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Pulmonary resection has been established as the treatment of choice for localized non–small-cell bronchogenie carcinoma in the healthy patient. Usually this entails lobectomy, but in certain circumstances, particularly when the tumor extends beyond the lobar bronchial orifice into the main bronchus, standard lobectomy will not accomplish a complete resection. Although pneumonectomy has traditionally been the alternative in this circumstance, sleeve lobectomy (lobectomy that involves resection of a segment of the main bronchus in continuity with that lobe) represents another logical option. Early reports of sleeve lobectomy in lung cancer proposed this technique as a compromise procedure in those patients whose pulmonary reserve was poor and insufficient to tolerate pneumonectomy.
However, subsequent published data have established that sleeve lobectomy in lung carcinoma is associated with lower morbidity and mortality than pneumonectomy (and, in fact, approaching that of standard lobectomy), a cure rate equivalent to that of pneumonectomy, and preservation of lung function commensurate with the conservation of lung parenchyma in the operated hemithorax.
The first description of conservative resection of the bronchial tree was by Sir Clement Price-Thomas.
In his report, Price-Thomas lamented having performed a left pneumonectomy in a young patient with a left upper-lobe bronchial adenoma in 1946. Therefore, in 1947, he performed a right upper-lobe sleeve lobectomy in a young royal air force cadet who would have been discharged from military service had he undergone pneumonectomy. Interestingly, Price-Thomas did not report these achievements until 1955.
Subsequently, there were other instances of sleeve resection for benign disease in the late 1940s and early 1950s. Sleeve lobectomy for lung carcinoma was promoted in the United States by Paulson et al,
mainly as a compromise procedure. In recent years, the notion of sleeve lobectomy in bronchogenic carcinoma has gained popularity, and in contemporary series, this procedure comprises 5% to 10% of elective lobectomies for lung carcinoma.
Patient Selection and Preoperative Evaluation
Traditionally, sleeve lobectomy for lung cancer was only proposed for patients who were elderly, or who had poor pulmonary function, notably where the predicted postoperative forced expiratory volume in 1 second (FEV1) was less than 1 L. Essentially, these circumstances indicated situations in which pneumonectomy, the most common alternative to standard lobectomy, posed a very high risk. Although these continue to constitute solid indications for sleeve lobectomy, sleeve resections should also be considered in virtually any situation that is anatomically favorable. These may be summarized as the following: (1) bronchoscopic evidence of endobronchial tumor extending to or beyond the lobar bronchial orifice into the main bronchus; (2) the presence of metastatic peribronchial (lobar) lymph nodes infiltrating the bronchial wall at its origin; (3) or the finding of a positive bronchial margin after an apparently straightforward standard lobectomy. The preoperative bronchoscopy is one of the most important parts of the evaluation, suggesting the possible need for sleeve lobectomy. The bronchoscopic findings should be carefully reviewed in conjunction with the computed tomographic (CT) scan of the chest.
Ultimately, the suitability of sleeve lobectomy is confirmed at surgery. In addition to preoperative verification of the above favorable anatomic features, sleeve lobectomy is feasible only when the bronchial and vascular structures to the remaining lobes or segments are free of disease. Therefore, the presence of bulky peribronchial carcinoma enveloping the main bronchus or invading the pulmonary artery, or the finding of metastatic lymph nodes adherent to the pulmonary artery within the fissure are contraindications to pursuing a sleeve lobectomy. In these circumstances, pneumonectomy is the procedure of choice.
Patient evaluation begins with a careful clinical assessment, including history and physical examination. Clinical evaluation seeks out symptoms or physical signs suggestive of metastatic carcinoma. Clinical evaluations also assesses the patient's cardiopulmonary status by questioning for symptoms of cardiac disease and regarding exercise tolerance.
Other imaging studies to achieve distant staging are occasionally indicated. These include CT or magnetic resonance scanning of the brain and radionuclide bone scanning. Because previously published reports failed to support the cost-effectiveness of routine multi-organ staging scans in lung cancer,
these additional studies are only obtained if there are clinical features raising concern about brain or bone metastases.
If the patient has symptoms consistent with coronary artery disease, a documented previous myocardial infarction, or an abnormal electrocardiogram, then formal cardiac evaluation is indicated before thoracotomy and pulmonary resection. All patients should undergo preoperative pulmonary function testing with careful attention to the FEV1 and arterial blood gas obtained on room air. Despite the fact that the planned procedure may be sleeve lobectomy, operative findings may dictate the necessity for pneumonectomy, and therefore, the preoperative evaluation should be conducted with this in mind. Thus, if the preoperative FEV1 is significantly less than 2 L, or if the predicted postoperative FEV1 is less than or equal to 1 L, then quantitative ventilationperfusion scintigraphy is necessary to evaluate the suitability of pneumonectomy in this patient. Typically, the presence of significant obstructive atelectasis or pneumonitis on the side of the carcinoma will result in the preponderance of both ventilation and perfusion being distributed to the contralateral lung.
It is the investigator's preference to use cervical mediastinoscopy in virtually every case of known or strongly suspected lung carcinoma. However, left anterior mediastinotomy, to evaluate subaortic (level 5) lymph modes is used selectively. This selective approach is based on the data from Patterson et al,
which shows a more favorable survival rate for completely resected left upper-lobe carcinomas in which the only site of mediastinal spread was the subaortic nodes. Therefore, if the cervical mediastinoscopy shows no evidence of superior mediastinal lymph node metastases, left anterior mediastinotomy should be performed only if the technical feasibility of resection is in question. It is preferable that the mediastinoscopy be conducted under the same anesthetic as the thoracotomy and sleeve resection. This is performed to avoid the fibrosis and fixation that can develop around the proximal main bronchi within 1 to 2 weeks of cervical mediastinoscopy with an associated loss of mobility. This concern applies more to right upper-lobe tumors than to left-sided tumors.
A very important part of the preoperative preparation of the patient for surgery is the bronchoscopic evaluation of the tumor and of the remainder of the lung. The diagnostic and therapeutic significance of this evaluation is shown in this next case. The posterioranterior (PA) and lateral chest radiograph of a patient ultimately found to be a suitable candidate for left upper-lobe sleeve lobectomy is shown in Figure I. The patient underwent thoracic surgical evaluation approximately 2 weeks after this radiograph was obtained. At the time of this evaluation, the patient was experiencing increasing shortness of breath and also fever, chills, and purulent and bloody sputum. By this time, the patient's chest radiograph showed further volume loss and obstructive pneumonitis of the left lung (Figure II). Appearance of selected cuts from the chest CT scan are shown in Figure III. Addition of rigid bronchoscopy allowed coring out of the majority of the endobronchially visible tumor. This served to confirm that the tumor did in fact originate in the left upper lobe, and that the lower lobe was free of disease. More importantly, a large amount of purulent secretions were cleared from the left lower lobe by resolving the bronchial obstruction. This led to considerable improvement in the chest radiographic appearance (Figure IV), and was associated with significant clinical improvement. This sequence of radiographs serves to underscore the importance of relieving obstruction of the bronchus to the lobes being preserved. Relief of obstruction, along with the institution of appropriate intravenous antibiotics and chest physical therapy, will minimize the incidence of postoperative pneumonia and other septic complications.
The procedure has essentially been completed. Verification of negative proximal and distal margins must be confirmed before the patient is awakened from the anesthesia. After securing proper hemostasis and irrigation of the chest with warm saline, two 28F chest tubes are positioned appropriately within the pleural space. The thoracotomy is then closed in standard fashion, using number 2 Vicryl (Ethicon, Inc) for pericostal sutures, number 1 Vicryl in the extracostal muscle layers, 2-0 Vicryl in subcutaneous tissues, and 4-0 Vicryl for subcuticular skin closure.
Data from previous publications have suggested the development of ipsilateral lung dysfunction after sleeve lobectomy in animals
This lung dysfunction is associated with secretion retention, and manifests also with impaired gas exchange. For this reason, several previous investigators have recommended the liberal use of periodic bedside fiberoptic bronchoscopy in the routine postoperative care of the sleeve lobectomy patient.
However, with modern techniques of anesthesia, perioperative pain control, and intensive physical therapy, the care of the sleeve lobectomy patient does not differ substantially from that of the patient undergoing standard pulmonary lobectomy, and routine fiberoptic bronchoscopy is not necessary. Intravenous fluids are limited on the night of surgery and are stopped the next morning when oral intake is resumed. Supplemental oxygen is administered by nasal prongs, and then weaned as tolerated, based on clinical status and pulse oximetry. Pain control is achieved through a lumbar epidural catheter placed preoperatively. This epidural catheter is retained for 48 to 72 hours postoperatively, and then removed and replaced with a patient controlled analgesia pump or oral analgesic tablets. Physical therapy, consisting of chest percussion and postural drainage, is commenced the morning after the procedure, and ambulation is begun the afternoon of the first postoperative day. Chest tubes are maintained at -20 cm of water suction and converted to water-seal drainage when no air leak is discernable. The chest tubes may then be removed when fluid drainage is also minimal. The significant majority of patients are ready for discharge from the hospital by the 4th or 5th postoperative day. Fiberoptic bronchoscopy (under topical anesthesia) should be performed to inspect the anastomosis before hospital discharge. At this point, the anastomosis should show evidence of satisfactory healing. Although there may be minimal fibrinous exudate along the suture line, there should be no mucosal slough or separation noted. The 4-month-postoperative-chest radiograph of the patient depicted earlier (Fig I, Fig II, Fig III, Fig IV) is shown in Figure V. The bronchoscopic appearance of the well-healed bronchial anastomosis after left upperlobe sleeve lobectomy in this patient is shown in Figure VI.
When used for appropriate indications, sleeve lobectomy achieves excellent results rivaling those of pneumonectomy with respect to operative mortality and late survival. Available data also show that sleeve lobectomy is superior to pneumonectomy by virtue of its preservation of lung tissue.
published a collective review of 1,915 bronchoplastic procedures for malignancy reported between 1980 to 1992, and evaluated 30-day mortality, the complication rate, and late survival. They noted a 30-day mortality of 62/1,125 sleeve lobectomies, or 5.5%. In a report dealing with their institutional experience with 145 sleeve resections for carcinoma, Van Schil et al
summarized the Massachusetts General Hospital experience with 72 sleeve lobectomies for lung cancer spanning 3 decades, and reported a 4% operative mortality. These figures compare favorably with the 6.2% operative mortality for elective pneumonectomy in lung cancer, as reported by the Lung Cancer Study Group in 1983.
In the report by Tedder et al, the main sources of morbidity after sleeve lobectomy for carcinoma were pneumonia, persistent atelectasis, and anastomotic stenosis (Table 1). Broncho-vascular fistula is a rare yet lethal complication of sleeve lobectomy, and was reported in 2.5% of the cases that comprised their collective review.
reported local recurrences in 10 of 69 sleeve lobectomies (14%). The 5-year survival in the collective review by Tedder et al was 245/614 (40%). However, when late survival was stratified by stage, it was found to be 63% for stage I, 37% for stage II, and 21% for stage III. Tedder et al point out that only approximately one third of the patients who comprised this collective review were staged preoperatively. Therefore, the predicted 5-year survival for standard lobectomy, if corrected based on the percentage of patients staged preoperatively, was 58% for stage I, 37% for stage II, and 22% for stage III. Similar survival rates have been reported by other authors. Van Schil et al
reported a 59% 5-year survival rate after sleeve lobectomy in stage I lung cancer, and 42% in stage II. Gaissert et al similarly noted a 57% 5-year survival after sleeve lobectomy in stage I and 38% in stage II. As expected, the presence or absence of lymph node metastases profoundly affected late survival in all of these studies,
and in the collective review by Tedder et al, 5-year survival after sleeve lobectomy for N0 lung cancers was 60%.
Another important aspect of sleeve lobectomy for bronchogenic carcinoma is the preservation of lung parenchyma that would otherwise be sacrificed if the alternative standard procedure, pneumonectomy, were performed. Unfortunately, there has been rather scanty documentation of the preservation of pulmonary function after sleeve lobectomy. This may be partly related to the fact that the greatest increase in implementation of this procedure has occurred only within the past decade.
used pulmonary function testing and quantitative ventilation-perfusion scintigraphy before and after sleeve lobectomy for lung cancer to evaluate this issue. From their review of 72 sleeve resections, 16 patients had postoperative spirometry (at a mean interval of 3.5 years after sleeve lobectomy) in addition to the routine preoperative spirometry. These investigators also used the preoperative quantitative ventilation-perfusion lung scan to predict the postoperative FEV1. In general, comparison of the observed to the predicted postoperative FEV1 yielded comparable values, with a correlation coefficient of 0.87. The predicted values tended to exceed the observed values by only about 15%. In their study, eight patients underwent postoperative quantitative ventilation-perfusion lung scintigraphy, at a mean interval of 4.5 years after sleeve lobectomy. Mean perfusion of the operated side was 35%, and mean ventilation was 44%. These impressive results support the notion that functional outcome is superior after sleeve lobectomy as compared with pneumonectomy in lung cancer patients.
In conclusion, sleeve lobectomy has recently gained significant popularity as a surgical option for patients with bronchogenic carcinoma. Although it was originally proposed as a compromise procedure for patients with poor pulmonary reserve, the available modern data support its use whenever the anatomic location of the tumor or involved lymph nodes are favorable. Recent series show that sleeve lobectomy is associated with a lower operative mortality compared with pneumo-nectomy in a similar group of patients. Available data also show that late survival after lung cancer resection by sleeve lobectomy is comparable with that for similarly staged tumors treated by standard lobectomy. With modern techniques of anesthesia and peri-operative care of the pulmonary resection patient, the management of the patient undergoing sleeve lobectomy does not generally pose any unusual difficulties. Careful preoperative evaluation and attention to selected key technical aspects of the operation will minimize the incidence of serious peri-operative complications and ensure a good late functional result.
Bronchial anastomosis and bronchoplastic procedures in the interest of preservation of lung tissue.