Advertisement

Parenchymal-Sparing Lung Resections: Technique of Sleeve Resections

  • James M. Isbell
    Affiliations
    Department of Thoracic and Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Virginia
    Search for articles by this author
  • David R. Jones
    Correspondence
    Address reprint requests to David R. Jones, MD, Department of Thoracic and Cardiovascular Surgery, University of Virginia Health System, 1215 Lee Street, Hospital Expansion, Charlottesville, VA 22908-0679
    Affiliations
    Department of Thoracic and Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Virginia
    Search for articles by this author
      Bronchial sleeve resections are generally indicated when a neoplasm originates from or extends to the origin of a lobar bronchus. Sleeve resection should also be considered when the presence of bulky peribronchial nodal disease would prevent a standard lobectomy. Sleeve resections are preferred over pneumonectomy for the preservation of pulmonary function, provided a complete (R0) resection can be achieved. Sleeve resection is oncologically equivalent to pneumonectomy in appropriately selected patients.
      • Yoshino I.
      • Yokoyama H.
      • Yano T.
      • et al.
      Comparison of the surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer.
      • Stallard J.
      • Loberg A.
      • Dunning J.
      • et al.
      Is sleeve lobectomy significantly better than pneumonectomy?.
      Moreover, several recent studies favor sleeve resection over pneumonectomy in terms of long-term survival, quality of life, and postoperative functional status.
      • Yoshino I.
      • Yokoyama H.
      • Yano T.
      • et al.
      Comparison of the surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer.
      • Stallard J.
      • Loberg A.
      • Dunning J.
      • et al.
      Is sleeve lobectomy significantly better than pneumonectomy?.
      • Okada M.
      • Yamagishi H.
      • Satake S.
      • et al.
      Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy.
      • Deslauriers J.
      • Gregoire J.
      • Jacques L.F.
      • et al.
      Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites of recurrences.
      Still somewhat controversial is the use of sleeve resection in patients with N1 disease. However, a recent study suggests that pneumonectomy provides no survival advantage over sleeve resection in the setting of N1 disease.
      • Okada M.
      • Yamagishi H.
      • Satake S.
      • et al.
      Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy.
      Preoperative evaluation should include a computed tomographic scan of the chest, fiberoptic bronchoscopy, and pulmonary function tests with diffusion capacity. We routinely obtain a positron emission tomographic scan to evaluate for nodal disease as well as for distant metastatic disease. If the forced expiratory volume in 1 second (FEV1) or diffusing capacity of lung for carbon monoxide (DLCO) are less than 60% predicted on the preoperative pulmonary function tests, a quantitative perfusion scan should be obtained preoperatively to assess the patient's suitability for pneumonectomy should intraoperative findings prove this necessary.
      The bronchoscopic examination should be performed by the surgeon to assess the endobronchial extent of disease and to aid in operative planning. As a general rule, mediastinoscopy should be performed in all patients with nonsmall-cell lung cancer being considered for sleeve resection to evaluate for N2 disease, regardless of the nodal status on preoperative staging exams. We typically perform the mediastinoscopy in the same setting as sleeve lobectomy. However, if mediastinoscopy is undertaken before the planned date of surgical resection, we recommend limiting the interval between the 2 procedures to no more than 14 days. Waiting longer may allow for significant fibrosis to develop, which can compromise the ability to perform a tension-free bronchial anastomosis if sufficient bronchial mobilization cannot be achieved.
      Selective lung ventilation is generally used in all patients undergoing sleeve lobectomy. Because they are easier to place than right-sided tubes, we typically use left-sided double lumen endotracheal tubes, even for left-sided sleeve resections. We reserve the use of right-sided tubes for cases with tumor extension into the proximal left mainstem bronchus. For most sleeve resections, a standard fifth intercostal posterolateral thoracotomy provides optimal exposure. Harvesting the intercostal muscle as a pedicled flap to be used as a buttress over the bronchial anastomosis may prevent postoperative bronchopleural fistulae and the more devastating complication of bronchovascular fistula. However, we more commonly use a pedicled pericardial fat pad for this purpose.
      On entering the chest, the absence of intrathoracic tumor spread must be confirmed. Dissection is usually begun by dividing the inferior pulmonary ligament. The anterior and posterior mediastinal pleuras are then divided, exposing the underlying hilar structures. Due to the central location of tumors considered for sleeve resection, it may be difficult to identify the hilar structures, especially in the setting of a large tumor. Only after resectability is confirmed should the appropriate pulmonary arterial and venous branches be divided.
      As a right upper lobe sleeve resection is the most common bronchoplastic procedure performed, we begin with this clinical scenario.

      Operative Technique

      Figure thumbnail gr1
      Figure 1We routinely perform a complete mediastinal lymph node dissection as we believe this approach reduces local recurrence. The right upper lobe vein is divided with a vascular stapler while taking care to avoid injury to the middle lobe vein. The truncus anterior branch of the right pulmonary artery is then divided in a similar manner with a vascular stapler. Further distal dissection on the interlobar right pulmonary artery reveals the arteries to the middle lobe and the superior segment of the right lower lobe, both of which are preserved. In addition, the posterior ascending artery (PAA) is identified with this dissection. (A) With the lung retracted anteriorly, posterior dissection between the bifurcation of the right upper lobe bronchus and the bronchus intermedius will reveal the so-called “sump” node. (B) Elevation of this node from the bronchus intermedius will demonstrate the PAA. Division of the arterial supply to the right upper lobe and identification of the arteries supplying the middle and lower lobes allow for safe completion of the major and minor fissures with a linear stapler. RLL = right lower lobe; RUL = right upper lobe.
      Figure thumbnail gr2
      Figure 2Following complete mobilization of the right upper lobe, the bronchial sleeve resection may begin. The right mainstem bronchus and the bronchus intermedius should be circumferentially dissected with care being taken not to devascularize the airway. With consideration given to the endobronchial extent of the tumor seen on the immediate preoperative bronchoscopy, the right mainstem and bronchus intermedius are divided sharply with a no. 15 blade. We generally divide the bronchus intermedius first to ensure the tumor does not extend more distally, which may necessitate a pneumonectomy to achieve an R0 resection. The bronchus should be divided at a right angle to its long axis and between cartilages. We typically leave an additional 2 to 3 mm on the proximal and distal sides of the membranous airway to reduce tension on this delicate tissue. Proximal and distal margins are then sent for frozen section analysis. If there is any history or evidence of postobstructive pneumonia, cultures from the airway should be submitted to direct postoperative antibiotic therapy. RLL = right lower lobe; RUL = right upper lobe.
      Figure thumbnail gr3a
      Figure 3(A) Once negative margins have been confirmed histologically, the bronchial reconstruction begins by placing a 3-0 polydioxanone (PDS; Ethicon, Somerville, NJ) traction suture at the cartilaginous-membranous junction on the mediastinal (medial) side of the airway. (B) Multiple interrupted 3-0 or 4-0 PDS sutures are placed to approximate the cartilaginous portions of the proximal and distal airways starting from the mediastinal side and moving laterally. These sutures are best left untied until several are placed. The membranous airway is reapproximated in a similar fashion with interrupted 4-0 PDS. It is critical to adjust for any size discrepancy between the proximal and distal airways with precise suture placement along the circumference of the anastomosis. We do not recommend purposeful intussusception of the smaller bronchus into the larger one. (C) The completed anastomosis should be tested for pneumostasis by submerging it under saline and inflating the lung to a pressure of 20 cm of water. If any air leaks are identified, they should be closed with additional interrupted 4-0 PDS sutures. Occasionally with an upper lobe sleeve resection, it is impossible to bring the proximal and distal airways together without tension despite extensive mobilization of the proximal airway and lower lobe. In this setting, an ipsilateral hilar release maneuver should be performed. (D) A hilar release is accomplished by making a U-shaped pericardiotomy around the inferior pulmonary vein, which provides the additional mobilization necessary to fashion a tension-free bronchial anastomosis.
      Figure thumbnail gr3b
      Figure 3(A) Once negative margins have been confirmed histologically, the bronchial reconstruction begins by placing a 3-0 polydioxanone (PDS; Ethicon, Somerville, NJ) traction suture at the cartilaginous-membranous junction on the mediastinal (medial) side of the airway. (B) Multiple interrupted 3-0 or 4-0 PDS sutures are placed to approximate the cartilaginous portions of the proximal and distal airways starting from the mediastinal side and moving laterally. These sutures are best left untied until several are placed. The membranous airway is reapproximated in a similar fashion with interrupted 4-0 PDS. It is critical to adjust for any size discrepancy between the proximal and distal airways with precise suture placement along the circumference of the anastomosis. We do not recommend purposeful intussusception of the smaller bronchus into the larger one. (C) The completed anastomosis should be tested for pneumostasis by submerging it under saline and inflating the lung to a pressure of 20 cm of water. If any air leaks are identified, they should be closed with additional interrupted 4-0 PDS sutures. Occasionally with an upper lobe sleeve resection, it is impossible to bring the proximal and distal airways together without tension despite extensive mobilization of the proximal airway and lower lobe. In this setting, an ipsilateral hilar release maneuver should be performed. (D) A hilar release is accomplished by making a U-shaped pericardiotomy around the inferior pulmonary vein, which provides the additional mobilization necessary to fashion a tension-free bronchial anastomosis.
      Figure thumbnail gr4
      Figure 4To prevent bronchopleural and bronchovascular fistulae, the bronchial anastomosis should be bolstered with some form of well-vascularized tissue. We most commonly use a pedicled pericardial fat pad. Alternatively, a pedicled intercostal muscle flap may be used. Regardless of the type of tissue used, it should not be too bulky as this may cause extrinsic compression of the bronchial anastomosis or the nearby pulmonary artery.
      Figure thumbnail gr5
      Figure 5Middle lobe sleeve resections are rare, but may be performed without undue difficulty when the tumor involves the middle lobe bronchial orifice. After circumferential dissection of the middle lobe vein, it is divided with a vascular stapler. Just posterior to the middle lobe vein lies the middle lobe bronchus. Care must be taken to avoid injury to the underlying middle lobe branch of the pulmonary artery, which is commonly superior to the middle lobe bronchus. If at all possible, the middle lobe artery should be dissected and divided before turning attention to the bronchus. Next, a linear stapler is then used to complete the minor fissure and the portion of the major fissure shared by the middle and lower lobes. The airway is then divided proximally and distally with careful attention paid to preserving the origin of the superior segmental bronchus. If not already done, the middle lobe artery is now exposed and may be easily divided with a vascular stapler. Once negative proximal and distal bronchial margins have been confirmed histologically, the bronchial anastomosis is completed as described above. When performing this anastomosis, the surgeon must avoid narrowing the bronchial origin of the superior segment of the lower lobe. A pedicled pericardial fat pad is used to cover the anastomosis. PA = pulmonary artery; RLL = right lower lobe; RML = right middle lobe; RUL = right upper lobe.
      Figure thumbnail gr6
      Figure 6A right lower lobe sleeve resection may be performed when a tumor involves the distal right lower lobe bronchus, allowing for preservation of the middle lobe. Right lower lobe sleeve resection has been associated with improved postoperative lung function and a similar complication rate when compared with bilobectomy.
      • Ludwig C.
      • Morand P.
      • Schnell J.
      • et al.
      Preserving middle lobe to improve lung function in non-small cell lung cancer.
      With this technique, the middle lobe is reimplanted into the bronchus intermedius. First, the right inferior vein is divided with a vascular stapler. The interlobar pulmonary artery is then identified along with the superior segmental artery, the middle lobe artery, and the common basilar trunk. The superior segmental artery and the common basilar trunk are ligated and divided separately with vascular staplers while the artery to the middle lobe is carefully preserved. Division of the pulmonary arterial branches is often facilitated by completing the oblique fissure with a linear stapler. (A) Circumferential dissection of the distal bronchus intermedius as well as the bifurcation of the right middle bronchus and lower lobe bronchus are then undertaken. (B) A no. 15 scalpel is used to divide the distal bronchus intermedius. Complete division of the middle lobe bronchus is done close to its segmental bifurcation where it is widest, minimizing any size discrepancy between the middle lobe bronchus and the distal bronchus intermedius. (C) After confirming negative bronchial margins, the bronchial anastomosis is fashioned with 4-0 PDS between the bronchus intermedius and the middle lobe bronchus. A pedicled pericardial fat pad may be used to buttress the anastomosis. RLL = right lower lobe; RML = right middle lobe; RUL = right upper lobe.
      Figure thumbnail gr7
      Figure 7(A) A left upper lobe sleeve resection is indicated for an endobronchial tumor that extends from the left upper lobe bronchus into the distal left mainstem bronchus. The presence of the aorta makes exposure of the left mainstem for an upper lobe sleeve resection more challenging. After identification of the left superior and inferior pulmonary veins, the superior vein is ligated and divided with a vascular stapler. The underlying pulmonary artery is dissected proximally to distally until the branches supplying the upper lobe have all been identified. The arterial branch to the superior segment of the left lower lobe should be identified in its usual location slightly proximal and posterior to the lingular arteries. The posterior fissure can then be completed with a linear stapler, being careful to preserve the nearby superior segmental artery. The individual pulmonary arterial branches supplying the left upper lobe can then be ligated and divided sequentially with vascular staplers. (B) The left lower lobe is retracted anteriorly to expose the posterior hilar structures. The left mainstem bronchus is circumferentially dissected as is the left lower lobe bronchus. A moistened umbilical tape is used to encircle and retract the mainstem bronchus. (C) After placing traction sutures on each side of the proximal left mainstem bronchus, a no. 15 blade is used to divide the mainstem just proximal to the bifurcation. The left lower lobe bronchus is divided just distal to its takeoff, being careful to avoid injury to the nearby superior segmental bronchus. When the tumor involves the left upper lobe orifice as well as the superior segmental bronchial orifice, a left upper lobe sleeve with an en bloc superior segmental sleeve resection may be attempted if negative margins can be achieved; otherwise a left pneumonectomy should be performed. The bronchial reconstruction is performed as described above for a right upper lobe sleeve resection. Special caution should be taken to avoid compromising the orifice of the superior segmental bronchus when performing the bronchial anastomosis. LLL = left lower lobe; LUL = left upper lobe; n. = nerve; PA = pulmonary artery.
      Figure thumbnail gr8
      Figure 8(A) A left lower sleeve resection may be performed for tumors extending from the origin of the left lower bronchus into the mainstem bronchus, provided that the upper lobe bronchus is uninvolved. After identifying the superior pulmonary vein, the inferior vein is taken with a vascular stapler. The fissure is then opened where it is most complete to reveal the interlobar pulmonary artery. Dissection is performed proximally and distally on the interlobar pulmonary artery so that the lingular and posterior segmental branches may be identified and preserved. The superior segmental artery originates proximal to the lingular artery. As such, the superior segmental artery and the common basilar artery are usually taken separately. Next, the left mainstem and upper lobe bronchi are circumferentially dissected and encircled with moistened umbilical tapes. (B) The left mainstem bronchus is divided proximally with a no. 15 blade. Similarly, the left upper lobe bronchus is divided at its takeoff. Once the bronchial margins have been cleared by frozen section analysis, the bronchial anastomosis is completed as described above for the right upper lobe sleeve resection. When completing the bronchial anastomosis, care must be taken to avoid kinking of the pulmonary artery or vein. LLL = left lower lobe; LUL = left upper lobe.

      Discussion

      The benefits of sleeve resection over pneumonectomy in terms of postoperative morbidity and mortality are now well established.
      • Yoshino I.
      • Yokoyama H.
      • Yano T.
      • et al.
      Comparison of the surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer.
      • Stallard J.
      • Loberg A.
      • Dunning J.
      • et al.
      Is sleeve lobectomy significantly better than pneumonectomy?.
      • Okada M.
      • Yamagishi H.
      • Satake S.
      • et al.
      Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy.
      Parenchymal-sparing resections are preferred as long as an R0 resection can be achieved, even in those patients predicted to tolerate pneumonectomy based on preoperative pulmonary function tests. A thorough N1 nodal dissection is critical to minimize recurrence.
      The postoperative management of patients following sleeve resection consists of early extubation (preferably in the operating room), adequate pain relief with an epidural catheter, and aggressive pulmonary toilet. Bronchial division results in impaired postoperative mucociliary clearance, which is compounded by the edema that inevitably occurs at the bronchial anastomosis. If postoperative atelectasis develops, there should be a low threshold to use flexible bronchoscopy to clear airway secretions.
      In conclusion, in cases where a tumor arises from the origin of a lobar bronchus, bronchial sleeve resection should be the procedure of choice, provided a complete resection can be obtained.

      References

        • Yoshino I.
        • Yokoyama H.
        • Yano T.
        • et al.
        Comparison of the surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer.
        J Surg Oncol. 1997; 64: 32-35
        • Stallard J.
        • Loberg A.
        • Dunning J.
        • et al.
        Is sleeve lobectomy significantly better than pneumonectomy?.
        Interact Cardiovasc Thorac Surg. 2010; 11: 660-666
        • Okada M.
        • Yamagishi H.
        • Satake S.
        • et al.
        Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy.
        J Thorac Cardiovasc Surg. 2000; 119: 814-819
        • Deslauriers J.
        • Gregoire J.
        • Jacques L.F.
        • et al.
        Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites of recurrences.
        Ann Thorac Surg. 2004; 77: 1152-1156
        • Ludwig C.
        • Morand P.
        • Schnell J.
        • et al.
        Preserving middle lobe to improve lung function in non-small cell lung cancer.
        Asian Cardiovasc Thorac Ann. 2009; 17: 153-156