This case was presented a couple years ago to surgeons visiting Quebec City for the American Surgical Association Meeting. The patient is about 50 years old and has a right upper lobe carcinoma. He had N2 disease documented by mediastinoscopy. He had induction treatment and at operation, we had the option of doing a sleeve resection, but we thought that we would get better tumore clearance by pneumonectomy. This postoperative x-ray shows typical post-pneumonectomy edema, a dreadful and highly fatal complication. Fortunately, the patient made a complete recovery being one of the few individuals that you will ever see recovering from that injury. The case was discussed by Drs. Grover and Harold Urschel and on this slide you will note the comment made by Dr. Urschel. The message is that pneumonectomy should be avoided whenever possible. In that context, sleeve resections are an alternative to pneumonectomy. The rationale being preservation of lung combined with adequate resection of the carcinoma. There are some controversies in the literature about the role of sleeve resection in lung cancer management and three main concerns have been identified. Are we getting an adequate tumor clearance? Are the operative mortality and morbidity higher than after more standard resections? What are the functional results and is it worth preserving lobes? Historically, the first sleeve resection was reported by Price Thomas in 1947 and it was done for a lung cancer and the first comprehensive report on bronchoplasties was that of Paulson and Shaw. In that article they report on 16 patients with strictures, cancers, bronchial adenomas treated by bronchoplasty techniques and they recommended that this type of surgery should be done for cancer patients. In 1959, Johnson and Jones reported long-term results after a number of sleeves had been done for lung cancer. Sleeve resection can be done on any lobe or segmental bronchi although most commonly, sleeve resections are done for centrally located right upper lobe tumors that cannot be removed completely by standard lobectomy. In these cases the alternative would be a complete pneumonectomy. This slide show right upper lobe being removed and the bronchus intermedius being reimplanted into the proximal main bronchus. In case of nodal disease--either in the subcarinal space or the peritracheal area--it is possible to remove both nodes and primary lobe and still reconstruct the airway by reimplanting the bronchus intermedius into the main bronchus. Nodal disease, in principle, is not a contraindication to sleeve resection. On the left side, this is the commonest sleeve resection that is done for left upper lobe tumores. On the left side, the surgery is more difficult, but quite feasible technically. You salvage the lower lobe which is reimplanted in the proximal left main bronchus. What are the important technical principles of the operation? The first principle is to have expert pathological frozen section analysis of proximal and distal bronchial margins. If one of these margins is positive for cancer, you can extend the operation to more complete resection of the bronchus or pneumonectomy. Distally, we divide the bronchus intermedius as close as possible to the lung shich is to be preserved in order to get additional blood supply from the pulmonary artery. The anastomotic technique is straightforward and the suture material most commonly used is vicryl. Whether you do a continuous or interrupted type of suture does not make a great deal of difference, though most people do use interrupted suture technique. The knots are tied outside the lumen. Two other principles are illustrated on this diagram. differences between the sizes of proximal and distal bronchi are very easily corrected by spacing your sutures differently on the larger and smaller lumen. This slide shows the proximity of the pulmonary artery to the bronchial anastomosis. Because of that proximity, one has to be careful not to traumatize the pulmonary artery while suturing the bronchi. In the past, this has been the cause of fistulae between the bronchial suture line and pulmonary artery, a catastrophic complication. This slide is an operating photograph where one can see the proximal and distal bronchus. There is seldom tension at the site of reconstruction if you mobilize the inferior pulmonary ligament. The right main bronchus is usually divided at the tracheal level so that you a resection margin as far as possible from the cancer. The back part of the anastomosisis done first putting all of the sutures in before they are tied with the knots outside the lumen. Again, the suture material being used is absorbable and this has eliminated the problem of granulation tissue at the bronchial anastomotic site. You can see that these two lumens come quite nicely together. This is an operative photograph showing the lack of tension and this is the completed anastomosis. There is some controversyover whether you should cover the anastomosis in order to prevent dehiscence. We nearly always leave the anastomosis uncovered because there is enough bronchial and pulmonary artery blood flow to these anastomoses which are not at risk of dehiscence unless there has been previous radiation therapy. Some surgeons, however, think that all bronchial sleeves should be reinforced. This is the completed operation with distal lung being reinflated. What about the role of flaps and wedges of main bronchi? In cases of a wedge bronchial resection, only a small segment of bronchus is removed and this is waht the reconstruction looks like. Flap bronchoplasty consists of leaving a flap of main bronchus which is used to close the origin of the upper lobe. There is very little literature on the use of wedges but generally speaking these procedures are seldom used. In one recent paper from the Netherlands published in the Journal of Thoracic Surgery, the authors reported on 25 patients. Eight of them had wedges, and 17 had flap bronchoplasties. These figures show a significant incidence of anastomotic problems, either kinking, or strictures after wedge bronchoplasties. In the flap bronchoplasties there is also a significant number of patients who will experience anastomotic complications. Based on such data, flap bronchoplasties should seldom be used as I think it is easier and safer to do a full circumferential sleeve. What about pulmonary artery sleeve resections and reconstructions? These procedures are generally indicated for central tumors with direct infiltration of the main pulmonary artery trunk that can be removed with a segment of the artery. The first large series of pulmonary artery reconstruction was reported by Dr. Vogt-Moykopf from Heidelberg. He described in the mid-80's a number of these reconstructions with a significant operative mortality in the range of 15-16%. More recently Dr. Rendina and his colleagues form Rome have written several articles on these techniques. Dr. Rendina has lent me some of his slides and I will try to show you how to conceive these reconstructions. If you have cancer infiltration at the origin of segmental arteries, the resection is easily performed through tangential resection of the pulmonary artery and closure. With partial infiltration of the main pulmonary artery, reconstruction is carried out usually with a pericardial patch made at the time of operation. If you have a complete circumferential infiltration of the pulmonary artery, you can do a full sleeve resection of the artery with anastomosis. The procedure is called a double sleeve if you do bronchial and pulmonary artery sleeve. You can also use a pericardial or prosthetic tube for reconstruction. This slide shows a left upper lobe tumor invading the segmental or distal portion of the pulmonary artery. In this case it is clear that the only options are either to reconstruct the artery or do a full pneumonectomy. This slide shows apatch reconstruction after resection of part of the PA which is clamped proximally. Distally clamping the inferior pulmonary vein will stop the back flow. This is a patch taken from the pericardium and fashioned in a way a way to have a nice reconstruction of the PA. This is a full reconstruction after pulmonary artery sleeve which show the proximal PA. The distal PA is not clamped because the vein has been clamped to prevent retrograde flow. This is an end-to-end reconstruction and it is surprising how these arteries come nicely together without any tension, if the amount of artery that is resected is not too large. This is the completed reconstruction after complete sleeve of the pulmonary artery. If you do a bronchial and a pulmonary artery sleeve, bronchial anastomosis is done first followed by the artery. This slide shows how to fashion a pericardial conduit. They are constructed around a #28 chest tube. This is what it looks like with the pericardial graft in place. Dr. Rendina and his group have done 52 patients with pulmonary artery reconstruction without operative deaths. Survival by stage shows that this procedure can be useful as an alternative to pneumonectomy. What about the role of bronchial sleeve resections in lung cancer management? We have now done 184 patients, the majority of them electively, between 1972 and July, 1998. This slide shows the number of sleeve resections done by five year intervals. In our institution sleeves represent about 5% of all lung cancer resections and we do about 8 or or 10 cases a year. These are the indications. One problem with sleeve resection and I suspect with pulmonary artery reconstruction is that you get very enthusiastic about these operations because they change your operating mode from standard cases of lobectomy and pneumonectomies. This may lead you to extend the indication and do these procedures when there is no indication. In this series, most cases were done electively in patients that could tolerate pneumonectomy. In 15 patients the sleeve was done as a comprom. This slide shows a sleeve resection of the right upper lobe for cancer with nodal disease and there was some 20 cases where the sole indication for sleeve resection was nodal disease. In these individuals, the tumor was peripheral with nodal metastatic disease, usually in the sump area. Most sleeve resections were done on the right side, with 52 patients having sleeve resections on the left side. There were a couple of sleeve of the main bronchi, for very localized tumors in that area. Lower lobe sleeves are not very common. One of the concerns about sleeve resection is the operative mortality which is reported to be higher than standard lobectomy or even higher than after pneumonectomy. The mortality in this series of sleeve resection is 1.6% which is basically the same as standard lobectomy. Two patients died of respiratory failure, which usually started as pneumonia and eventually progressed to ARDS and one patient died of pulmonary embolus. How many anastomotic problems did we encounter? Very few as compared to wedge or flap bronchoplasties. We had two early partial dehiscences and both resolved with conservative treatment. There was no vascular fistulae, and I think that this has to do with the principles of healthy reconstruction plus the type of sutures that was used. There were four patients with late complications. Two had granulations and they were treated by bronchoscopic removal. Two had strictures and one could be dilated while the last one had to have a completion pneumonectomy. What about survival? We have been reporting on sleeve resections for many years, and the survival has always been the same. If we look at all 184 patients, the five year survival is 52%, the ten year survival is 34%, and the median survival time is 1200 days. We looked at survival and histology and patients were divided into squamous and nonsquamous. Ten patients had carcinoids and were excluded from these statistics. There is a significant difference between squamous and nonsquamous, survival being lower at 5 and at 10 years for nonsquamous patients. This slide shows survival by nodal status. No patient N2 disease survived more than seven years and survival at five years is 5%. This data makes you wonder if sleeve resection is a good operation for N2 disease. Five year survival for N1 patients is worse than in N0 patients, but it still is in the range of 48% at five years, which I would suggest is good proof that this procedure as a cancer operation is very adequate. We also looked at right side versus left side because there was some suggestion in the literature that these bronchoplasties were not good operations for left-sided tumors. The curves are exactly the same whether sleeve resection is done on the right side or on the left side. This is a slide that shows you the results of sleeve resections done by surgeions who have been writing extensively on these procedures. The report is from Dr. Bennett and Abby Smith from Coventry. They reported 80 patients with significant operative mortality. These are the five year survival and ten year survival figures. You all know of Dr. Jensik's and Faber's publications. The last report that I have seen from that group had 115 patients with a lower operative mortality. Five year survival figures are in the same range as those of Bennett and Smith. Dr. Van Schill from Belgium has been writing many papers on the role of sleeve resections in lung cancer treatment. These are the survival figures in the current study with an operative mortality of 1.6%, and 5-year survival of 52%. From all these data, one can conclude that sleeve resections can be done with low operative mortalitywith survival figures similar to what is reported with more standard procedures. In conclusion, sleeve resection can be done with a low operative mortality. I think it is an adequate operation for N0 or N1 disease, but I would put a question mark for patients with N2 disease. In this cohort, it may be better to do a pneumonectomy because you get a better tumor clearance, especially in the distal lung. Thank you. |
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