      A detailed operative plan, including airway management, is also invaluable. The airway is best managed with a left-sided dual lumen endotracheal tube; however, other methods may be employed, such as placing a bronchial blocker in the right main bronchus or directly intubating the left main bronchus.
      A complete hilar and mediastinal lymph node dissection is mandatory before resection. In patients with benign disease, such as histoplasmosis, significant hilar involvement may best be managed with laser, dilatation, or stent placement. In patients with malignant disease, significant hilar lymph node involvement should be treated by pneumonectomy.
      After complete hilar and mediastinal dissection, the distal bronchotomy is initially performed, and the distal airway is inspected. After the proximal transection, frozen section analysis is performed on both margins before completing the anastomosis.
      The most important technical aspect of the anastomosis is the elimination of tension, which may be accomplished with full hilar mobilization, division of the inferior pulmonary ligament, and intrapericardial release, if necessary. The anastomosis is performed with interrupted 4-0 sutures, and either polypropylene or polydioxanone may be used. Full-thickness or subepithelial suture techniques may be employed, with equivalent results. Although a size mismatch may be present, compensation is usually achieved best with sutures that allow for gradual minimization of the discrepancy over the entire circumference of the anastomosis.
      Patients should be extubated early to decrease the exposure of the anastomosis to positive pressure. The postoperative care is directed toward optimizing pulmonary toilet. Fiberoptic bronchoscopy is routinely per formed on the first postoperative day to examine the anastomosis and to aspirate retained secretions, if present. Pulmonary toilet is ascertained aggressively with conservative measures. The need for repeated bronchoscopy is dictated by the status of pulmonary toilet.
      The overall complication rate is 15% to 30%, and the mortality is 5% to 8%.
      • Tsuchiya R
      Bronchoplastic bronchovascular techniques.
      The most common short-term complications include retention of secretions, pneumonia, and respiratory insufficiency. Kinking of the pulmonary artery secondary to bronchial foreshortening is rare.
      Long-term complications include local recurrence (10%),
      • Lowe JE
      • Tedder M
      • Sabiston Jr, DC
      Bronchoplastic techniques in the surgical management of benign and malignant pulmonary lesions.
      benign stricture (5%), and the development of bronchovascular fistula (3%). Preoperative irradiation chemotherapy may increase the likelihood of bronchovascular fistula. The overall 5-year survival for patients who undergo sleeve lobectomy for cancer is approximately 40%. The 5-year survival for patients with ipsilateral mediastinal lymph nodes disease who undergo sleeve lobectomy is less than 10%.

      References

        • Cerfolio RJ
        • Deschamps C
        • Allen MS
        • et al.
        Mainstem bronchial sleeve resection with pulmonary preservation.
        Ann Thorac Surg. 1996; 61: 1458-1463
        • Tsuchiya R
        Bronchoplastic bronchovascular techniques.
        in: Pearson FG Delauriers J Ginsberg RJ Thoracic Surgery. Churchill Livingstone, New York, NY1995
        • Lowe JE
        • Tedder M
        • Sabiston Jr, DC
        Bronchoplastic techniques in the surgical management of benign and malignant pulmonary lesions.
        in: Sabiston Jr, DC Spencer FC Surgery of the Chest. ed 6. Saunders, Philadelphia, PA1995