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After 40 years of alternating enthusiasm and doubt, these procedures remain technically demanding; however, they now have a definite role in the management of lung cancer. We can now achieve complete resection while preserving viable functioning lung parenchyma and respecting the principles of surgical oncology.
A sleeve resection for lung cancer is indicated in the case of a tumor arising at the origin of a lobar bronchus, a situation that precludes simple lobectomy but does not require pneumonectomy. The bulk of the tumor or the satellite lymph nodes may invade the PA, requiring reconstruction of the vessel. The artery can be involved to various degrees, from partial infiltration to a more extensive and even circumferential involvement. In the former case, a simple tangential resection with direct suture is indicated
; however, this procedure should not be considered as vascular reconstruction but rather as a simple variation of standard lobectomy. Extensive defects in the arterial wall usually require patch reconstruction, end-to-end anastomosis, or interposition of a prosthetic conduit. Invasion of the main PA requires proximal reconstruction with the use of cardiopulmonary bypass.
A sleeve lobectomy avoids pneumonectomy and preserves lung function, with no effect on oncologic results. This issue has been fully debated: recent studies demonstrate not only that functional performance, associated morbidity, and quality-of-life outcomes are superior but also that the oncologic outcome with sleeve lobectomy is equivalent to that with pneumonectomy.
These findings support the conclusion that sleeve resection should be performed whenever anatomically feasible, regardless of the cardiopulmonary status of the patient. Most of the oncologic debate concerns N1 disease; the argument in favor of a more extended resection is that tumor cells may progress along the bronchial tree through the lymphatic network. However, evidence shows that N1 disease does not mandate pneumonectomy as an alternative to sleeve resection just as hilar nodal involvement does not require pneumonectomy when simple lobectomy is feasible.
Advantages include less tension on the distal stump, more efficient blood supply to the airway, and placement of the anastomosis inside the lung parenchyma, such that the pull is outside the suture line with its negative pressure. In these cases, the fissure should not be entered. The intersegmentary plane should be isolated as for a standard segmentectomy, and the bronchus should be reimplanted with the anastomotic technique previously described. Development of bare surface of the lung after isolating the segment to be removed rarely causes problems during the postoperative course.
After induction therapy, the bronchus and PA can be infiltrated not only by residual tumor but also by desmoplastic reaction, scarring tissue, or fibrosis; bronchovascular reconstruction can also be performed safely in this subset of patients.
Preoperative evaluation and screening always include computed tomographic (CT) scans and fiberoptic bronchoscopy. The infiltration of the origin of a lobar bronchus can be easily ascertained by these two exams. It may, however, be difficult to establish preoperatively an indication for PA reconstruction. Angiographic, CT, and magnetic resonance imaging scans may contribute to the assessment of the extent of infiltration, but the decision is usually made intraoperatively.
Bronchial Sleeve Resection
Most bronchial sleeve resections can be planned preoperatively. An intercostal pedicle flap should be prepared before opening the chest; we routinely use this flap to wrap the anastomosis: it favors protection and revascularization and separates the bronchial from the arterial side when a combined bronchovascular reconstruction is performed, avoiding broncho-arterial fistulas
; a small dehiscence can be “contained” by the wrap. Alternatively, the anastomosis can be encircled by thymic or mediastinal tissue.
Pulmonary Artery Reconstruction
The techniques of pulmonary artery reconstruction include different options, as follows:
Patch reconstruction after partial resection
Sleeve resection with end-to-end-anastomosis
Sleeve resection followed by reconstruction with a prosthetic conduit
Reconstruction of the main PA at its origin under cardiopulmonary bypass
Partial Resection and Patch Reconstruction
End-to-End Anastomosis After Sleeve Resection
Reconstruction by a Prosthetic Conduit
Reconstruction of the Main Pulmonary Artery via Cardiopulmonary Bypass
The recent international literature reports results with sleeve resection of the bronchus and reconstruction of the PA with a favorable outcome in terms of reduced complications and mortality, preserved cardiopulmonary function, and survival rates; this strongly supports the use of these procedures compared with pneumonectomy.
When the main bronchus is partially or completely obstructed by the abutting tumor, preoperative laser recanalization may be helpful. It contributes to improved morphological and functional evaluation of the distal airway and lung parenchyma, helps to prevent infectious complications during induction chemotherapy, does not affect the adjacent mucosa, and does not increase postoperative complications.
; we strongly encourage the protection of the bronchial anastomosis, especially when PA reconstruction is involved.
Specific vascular complications include thrombosis and leakage and are observed in fewer than 5% of cases. Bronchoarterial fistula may occur with bronchial and vascular reconstruction, but the interposition of the intercostal muscle between the two structures helps prevent it.
Kinking and rotation of the axis may occur after lung re-expansion; anastomotic stricture is extremely rare.
Results of vascular reconstruction should be evaluated in terms of patency of the vessel, function of the right compartments of the heart, and rates of survival. Patency problems are observed in fewer than 2% of cases.
In such cases, CT is a versatile diagnostic tool; magnetic resonance provides improved imaging for diagnosing this complication during the immediate postoperative period. These noninvasive techniques have completely replaced standard angiography.
In terms of heart function, lobectomy associated with PA reconstruction behaves like standard lobectomy.
In the absence of complications like kinking or thrombosis, right ventricle morphology and function and PA pressure are equally related to standard lobectomy. The advantages of sleeve resection over pneumonectomy in the presence of a well-perfused residual lung have been extensively described.
From the oncologic point of view, comparison between the different series is difficult because of the differences in size of the groups, demographics, selection criteria, and length of follow-up. It was recently reported that survival after lobectomy associated with PA reconstruction is comparable, stage by stage, to that reported in the major reviews on lung cancer surgery and sleeve resection.
The impact of the nodal status on survival is also comparable with that reported for bronchial sleeve and standard resection. When N1 and N2 are involved, PA reconstruction can safely be performed when anatomically required, although some surgeons still advocate pneumonectomy. No statistically significant difference has been observed between PA reconstruction alone or PA reconstruction combined with bronchial sleeve resection. This finding strongly suggests that these complex lung-sparing procedures can be performed with curative intent as long as complete resection is obtained.
In conclusion, morbidity, mortality, functional results, and long-term survival rates support parenchyma-sparing operations not only as a viable option in the treatment of lung cancer invading the airway and the PA but as the gold standard.