Transsternal Transpericardial Approach for Left Main Bronchus Sleeve Resection Due to Pulmonary Glomus Tumor

Introduction

Glomus tumors (GT) are rare benign neoplasms mostly affecting the deep dermis of extremities, and they constitute less than 2% of all soft tissue tumors. GTs can sporadically appear extracutaneously in the gastrointestinal tract, bone, cervix, and ovary, but GT occurrence in major airways is extremely rare. Only about 40 cases have been reported in the English literature. Patients are usually asymptomatic or present nonspecific symptoms such as cough, dyspnea, or hemoptysis, due to intrabronchial growth of the neoplasm. Even if bronchoscopic management has been reported for tracheal localizations, the risk of local recurrence and the attested malignant potential make surgical resection widely accepted as the treatment of choice, with optimal oncological results and without recurrences if R0 resection is performed.

The transsternal transpericardial approach represents the optimal access for the resection and reconstruction of the carina and proximal part of main bronchi. First described by Abbruzzini, Perelman, and Ambatjello for the closure of a chronic bronchopleural fistula following pneumonectomy, this technique has also been used for the treatment of acute descending necrotizing mediastinitis, and for the exposure of the distal part of the esophagus and descending thoracic aorta. In the authors’ experience, this access allows the perfect exposure for surgical resection and reconstruction of the carina and main bronchi, ensuring the optimal control of possible related complications.

Case Report

A 61-year-old man was admitted due to a left main bronchus mass accidentally discovered during cardiac investigations conducted for sporadic episodes of syncope, fatigue, and cough, which increased during a period of one month. Computed tomography (CT) and positron emission tomography (PET) revealed a 13 mm mass arising from the left main bronchus near the carina. The lung parenchyma appeared normal and no mediastinal or hilar lymph node involvement was detected. A flexible bronchoscopy was performed and a sessile endobronchial mass with hyperemic appearance was found. The lesion originated from the membranous portion of the left main bronchus, immediately close to the carinal bifurcation and it occupied more than 80% of the bronchus lumen. A biopsy was conducted on the specimen, which resulted in the diagnosis of a GT. The patient was thus a candidate for surgery, and a left main bronchus sleeve resection with end-to-end anastomosis via a transsternal transpericardial approach was performed, as shown in the video. The patient’s postoperative course was uneventful and they were discharged nine days after surgery. Before hospital discharge, a flexible bronchoscopy showed no stenosis or leakage of the anastomosis. At a three-month follow-up visit, the patient was in good physical condition and no recurrences were detected.

Surgical Description

This video shows the transsternal transpericardial approach used to perform a left main bronchus sleeve resection in a patient affected by an endobronchial GT. Under general anesthesia with a double-lumen endotracheal tube, a median sternotomy was performed. The thymus gland was thus resected. The anterior pericardium was opened, and the ascending aorta was isolated and mobilized to expose the right pulmonary artery, which was loaded on a vessel loop. Lymph node dissection of paratracheal (R4) and subcarinal (7) stations was performed to facilitate the isolation of the trachea and the carina. The right main bronchus was loaded on a loop. With the proper control of the large airways’ bifurcation, the left main bronchus was resected. The resected tissue was long enough to encompass the tumor-bearing area with macroscopic free margins. An end-to-end anastomosis was then performed using two running sutures—one for the membranous wall and one for the cartilage—using 4-0 polypropylene sutures.

Intraoperative flexible bronchoscopy demonstrated the tracheobronchial patency. Two chest tubes were positioned in order to drain the mediastinum and right pleural cavity. The sternum was repaired using stainless steel wires, and the wound was closed with intradermic absorbable sutures.

Suggested Reading

1. Choi IH, Song DH, Kim J, Han J. Two cases of glomus tumor arising in large airway: well organized radiologic, macroscopic and microscopic findings. Tuberc Respir Dis (Seoul). 2014;76(1):34-37.
2. Stella F, Petrella F. Transsternal transpericardial approach for acute descending necrotizing mediastinitis. J Thorac Cardiovasc Surg. 2005;129(1):212-214.
3. Galetta D, Spaggiari L. Thymectomy and transpericardial nodal dissection. Thorac Cancer. 2015;6(3):375-377.