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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
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.
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.
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.
The benefits of sleeve resection over pneumonectomy in terms of postoperative morbidity and mortality are now well established.
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.
Comparison of the surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer.