U-VATS Sleeve Left Upper Lobectomy

Typical carcinoids are low-grade tumors that can be localized in the large airways, often growing on the bronchial bifurcations. Their main treatment method is surgical resection. Guidelines and previous experience in the treatment of such tumors show that complete tumor resection allows for excellent survival rates (1, 2). 

With the development of minimally invasive surgical methods, the majority of peripherally located lung tumors are now operated on using minimally invasive techniques. The benefits of minimally invasive approaches, such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS), over open thoracotomy have been clearly demonstrated in numerous studies (3, 4, 5).  

However, in cases of central lung tumors, the operations are often more technically demanding. In many cases, bronchoplastic or angioplastic procedures may be necessary to avoid pneumonectomy, and such operations are more frequently performed using an open approach (6, 7). Recently, different types of sleeve resections have been reported using minimally invasive approaches (8, 9). Here, the authors present their approach for a bronchial sleeve left upper lobectomy using a uniportal VATS technique. 

The authors present the case of a 33-year-old male patient who was diagnosed with a centrally located left upper lobe pulmonary tumor. The tumor was hypermetabolic on PET/CT scan, but there were no signs of lymph node involvement or distant metastases. Bronchoscopy was performed, revealing that the tumor was located at the orifice of the left upper lobe bronchus, partially obstructing it. A biopsy of the tumor revealed a typical carcinoid. The case was discussed at a multidisciplinary team (MDT) meeting, and surgical resection via a sleeve left upper lobectomy was proposed. Intraoperative evaluation of the bronchial resection margins was necessary to confirm complete resection of the tumor. The operation was successfully performed without any intraoperative complications. The lung was fully expanded, and there was no air leak. The chest tube was removed on postoperative day two. However, the postoperative course was complicated by two episodes of atrial fibrillation on postoperative day two and postoperative day four. Cardioversion was achieved pharmacologically in both cases. The patient was discharged on postoperative day six. The histopathological examination reported pT2aN0 typical carcinoid and R0 resection. 

References

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2. Biancosino C, Redwan B, Welker L, Nakashima M, Branscheid D, Koesek V, Diemel KD, Krüger M. Surgical Strategy and Clinical Outcome in Patients with Bronchial Carcinoids. Adv Exp Med Biol. 2022;1374:17-25. doi: 10.1007/5584_2021_668. PMID: 34550557.
3. Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016 Jun;17(6):836-844. doi: 10.1016/S1470-2045(16)00173-X. Epub 2016 May 6. PMID: 27160473.
4. Lim E, Harris RA, McKeon HE, Batchelor TJ, Dunning J, Shackcloth M, Anikin V, Naidu B, Belcher E, Loubani M, Zamvar V, Dabner L, Brush T, Stokes EA, Wordsworth S, Paramasivan S, Realpe A, Elliott D, Blazeby J, Rogers CA. Impact of video-assisted thoracoscopic lobectomy versus open lobectomy for lung cancer on recovery assessed using self-reported physical function: VIOLET RCT. Health Technol Assess. 2022 Dec;26(48):1-162. doi: 10.3310/THBQ1793. PMID: 36524582; PMCID: PMC9791462.
5. Kent MS, Hartwig MG, Vallières E, Abbas AE, Cerfolio RJ, Dylewski MR, Fabian T, Herrera LJ, Jett KG, Lazzaro RS, Meyers B, Mitzman BA, Reddy RM, Reed MF, Rice DC, Ross P, Sarkaria IS, Schumacher LY, Tisol WB, Wigle DA, Zervos M. Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: An Analysis of 5721 Cases. Ann Surg. 2023 Mar 1;277(3):528-533. doi: 10.1097/SLA.0000000000005115. Epub 2021 Sep 16. PMID: 34534988; PMCID: PMC9891268.
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7. Bölükbas S, Baldes N, Bergmann T, Eberlein M, Beqiri S. Standard and extended sleeve resections of the tracheobronchial tree. J Thorac Dis. 2020 Oct;12(10):6163-6172. doi: 10.21037/jtd.2020.02.65. PMID: 33209454; PMCID: PMC7656394.
8. Gonzalez-Rivas D, Yang Y, Stupnik T, Sekhniaidze D, Fernandez R, Velasco C, Zhu Y, Jiang G. Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections†. Eur J Cardiothorac Surg. 2016 Jan;49 Suppl 1:i6-16. doi: 10.1093/ejcts/ezv410. Epub 2015 Nov 25. PMID: 26609055.
9. Zhao J, Zeng Q, Li J, Tan F, Xue Q, Mu J, Gao Y, Wang D, Gao S. Uniportal versus multiportal thoracoscopic sleeve lobectomy for the surgical treatment of centrally located lung cancer: a single institution experience. J Thorac Dis. 2020 Dec;12(12):7145-7155. doi: 10.21037/jtd-20-2695. PMID: 33447403; PMCID: PMC7797837.

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