|Figure 1 Computed tomography before (top) and after (bottom) induction chemotherapy. Despite marked shrinkage, the tumor still infiltrates the origin of the right upper lobe and possibly the superior vena cava. Mediastinoscopy was performed to rule out N2 nodal involvement.|
The indication for a sleeve resection for lung cancer is well established: a tumor arising at the origin of a lobar bronchus precluding simple lobectomy, but not infiltrating as far as to require pneumonectomy. 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.
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. These considerations apply also to patients with nodal involvement limited to hilar lymph nodes (N1).
Reconstructive surgery of the pulmonary artery has exactly the same indications, although this operation has been less frequently performed to date.
The first case illustrates a right upper lobe sleeve resection. The patient has already had patch reconstruction of the SVC (Figure 2). The azygos vein arch has been resected and the ends are ligated with silk. The right upper lobe has been resected, and a clear distal margin on the bronchus intermedius and proximal margin on the trachea have been obtained. It is important that the suture line is tension-free. 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.
|Figure 2: The right upper lobectomy has been completed, as has patch reconstruction of the SVC. The azygos vein arch has been resected. The margins of the trachea and bronchus intermedius are lying in close proximity, indicating the absence of tension that will be present once the anastomosis.||Figure 3: The initial bronchial cartilaginous sutures have been placed and tied, and the membranous portion sutures have been placed and tied, bringing the edges of the cartilaginous portions into closer approximation.|
|Figure 4: The remainder of the cartilaginous sutures have been placed. They will subsequently be tied beginning at either end and working towards the center.|
The bronchial anastomosis is performed with interrupted monofilament absorbable 4/0 sutures placed extramucosally on the cartilaginous portion. On the membranous portion, placing the sutures submucosally is not necessary because the sutures do not bulge in the bronchial lumen if they are properly tied. Initially, two sutures are placed on the far (mediastinal) end of the cartilaginous portion and are tied extraluminally. 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. The membranous portion sutures are then placed and tied (Figure 3).
The remaining sutures are then placed on the rest of the bronchial circumference and are left untied (Figure 4). The sutures are then tied, starting from the either end of the cartilaginous portion and working towards the middle. Placing and tying the sutures in this order allows compensation for even large caliber discrepancies. This 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 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.
|Figure 5: The right upper lobe bronchus has been preserved for reimplantation. Its short length before (left) and after (right) division is evident.|
In case of upper lobe reimplantation after “Y” sleeve resection, a few technical points should be considered. The upper lobe bronchus is often so short that it is reduced to a disk of bronchial tissue where the openings of the segmental bronchi can be seen. This is more frequent on the right side (Figure 5). Also, the pulmonary artery and the lung are very close to the suture line and the exposure is poor, especially on the mediastinal side of the anastomosis (Figure 6). The anastomosis is performed in the same fashion as described above (Figure 7).
|Figure 6: The right upper lobe bronchus (right) and right mainstem bronchial stump (left) are brought into close approximation. Note the proximity of the azygos vein, pulmonary artery, and lung parenchyma.||Figure 7: The anastomosis between the right upper lobe bronchus and the right mainstem bronchus is performed.|
|Figure 8: Computed tomographic evidence of infiltration of the left pulmonary artery.|
This technique is very versatile and can be used in a variety of circumstances. These range from limited infiltration involving the origin of segmental arteries to large defects extended longitudinally on the PA (Figures 8, 9). The only necessary condition is that the opposite side of the circumference of the PA is free from tumor.
|Figure 9: Line drawing (left) and intraoperative image (right) showing the usual pattern of infiltration of the interlobar portion of the pulmonary artery posterior to the left upper lobe bronchus.*|
|Figure 10: Oval defect in the interlobar portion of the left pulmonary artery after left upper lobectomy.|
During resection control of the main pulmonary artery and the inferior pulmonary vein is obtained. The superior pulmonary vein is divided in a standard fashion. 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 (Figure 10). 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 (Figure 11). After the patch is secured to the artery by 5/0 or 6/0 monofilament running suture, the PA is declamped (Figure 12). 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.
|Figure 11: A suitable portion of the pericardium is harvested for use in patch reconstruction of a pulmonary artery defect.||Figure 12: The pulmonary artery defect has been successfully patched with autologous pericardium.|
|Figure 13: Intraoperative image of a lung cancer of the posterior segment of the right upper lobe infiltrating the pulmonary artery. The upper lobe is retracted upward and backward. The upper lobe vein has been divided and the artery to the middle lobe is visible in the lower portion of the image.||Figure 14: After right upper sleeve lobectomy en bloc with partial resection of the PA, the stump of the main bronchus and the PA defect are visible open in the field.|
Infiltration of the PA on the right side requiring arterial reconstruction is less frequent. Partial resection of the PA often is performed in conjunction with right upper lobe sleeve resection (Figure 13). After right upper sleeve lobectomy en bloc with partial resection of the PA, the stump of the main bronchus and the PA defect are left open in the field (Figure 14). Harvesting of the pericardium is performed as above, based on the size of the portion of the resected pulmonary artery. Patch reconstruction of the PA is completed as above before reimplantation of the bronchus to reduce the arterial clamping time (Figure 15).
|Figure 15: Patch reconstruction of the pulmonary artery is completed before the bronchial anastomosis is performed.||Figure 16: After a sleeve resection of the left upper lobe with en bloc resection of the entire circumference of the pulmonary artery, the defects are visible.|
|Figure 17: Construction of a pulmonary artery replacement conduit using a piece of autologous pericardium. The piece is sized to match the defect, and is wrapped around a 32 Fr chest tube (left). The free edges are approximated with 6/0 or 7/0 monofilament suture (right).|
|Figure 18: The bronchial anastomosis is completed first.|
On occasion a sleeve resection of the upper lobe and the pulmonary artery is necessary (Figure 16). Pulmonary artery and inferior pulmonary vein control are obtained as described above. The vascular conduit is constructed from a segment of autologous pericardium (Figure 17). When sizing the conduit, two points must be considered: the PA stumps can be approximated closer than it seems, and the conduit will stretch more than predicted. It is advisable to tailor the length of the conduit on the basis of the resected arterial segment, because the elasticity of the two tissues is comparable. The bronchial anastomosis is performed first to avoid traumatizing the PA (Figure 18). The PA is reconstructed by end-to-end anastomosis with running 5/0 or 6/0 monofilament suture (Figure 19).
|Figure 19: The arterial conduit is interposed (left) and the proximal and distal anastomoses have been completed (right).|
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 fiew years. A summary of the most recently published data is presented in Tables I to IV. All the quoted papers appear in the English literature and can easily been found in Medline.
(5 yr; %)
|* From 6 to 168 months, **2 years, ***58 months|
(5 yr; %)
|* Overall survival of PA and bronchial reconstruction|
|Author||Year||Patients||5 year survival (%)||10 year survival (%)|
|Author||Year||Patients||Complications (%)||Mortality (%)||5 year survival (%)||Local recurrence (%)|
|Sl : Sleeve Lobectomy Pn : Pneumonectomy
* 3 year survival ** only postoperative respiratory failure
Publication Date: 1-Dec-2003
Last Modified: 9-Sep-2008