Extended Resections for Lung Cancer: Bronchovascular Sleeve Resections

Summary of Key Points

Bronchovascular sleeve resection is an essential technique for general thoracic surgeons to preserve as much as possible the patient’s lung function and quality of life after pulmonary resection.
Previous reports suggested that the incidence rates of bronchopleural fistula and surgical mortality after sleeve lobectomy and sleeve pneumonectomy were 3% and 2.5%, and 5.5% and 20.9%, respectively.
In the tissue-healing process of the anastomotic site after bronchial sleeve resection, previous reports suggested that the blood flow in the bronchial arteries proximal to the anastomosis comes from the aorta, but the blood flow distal to the anastomosis comes from the pulmonary artery.
There are controversies in techniques of bronchial sleeve resections regarding suturing methods, suturing layers, types of anastomosis, types of sleeve resection, and the necessity of wrapping the anastomosis.
There are controversies in techniques of pulmonary artery angioplasty regarding types of resection, types of reconstruction, order of reconstruction in a double sleeve resection, and the necessity of anticoagulant therapy.

Bronchoplastic and angioplastic procedures are essential techniques in general thoracic surgery. When performing lung cancer operations, thoracic surgeons sometimes encounter situations that require these techniques; therefore thoracic surgeons should know how to perform these procedures. This chapter describes the history of, and strategy and techniques for, bronchoplastic and angioplastic surgical procedures.

History and Surgical Outcomes of Bronchovascular Sleeve Resection

Bronchial Sleeve Resection

The first bronchoplastic surgical procedure was described by Bigger in 1932. The patient was a 14-year-old boy with a tumor in the left main bronchus, and the tumor was removed with an incision in the bronchus. Postoperative examination of the pathologic specimen indicated that the resected tumor was malignant. Therefore a week after the surgical procedure, a left pneumonectomy was done. However, the patient died of infectious pericarditis after these repeated thoracotomy procedures. The first bronchial sleeve resection was performed by Thomas in 1947. The patient was a young man who was awaiting a commission in the Royal Air Force. An adenoma on the right upper lobe bronchus was detected at clinical examination, and the tumor was found to be occluding the right main bronchus. A sleeve resection and an end-to-end anastomosis of the right main bronchus were performed. The patient was able to serve as an Air Force pilot in active flying duties after this lung-preserving operation.

In 1959, Johnston and Jones described the first successful sleeve lobectomy for primary lung cancer, a procedure that had been performed by Allison in 1952. In 1955, Paulson and Shaw named this procedure a “bronchoplastic surgery.” In the 1970s and 1980s, Jensik et al., Bennett and Smith, and Faber et al. reported on case series of patients who had sleeve lobectomies. The first report of a carinal resection was made by Mathey et al. in 1966, and in 1978, Grillo reported success with 38 cases.

The results of bronchoplastic procedures have been reported in several studies ( Table 31.1 ). In most of these reports, 5-year survival rates were 40% to 50% and mortality rates were relatively low, ranging from 0% to 7.5%. Tedder et al. reviewed the results of 1915 bronchoplastic procedures for primary lung cancer that were performed over 12 years, starting in 1979. According to that report, the incidence rates of bronchopleural fistula, bronchovascular fistula, and surgical mortality after sleeve lobectomy and sleeve pneumonectomy procedures were 3% and 10.1%, 2.5% and 2.9%, and 5.5% and 20.9%, respectively.

TABLE 31.1

Results for the Bronchial Sleeve Resection: Previous Reports With More Than 100 Cases

Reference	No. of Patients	Mortality (%)	5-Year Survival Rate (%)
Tedder et al. (1992)	1915	7.5	40
Van Schil et al. (1996)	145	4.8	46
Rea et al. (1997)	217	6.2	49
Icard et al. (1999)	110	2.8	39
Kutlu et al. (1999)	100	2.0	49
Tronc et al. (2000)	184	1.6	52
Okada et al. (2000)	151	0	48
Rendina et al. (2000)	145	3.0	38
Deslauriers et al. (2004)	300	2.7	54
Ludwig et al. (2005)	116	4.3	43
Yildizeli et al. (2007)	218	4.1	43

Pulmonary Artery Angioplasty

Gundersen published the first report of a pulmonary artery sleeve resection in 1967. That report described two cases of successful pulmonary artery sleeve resection and end-to-end anastomosis. After the publication of these results, many successful cases were reported. More recently, an increasing number of studies have described the results of concurrent bronchoplasty and pulmonary artery angioplasty procedures ( Table 31.2 ). For example, Rendina et al. reported on 40 cases of concurrent procedures. The 5-year survival rate was 38.6%, which was equivalent to the 5-year survival rate of 38.7% recorded for 80 cases of only bronchoplastic surgical procedures.

TABLE 31.2

Results for Concurrent Bronchoplastic and Angioplastic Procedures

Reference	No. of Patients	Mortality (%)	5-Year Survival Rate (%)
Icard et al. (1999)	16	NA	39
Rendina et al. (2000)	40	0	39
Okada et al. (2000)	21	0	48
Fadel et al. (2002)	11	0.7	52
Chunwei et al. (2003)	21	NA	33
Lausberg et al. (2005)	67	1.5	43
Nagayasu et al. (2006)	29	17.2	24

NA, not available.

Healing of the Anastomotic Site After Bronchial Sleeve Resection

Ishihara et al. detailed the results obtained in animal models regarding the tissue-healing process of the anastomotic site after bronchial sleeve resection. He injected silicone rubber of different colors into the bronchial artery and pulmonary artery after a sleeve lobectomy. The results confirmed that the blood flow in the bronchial arteries proximal to the anastomosis came from the aorta, but the blood flow distal to the anastomosis came from the pulmonary artery ( Fig. 31.1 ). Inui et al. evaluated bronchial blood flow by laser Doppler velocimetry in dogs. Their results suggested that the bronchial mucosal blood flow was reduced when the peribronchial tissue was detached, and blood flow was restored by dressing the anastomosis with the greater omentum.

Fig. 31.1, Stereomicroscopic view of the bronchial circulation at the anastomosis site. The bronchial arteries were perfused with different colors of silicone rubber. Bronchial arteries proximal to the anastomosis are filled with orange silicone rubber, which was injected into the aorta. Bronchial arteries distal to the anastomosis are filled with yellow silicone rubber, which was injected into the pulmonary artery.

According to some reports, systemic administration of small doses of steroids after the bronchoplastic procedure prevented an inflammatory reaction and edema in the tissue around the anastomotic site. Consequently, this treatment was believed to improve blood flow and promote healing of the anastomosis. However, Inui et al. suggested that treatment with steroids did not improve blood flow at the anastomotic site in animal models as evaluated by laser Doppler velocimetry. Rendina et al. reported that treatment with steroids in the clinical setting substantially decreased the incidence of postoperative morbidity and shortened the postoperative intensive care unit and hospital stays. The patients in that study received postoperative aerosol steroid inhalation three times per day and intravenous injections of 10 mg methylprednisolone twice a day.

Surgical Techniques and Controversies Regarding Bronchial Sleeve Resections

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