doi:10.1510/mmcts.2004.000067
Bronchial and pulmonary arterial sleeve resection Mohsen Ibrahima, Federico Venutab, Erino A. Rendinaa,* University of Rome ‘La Sapienza’, Ospedale Sant’Andrea, Division of Thoracic Surgery, Via di Grottarossa 1035, 00189 Rome, Italy b University of Rome, Division of Thoracic Surgery, Policlinico Umberto I, V.le del Policlinico 155, Rome, Italy a
This chapter deals with the indications and techniques of resection and reconstruction of the bronchi and pulmonary artery associated with sleeve lobectomy for lung cancer. The techniques of bronchial suture are described in detail, and the indications and the various techniques of pulmonary artery reconstruction, such as sleeve resection and end-to-end anastomosis, or partial resection and patch reconstruction are described and evaluated comparatively. Finally, the results of sleeve resection are reported, and a review of the literature on the subject is presented.
Keywords: Lung cancer; Sleeve resection; Bronchial surgery; Pulmonary artery surgery Introduction A sleeve resection is indicated w1–6x or tumors arising at the origin of a lobar bronchus precluding simple
lobectomy, but not infiltrating as far as to require pneumonectomy (Schematic 1, Photos 1, 2, 3). Bronchial sleeve lobectomy is reported to be adequate for 5 to 8% of patients with resectable lung cancer but rates as high as 13% have been reported recently. It is important to point out that this increased rate of sleeve lobectomy is achieved at the expense of a decreased incidence of pneumonectomy and not of lobectomy, while the oncologic results remain unchanged. From a functional point of view, sleeve lobectomy is strictly indicated in patients who cannot withstand pneumonectomy, but recent experiences have shown that the advantages of sparing one lung lobe are evident also in patients without cardio-pulmonary impairment.
Schematic 1. Drawing of tumor infiltration into the right upper lobe bronchus and pulmonary artery.
* Corresponding author: Tel.: q39-06-8034 5633/5650/5773; fax: q39-06-8034 5003. E-mail: [email protected] 䉷 2005 European Association for Cardio-thoracic Surgery
Oncologically, the primary goal of surgery is complete resection of lung cancer with adequate resection margins free of tumor. This is all the more true for carcinoid tumors or benign lesions. Evidence has been obtained that there is little if any gain in extending the resection as far as pneumonectomy. Mediastinal dissection and radical hilomediastinal lymphadenectomy are routinely performed. Consequent skeletonization 1
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Photo 1. CT and bronchoscopic appearance of a right upper lobe tumor amenable to sleeve resection.
Photo 4. CT appearance of a large tumor of the right upper lobe infiltrating the bronchus and pulmonary artery.
Surgical technique Lobar sleeve resection The standard approach to sleeve resection is through a posterolateral thoracotomy. However, our preference is a lateral thoracotomy that allows posterior mobilization of the latissimus dorsi and preservation Photo 2. CT of N1 lymph nodes infiltrating the left upper lobe bronchus.
Photo 3. CT and intraoperative appearance of an endobronchial carcinoid tumor.
Video 1. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: resection phase. Resection of the distal and proximal pulmonary artery and bronchus.
of bronchial stumps is not considered a problem as we believe that skeletonization of the bronchi does not jeopardize the anastomosis if the anastomosis is properly encircled by a well-vascularized full-thickness musculopleural flap. These considerations apply also to patients with nodal involvement limited to hilar lymph nodes (N1) (Photo 2). Reconstructive surgery of the pulmonary artery has exactly the same indications, although this operation has been less frequently performed to date (Photo 4). 2
Video 2. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: resection phase. Resection of the proximal and distal pulmonary artery and bronchus.
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Video 3. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: approximation of the proximal and distal bronchial stumps.
Video 7. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: completed suture placement on the bronchial anastomosis.
Videos 1–7 show a right upper lobe sleeve resection with sleeve resection of the PA. The right upper lobe is resected, and a clear distal margin on the bronchus intermedius and proximal margin on the trachea are obtained. It is important that the suture line is tensionfree. This can be achieved by dividing the pulmonary ligament and, more often on the right side, by incising the pericardium around the inferior pulmonary vein. Video 4. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: positioning of the first two sutures of the bronchial anastomosis.
Video 5. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: mediastinal (deep) side of the anastomosis.
Video 6. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: completion of the mediastinal (deep) side of the anastomosis.
of the muscle, while the serratus anterior is split in the direction of its fibers; furthermore, lateral thoracotomy ensures good mediastinal exposure and accurate preparation of the intercostal muscle of the fifth intercostal space, preserving its posterior vascular supply and tailoring a wide musculopleural flap.
Video 1 shows the resection phase; the distal portion of the PA is resected first. Then the proximal PA is divided and subsequently the main bronchus and the bronchus intermedius are divided. The bronchial anastomosis is performed with interrupted monofilament absorbable 4/0 sutures. An alternative method to perform the bronchial anastomosis is the running suture technique, but we prefer interrupted sutures because we believe they better allow to equal the size discrepancies of the bronchi. Initially, two sutures are placed on the far (mediastinal) end of the cartilaginous portion and are tied extraluminally (Video 3). The surgeon ties the suture on his side while the assistant approximates his to relieve tension. Subsequently, the assistant ties his suture without tension thanks to the previously tied suture. Subsequent sutures are then placed and tied on the mediastinal (deep) portion of the anastomosis (Video 4). The remaining sutures are then placed on the rest of the bronchial circumference and are left untied (Videos 5 and 6). The sutures are then tied, starting from each end of the cartilaginous portion and working towards the middle (Video 7). Bronchial size matching is sometimes a problem, especially when a tiny upper lobe bronchus has to be reimplanted on a large main-stem bronchus. However, we do not advocate wedge resection of the larger bronchus. We perform the anastomosis with interrupted monofilament absorbable sutures and take care to place the sutures in order to compensate for calibre discrepancy. Placing and tying the sutures in this order allows compensation for even large caliber discrepancies. This 3
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Video 10. Left upper lobe bronchial sleeve resection with partial resection and patch reconstruction of the pulmonary artery: patch suture to the pulmonary artery.
Photo 5. Bronchoscopic appearance in the first postoperative day of the reimplanted bronchus intermedious after right upper lobe sleeve lobectomy. Note the patency of B6 despite the proximity to the suture line.
Video 8. Left upper lobe bronchial sleeve resection with partial resection and patch reconstruction of the pulmonary artery: resection phase.
Video 9. Left upper lobe bronchial sleeve resection with partial resection and patch reconstruction of the pulmonary artery: preparation of the autologous pericardial patch.
technique prevents torsion of the bronchial axis and gently stretches and dilates the circumference of the distal bronchus. The larger bronchial stump works as a stent, increasing the caliber of the anastomosis and 4
Video 11. Left upper lobe bronchial sleeve resection with partial resection and patch reconstruction of the pulmonary artery: completed reconstruction.
minimizing secretion retention in the early postoperative course when edema at the site of the anastomosis is more likely to occur. The anastomosis is wrapped with a vascularized pedicle of autologous tissue, usually an intercostal muscle flap (as described later). Postoperatively, it is important to check that all segmental bronchi are patent and that all the sutures are placed in a way that does not jeopardize the patency of the minute segmental bronchi (Photo 5). Patch reconstruction of the pulmonary artery (Videos 8–11) The pulmonary arterial tissue is resected en bloc with the specimen. After the resection, an oval defect oriented along the PA axis remains, even if the resected portion was circular in shape. This is due to the tension applied on the vessel by the lower lobe. The patch should be tailored according to the size and shape of the resected portion rather than according to the PA defect. After the patch is secured to the artery by 5/0 or 6/0 monofilament running suture, the PA is declamped. The suture line must be checked carefully for oozing, which might not be evident due to the low PA pressure. Also it is important to check the position of the artery after reexpansion of the lower lobe, for kinking might occur. The resection of a circumferential portion of the pulmonary artery may on occasion be necessary (PA
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Video 12. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: completed bronchial anastomosis.
Video 13. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: end-to-end suture of the pulmonary artery.
Video 14. Preparation of the intercostals-pleural flap and its positioning around the completed bronchial anastomosis after left upper lobe sleeve lobectomy.
sleeve resection) (Videos 12 and 13). Pulmonary artery and inferior pulmonary vein control are obtained as described above. The bronchial anastomosis is performed first to avoid traumatizing the PA. The PA is reconstructed by end-to-end anastomosis with running 5/0 or 6/0 monofilament suture. The arterial anastomosis is performed with no clamps in the vicinity of the suture line. The PA is occluded at its origin with a Satinsky clamp. The artery is left open distally, and backflow is avoided by clamping the inferior pulmonary vein. The venous clamp is removed before the suture is tied, and the backflow is restored to allow air drainage. Systemic anticoagulation was initiated during operation (3000 to 5000 U heparin sodium not reversed by protamine sulphate at the end of the procedure) and maintained by subcutaneous injection of heparin (15 000 U/day) for 7 to 10 days.
After the bronchial and vascular reconstructive procedures have been performed, the previously prepared intercostal pedicle flap is passed around the anastomosis (Video 14). The preparation of the flap is performed before opening the chest, and the rib retractor is not inserted until the procedure is completed to avoid crushing the intercostal vessels. The periosteum of the fifth rib is incised and then separated from the bone in continuity with the underlying intercostal muscle. Care must be taken to preserve the muscular insertion to the periosteum to avoid injuring the intercostal neurovascular bundle. The intercostal muscle is now incised in the vicinity of the underlying sixth rib, the rib retractor is inserted, and the anterior insertion of the flap is divided. The blood flow in the intercostal artery is checked, and the pedicle is ligated at its anterior extremity. When the bronchial anastomosis is completed, a large rightangle clamp is slid between the pulmonary artery and the bronchus, and the suture at the extremity of the flap is slid backward around the bronchial anastomosis and between the bronchus and the pulmonary artery. The flap is then twisted until its pleural side is in contact with the bronchial anastomosis and the pleura is secured to the bronchus by interrupted absorbable 4-0 sutures. It is important that in candidates for a sleeve resection preoperative bronchoscopy is performed by one of the operating surgeons. This is advantageous at the time of the operation, when the bronchi are incised and divided. It is also useful to have precise knowledge of the preoperative and intraoperative appearance of the airway if any bronchial complication should occur and laser recanalization or stenting should become necessary. Bronchoscopy is performed under local anesthesia to observe bronchial motion during voluntary breathing and coughing, and multiple biopsies are taken. Careful evaluation of bronchial motion is important to infer the state of tissues outside the bronchus, for stiffness of the bronchial wall may indicate peribronchial tumor infiltration. This is particularly important in areas where the bronchus is known to be adjacent to the PA, which might consequently be involved. Sometimes the distal bronchial incision falls close to the takeoff of the superior segmental bronchus or middle lobe bronchus. This is not a contraindication to the operation, but care must be taken to avoid stricture of the tiny segmental bronchi falling close to the suture line. The use of steroids in the perioperative period in patients undergoing tracheobronchial resection is 5
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067 controversial. We believe that the antiedema effect of steroids is beneficial because it reduces secretion retention and atelectasis, it facilitates parenchymal reexpansion, and it minimizes the risk of dehiscence and granuloma formation. Aerosolized steroids (methylprednisolone 5 mg twice a day) are also part of our preoperative treatment when sleeve lobectomy can be predicted beforehand. It is our experience that patients treated with steroids do not need bronchoscopy or close observation in the postoperative period. They recover faster and leave the hospital earlier. Vigorous physiotherapy is started on the first postoperative day, and aspiration of secretions is performed by fiberoptic bronchoscopy when needed. Routine bronchoscopies were performed at the end of the surgical procedure, before discharge from the hospital, and after 1 and 6 months.
the anastomosis is satisfactory even in cases of complete dehiscence. The postoperative course of bronchial sleeve resection depends to some extent on patient compliance and judicious clinical management. The short-term results of PA reconstruction depend mostly on operative judgment and technique. If the operation has been correctly performed, specific complications may be expected in no more than 5% of the patients. Because the PA is a low pressure vessel, leakage from the suture line may go unnoticed intraoperatively. However, in the postoperative period, when the reexpansion of the lower lobe elevates the hilum, the rotation and kinking of the PA may distort the suture line and open a bleeding site. It is therefore very important, especially when using autologous pericardial patches, to carefully check the suture line and test the PA position after reexpansion of the residual lobe.
When the sleeve resection is planned preoperatively, we prepare an intercostal pedicle flap before opening the chest to avoid crushing the intercostal vascular bundle. The intercostal muscle flap is precious for protecting the anastomosis, and we use it routinely in all our bronchial reconstructions. The flap affords additional protection against anastomotic failure and preserves the continuity of the airway in case of small dehiscence, thus avoiding bronchopleural fistulas. The risk of erosion of the adjacent PA is also minimized. In addition, the revascularization of the distal bronchus avoids problems related to ischemia. We prefer this technique for encircling the bronchial anastomosis because the intercostal flap is faster and simpler in comparison with other techniques: omentopexy has the disadvantage of requiring abdominal exploration, and pleural, pericardial, thymic, or mediastinal tissue flaps are often insufficient in length, width, consistency, or vascularization. In our experience osteogenesis of the periosteum, whenever it may have occurred, did not cause stenosis or other problems; furthermore, we have demonstrated that, with the technique that we have used, the sealing of
Sometimes sleeve resection and end-to-end anastomosis are anatomically impossible, such as in cases of left upper lobe tumors infiltrating the concave surface of the PA from its origin down to the anterobasal artery. On the right side, the same problem may arise when the posterolateral aspect of the PA is infiltrated from the upper division artery to the artery for the superior segment of the lower lobe. Sleeve resection is sometime excessive if the artery is only partially infiltrated. An end-to-end anastomosis can be technically difficult, owing to unexpected traction between the stumps and caliber discrepancy. Tears on the arterial wall while suturing are difficult to repair, and failure to do so may produce disastrous results. The main pitfalls of the use of a conduit are its sizing and length. Application of the previously mentioned technical insights will prevent this problem.
Table 1. Comparative results of sleeve lobectomy and pneumonectomy in NSCLC Author
Year
Patients
Sl Yoshino w6x Suen w4x Okada w1x Deslauriers w5x
1997 1999 2000 2004
29 58 60 184
Complications (%)
Mortality (%)
5-year survival (%)
Local recurrence (%)
Pn
Sl
Pn
Sl
Pn
Sl
Pn
Sl
Pn
29 142 60 1046
13.7 1.7 13 –
24.1 7.0 ** 22 –
0 5.2 0 16
6.9 4.9 2 5.3
65.7 37.5 48 52
58.8* 35.8 36 31
– – 8 22
– – 10 35
Sl: Sleeve lobectomy; Pn: Pneumonectomy. * 3-year survival; ** only postoperative respiratory failure.
6
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Results The recent literature contains a number of reports on the favorable results of sleeve resection. Compared to pneumonectomy, complications and mortality are lower, cardiopulmonary function is more satisfactory, and long-term survival rates are comparable. In addition, a number of papers dealing more specifically with resection of the pulmonary artery have been published during the last few years. A summary of the most recently published data is presented in Table 1. These data are important because they refer to uniinstitutional series comparing the results of pneumonectomy and sleeve lobectomy obtained at the same time.
References w1x Okada M, Yamagishi H, Stake S, Matsuoka H, Miyamoto Y, Yoshimura M, Tsubota N. Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy. J Thorac Cardiovasc Surg 2000; 119:814–819.
w2x Rendina EA, De Giacomo T, Venuta F, Ciccone AM, Coloni GF. Lung conservation techniques: bronchial sleeve resection and reconstruction of the pulmonary artery. Semin Surg Oncol 2000; 18:165–172. w3x Rendina EA, Venuta F, De Giacomo T, Ciccone AM, Moretti M, Ruvolo G, Coloni GF. Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer. Ann Thorac Surg 1999;68:995–1002. w4x Suen HC, Meyers BF, Gutrie T, Pohl MS, Sundaresan S, Roper CL, Cooper JD, Patterson GA. Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies. Ann Thorac Surg 1999;67:1557–1562. w5x Deslauriers J, Gre´goire J, Jacques LF, Piraux M, Guojin L, Lacasse Y. Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites or recurrences. Ann Thorac Surg 2004;77:1152–1156. w6x Yoshino I, Yokoyama H, Yano T, Ueda T, Takai E, Mizutani K, Asoh H, Ichinose Y. Comparison of the surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer. J Surg Oncol 1997;64:32-35.
7
Bronchial and pulmonary arterial sleeve resection Mohsen Ibrahima, Federico Venutab, Erino A. Rendinaa,* University of Rome ‘La Sapienza’, Ospedale Sant’Andrea, Division of Thoracic Surgery, Via di Grottarossa 1035, 00189 Rome, Italy b University of Rome, Division of Thoracic Surgery, Policlinico Umberto I, V.le del Policlinico 155, Rome, Italy a
This chapter deals with the indications and techniques of resection and reconstruction of the bronchi and pulmonary artery associated with sleeve lobectomy for lung cancer. The techniques of bronchial suture are described in detail, and the indications and the various techniques of pulmonary artery reconstruction, such as sleeve resection and end-to-end anastomosis, or partial resection and patch reconstruction are described and evaluated comparatively. Finally, the results of sleeve resection are reported, and a review of the literature on the subject is presented.
Keywords: Lung cancer; Sleeve resection; Bronchial surgery; Pulmonary artery surgery Introduction A sleeve resection is indicated w1–6x or tumors arising at the origin of a lobar bronchus precluding simple
lobectomy, but not infiltrating as far as to require pneumonectomy (Schematic 1, Photos 1, 2, 3). Bronchial sleeve lobectomy is reported to be adequate for 5 to 8% of patients with resectable lung cancer but rates as high as 13% have been reported recently. It is important to point out that this increased rate of sleeve lobectomy is achieved at the expense of a decreased incidence of pneumonectomy and not of lobectomy, while the oncologic results remain unchanged. From a functional point of view, sleeve lobectomy is strictly indicated in patients who cannot withstand pneumonectomy, but recent experiences have shown that the advantages of sparing one lung lobe are evident also in patients without cardio-pulmonary impairment.
Schematic 1. Drawing of tumor infiltration into the right upper lobe bronchus and pulmonary artery.
* Corresponding author: Tel.: q39-06-8034 5633/5650/5773; fax: q39-06-8034 5003. E-mail: [email protected] 䉷 2005 European Association for Cardio-thoracic Surgery
Oncologically, the primary goal of surgery is complete resection of lung cancer with adequate resection margins free of tumor. This is all the more true for carcinoid tumors or benign lesions. Evidence has been obtained that there is little if any gain in extending the resection as far as pneumonectomy. Mediastinal dissection and radical hilomediastinal lymphadenectomy are routinely performed. Consequent skeletonization 1
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Photo 1. CT and bronchoscopic appearance of a right upper lobe tumor amenable to sleeve resection.
Photo 4. CT appearance of a large tumor of the right upper lobe infiltrating the bronchus and pulmonary artery.
Surgical technique Lobar sleeve resection The standard approach to sleeve resection is through a posterolateral thoracotomy. However, our preference is a lateral thoracotomy that allows posterior mobilization of the latissimus dorsi and preservation Photo 2. CT of N1 lymph nodes infiltrating the left upper lobe bronchus.
Photo 3. CT and intraoperative appearance of an endobronchial carcinoid tumor.
Video 1. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: resection phase. Resection of the distal and proximal pulmonary artery and bronchus.
of bronchial stumps is not considered a problem as we believe that skeletonization of the bronchi does not jeopardize the anastomosis if the anastomosis is properly encircled by a well-vascularized full-thickness musculopleural flap. These considerations apply also to patients with nodal involvement limited to hilar lymph nodes (N1) (Photo 2). Reconstructive surgery of the pulmonary artery has exactly the same indications, although this operation has been less frequently performed to date (Photo 4). 2
Video 2. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: resection phase. Resection of the proximal and distal pulmonary artery and bronchus.
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Video 3. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: approximation of the proximal and distal bronchial stumps.
Video 7. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: completed suture placement on the bronchial anastomosis.
Videos 1–7 show a right upper lobe sleeve resection with sleeve resection of the PA. The right upper lobe is resected, and a clear distal margin on the bronchus intermedius and proximal margin on the trachea are obtained. It is important that the suture line is tensionfree. This can be achieved by dividing the pulmonary ligament and, more often on the right side, by incising the pericardium around the inferior pulmonary vein. Video 4. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: positioning of the first two sutures of the bronchial anastomosis.
Video 5. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: mediastinal (deep) side of the anastomosis.
Video 6. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: completion of the mediastinal (deep) side of the anastomosis.
of the muscle, while the serratus anterior is split in the direction of its fibers; furthermore, lateral thoracotomy ensures good mediastinal exposure and accurate preparation of the intercostal muscle of the fifth intercostal space, preserving its posterior vascular supply and tailoring a wide musculopleural flap.
Video 1 shows the resection phase; the distal portion of the PA is resected first. Then the proximal PA is divided and subsequently the main bronchus and the bronchus intermedius are divided. The bronchial anastomosis is performed with interrupted monofilament absorbable 4/0 sutures. An alternative method to perform the bronchial anastomosis is the running suture technique, but we prefer interrupted sutures because we believe they better allow to equal the size discrepancies of the bronchi. Initially, two sutures are placed on the far (mediastinal) end of the cartilaginous portion and are tied extraluminally (Video 3). The surgeon ties the suture on his side while the assistant approximates his to relieve tension. Subsequently, the assistant ties his suture without tension thanks to the previously tied suture. Subsequent sutures are then placed and tied on the mediastinal (deep) portion of the anastomosis (Video 4). The remaining sutures are then placed on the rest of the bronchial circumference and are left untied (Videos 5 and 6). The sutures are then tied, starting from each end of the cartilaginous portion and working towards the middle (Video 7). Bronchial size matching is sometimes a problem, especially when a tiny upper lobe bronchus has to be reimplanted on a large main-stem bronchus. However, we do not advocate wedge resection of the larger bronchus. We perform the anastomosis with interrupted monofilament absorbable sutures and take care to place the sutures in order to compensate for calibre discrepancy. Placing and tying the sutures in this order allows compensation for even large caliber discrepancies. This 3
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Video 10. Left upper lobe bronchial sleeve resection with partial resection and patch reconstruction of the pulmonary artery: patch suture to the pulmonary artery.
Photo 5. Bronchoscopic appearance in the first postoperative day of the reimplanted bronchus intermedious after right upper lobe sleeve lobectomy. Note the patency of B6 despite the proximity to the suture line.
Video 8. Left upper lobe bronchial sleeve resection with partial resection and patch reconstruction of the pulmonary artery: resection phase.
Video 9. Left upper lobe bronchial sleeve resection with partial resection and patch reconstruction of the pulmonary artery: preparation of the autologous pericardial patch.
technique prevents torsion of the bronchial axis and gently stretches and dilates the circumference of the distal bronchus. The larger bronchial stump works as a stent, increasing the caliber of the anastomosis and 4
Video 11. Left upper lobe bronchial sleeve resection with partial resection and patch reconstruction of the pulmonary artery: completed reconstruction.
minimizing secretion retention in the early postoperative course when edema at the site of the anastomosis is more likely to occur. The anastomosis is wrapped with a vascularized pedicle of autologous tissue, usually an intercostal muscle flap (as described later). Postoperatively, it is important to check that all segmental bronchi are patent and that all the sutures are placed in a way that does not jeopardize the patency of the minute segmental bronchi (Photo 5). Patch reconstruction of the pulmonary artery (Videos 8–11) The pulmonary arterial tissue is resected en bloc with the specimen. After the resection, an oval defect oriented along the PA axis remains, even if the resected portion was circular in shape. This is due to the tension applied on the vessel by the lower lobe. The patch should be tailored according to the size and shape of the resected portion rather than according to the PA defect. After the patch is secured to the artery by 5/0 or 6/0 monofilament running suture, the PA is declamped. The suture line must be checked carefully for oozing, which might not be evident due to the low PA pressure. Also it is important to check the position of the artery after reexpansion of the lower lobe, for kinking might occur. The resection of a circumferential portion of the pulmonary artery may on occasion be necessary (PA
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Video 12. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: completed bronchial anastomosis.
Video 13. Right upper sleeve lobectomy associated with sleeve resection of the bronchus and pulmonary artery: end-to-end suture of the pulmonary artery.
Video 14. Preparation of the intercostals-pleural flap and its positioning around the completed bronchial anastomosis after left upper lobe sleeve lobectomy.
sleeve resection) (Videos 12 and 13). Pulmonary artery and inferior pulmonary vein control are obtained as described above. The bronchial anastomosis is performed first to avoid traumatizing the PA. The PA is reconstructed by end-to-end anastomosis with running 5/0 or 6/0 monofilament suture. The arterial anastomosis is performed with no clamps in the vicinity of the suture line. The PA is occluded at its origin with a Satinsky clamp. The artery is left open distally, and backflow is avoided by clamping the inferior pulmonary vein. The venous clamp is removed before the suture is tied, and the backflow is restored to allow air drainage. Systemic anticoagulation was initiated during operation (3000 to 5000 U heparin sodium not reversed by protamine sulphate at the end of the procedure) and maintained by subcutaneous injection of heparin (15 000 U/day) for 7 to 10 days.
After the bronchial and vascular reconstructive procedures have been performed, the previously prepared intercostal pedicle flap is passed around the anastomosis (Video 14). The preparation of the flap is performed before opening the chest, and the rib retractor is not inserted until the procedure is completed to avoid crushing the intercostal vessels. The periosteum of the fifth rib is incised and then separated from the bone in continuity with the underlying intercostal muscle. Care must be taken to preserve the muscular insertion to the periosteum to avoid injuring the intercostal neurovascular bundle. The intercostal muscle is now incised in the vicinity of the underlying sixth rib, the rib retractor is inserted, and the anterior insertion of the flap is divided. The blood flow in the intercostal artery is checked, and the pedicle is ligated at its anterior extremity. When the bronchial anastomosis is completed, a large rightangle clamp is slid between the pulmonary artery and the bronchus, and the suture at the extremity of the flap is slid backward around the bronchial anastomosis and between the bronchus and the pulmonary artery. The flap is then twisted until its pleural side is in contact with the bronchial anastomosis and the pleura is secured to the bronchus by interrupted absorbable 4-0 sutures. It is important that in candidates for a sleeve resection preoperative bronchoscopy is performed by one of the operating surgeons. This is advantageous at the time of the operation, when the bronchi are incised and divided. It is also useful to have precise knowledge of the preoperative and intraoperative appearance of the airway if any bronchial complication should occur and laser recanalization or stenting should become necessary. Bronchoscopy is performed under local anesthesia to observe bronchial motion during voluntary breathing and coughing, and multiple biopsies are taken. Careful evaluation of bronchial motion is important to infer the state of tissues outside the bronchus, for stiffness of the bronchial wall may indicate peribronchial tumor infiltration. This is particularly important in areas where the bronchus is known to be adjacent to the PA, which might consequently be involved. Sometimes the distal bronchial incision falls close to the takeoff of the superior segmental bronchus or middle lobe bronchus. This is not a contraindication to the operation, but care must be taken to avoid stricture of the tiny segmental bronchi falling close to the suture line. The use of steroids in the perioperative period in patients undergoing tracheobronchial resection is 5
M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067 controversial. We believe that the antiedema effect of steroids is beneficial because it reduces secretion retention and atelectasis, it facilitates parenchymal reexpansion, and it minimizes the risk of dehiscence and granuloma formation. Aerosolized steroids (methylprednisolone 5 mg twice a day) are also part of our preoperative treatment when sleeve lobectomy can be predicted beforehand. It is our experience that patients treated with steroids do not need bronchoscopy or close observation in the postoperative period. They recover faster and leave the hospital earlier. Vigorous physiotherapy is started on the first postoperative day, and aspiration of secretions is performed by fiberoptic bronchoscopy when needed. Routine bronchoscopies were performed at the end of the surgical procedure, before discharge from the hospital, and after 1 and 6 months.
the anastomosis is satisfactory even in cases of complete dehiscence. The postoperative course of bronchial sleeve resection depends to some extent on patient compliance and judicious clinical management. The short-term results of PA reconstruction depend mostly on operative judgment and technique. If the operation has been correctly performed, specific complications may be expected in no more than 5% of the patients. Because the PA is a low pressure vessel, leakage from the suture line may go unnoticed intraoperatively. However, in the postoperative period, when the reexpansion of the lower lobe elevates the hilum, the rotation and kinking of the PA may distort the suture line and open a bleeding site. It is therefore very important, especially when using autologous pericardial patches, to carefully check the suture line and test the PA position after reexpansion of the residual lobe.
When the sleeve resection is planned preoperatively, we prepare an intercostal pedicle flap before opening the chest to avoid crushing the intercostal vascular bundle. The intercostal muscle flap is precious for protecting the anastomosis, and we use it routinely in all our bronchial reconstructions. The flap affords additional protection against anastomotic failure and preserves the continuity of the airway in case of small dehiscence, thus avoiding bronchopleural fistulas. The risk of erosion of the adjacent PA is also minimized. In addition, the revascularization of the distal bronchus avoids problems related to ischemia. We prefer this technique for encircling the bronchial anastomosis because the intercostal flap is faster and simpler in comparison with other techniques: omentopexy has the disadvantage of requiring abdominal exploration, and pleural, pericardial, thymic, or mediastinal tissue flaps are often insufficient in length, width, consistency, or vascularization. In our experience osteogenesis of the periosteum, whenever it may have occurred, did not cause stenosis or other problems; furthermore, we have demonstrated that, with the technique that we have used, the sealing of
Sometimes sleeve resection and end-to-end anastomosis are anatomically impossible, such as in cases of left upper lobe tumors infiltrating the concave surface of the PA from its origin down to the anterobasal artery. On the right side, the same problem may arise when the posterolateral aspect of the PA is infiltrated from the upper division artery to the artery for the superior segment of the lower lobe. Sleeve resection is sometime excessive if the artery is only partially infiltrated. An end-to-end anastomosis can be technically difficult, owing to unexpected traction between the stumps and caliber discrepancy. Tears on the arterial wall while suturing are difficult to repair, and failure to do so may produce disastrous results. The main pitfalls of the use of a conduit are its sizing and length. Application of the previously mentioned technical insights will prevent this problem.
Table 1. Comparative results of sleeve lobectomy and pneumonectomy in NSCLC Author
Year
Patients
Sl Yoshino w6x Suen w4x Okada w1x Deslauriers w5x
1997 1999 2000 2004
29 58 60 184
Complications (%)
Mortality (%)
5-year survival (%)
Local recurrence (%)
Pn
Sl
Pn
Sl
Pn
Sl
Pn
Sl
Pn
29 142 60 1046
13.7 1.7 13 –
24.1 7.0 ** 22 –
0 5.2 0 16
6.9 4.9 2 5.3
65.7 37.5 48 52
58.8* 35.8 36 31
– – 8 22
– – 10 35
Sl: Sleeve lobectomy; Pn: Pneumonectomy. * 3-year survival; ** only postoperative respiratory failure.
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M. Ibrahim et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000067
Results The recent literature contains a number of reports on the favorable results of sleeve resection. Compared to pneumonectomy, complications and mortality are lower, cardiopulmonary function is more satisfactory, and long-term survival rates are comparable. In addition, a number of papers dealing more specifically with resection of the pulmonary artery have been published during the last few years. A summary of the most recently published data is presented in Table 1. These data are important because they refer to uniinstitutional series comparing the results of pneumonectomy and sleeve lobectomy obtained at the same time.
References w1x Okada M, Yamagishi H, Stake S, Matsuoka H, Miyamoto Y, Yoshimura M, Tsubota N. Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy. J Thorac Cardiovasc Surg 2000; 119:814–819.
w2x Rendina EA, De Giacomo T, Venuta F, Ciccone AM, Coloni GF. Lung conservation techniques: bronchial sleeve resection and reconstruction of the pulmonary artery. Semin Surg Oncol 2000; 18:165–172. w3x Rendina EA, Venuta F, De Giacomo T, Ciccone AM, Moretti M, Ruvolo G, Coloni GF. Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer. Ann Thorac Surg 1999;68:995–1002. w4x Suen HC, Meyers BF, Gutrie T, Pohl MS, Sundaresan S, Roper CL, Cooper JD, Patterson GA. Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies. Ann Thorac Surg 1999;67:1557–1562. w5x Deslauriers J, Gre´goire J, Jacques LF, Piraux M, Guojin L, Lacasse Y. Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites or recurrences. Ann Thorac Surg 2004;77:1152–1156. w6x Yoshino I, Yokoyama H, Yano T, Ueda T, Takai E, Mizutani K, Asoh H, Ichinose Y. Comparison of the surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer. J Surg Oncol 1997;64:32-35.
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