21 - Preanesthetic Evaluation and Preparation

Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.

Title: General Thoracic Surgery, 6th Edition

Copyright 2005 Lippincott Williams & Wilkins

> Table of Contents > Volume I - The Lung, Pleura, Diaphragm, and Chest Wall > Section VII - Pulmonary Resections > Chapter 28 - Sleeve Lobectomy

Chapter 28

Sleeve Lobectomy

Penfield L. Faber

A sleeve lobectomy is the removal of a portion of a main bronchus in conjunction with the involved lobar bronchus and associated lung tissue (Fig. 28-1). Sleeve lobectomies can be accomplished in selected patients with specific technical criteria:

  • The bronchial margin must be free of microscopic cancer.

  • A complete resection of all bronchial and lymphatic cancer must be achieved.

  • The main pulmonary artery must be preserved.

  • The tumor must be confined to the resected portion of lung.

A sleeve lobectomy is the alternative to a pneumonectomy; when compared with pneumonectomy, it is achieved with decreased morbidity and mortality and similar long-term results for lung cancer.

In 1947, Price-Thomas carried out the first sleeve lobectomy for a bronchial adenoma, which was reported by him in 1956. A bronchoplastic wedge resection of a portion of the left main bronchus for a bronchial adenoma was then accomplished by D'Abreu and McHale in 1949 and reported by these surgeons in 1951. Allison (1959) reported the first successful sleeve lobectomy for carcinoma and was the first to report resection and reconstruction of a portion of the adjacent pulmonary artery infiltrated by tumor in the patient undergoing sleeve lobectomy for carcinoma. Price-Thomas summarized the role of sleeve resection in selected patients with lung cancer in 1960.

INDICATIONS

Sleeve resections are applicable in patients with lung cancer, bronchial carcinoids, other bronchial tumors, benign bronchial strictures related to trauma or inflammatory disease, acute traumatic disruption of the airway, and metastatic malignancies with lobar extension to the main bronchus. Approximately 6% to 8% of resections for primary lung cancer are sleeve resections.

Tumor in a lobar orifice or a lobar tumor invading the main bronchus precludes a standard lobectomy, and sleeve lobectomy becomes the procedure of choice (Fig. 28-2). Preoperative bronchoscopy can identify the need for a sleeve lobectomy by the visualization of tumor in the lobar orifice. If cancer is found at the lobar resection margin on frozen section analysis or there is extraluminal extension of the tumor to the main-stem bronchus, a more extensive resection than standard lobectomy is required. Lymph nodes involved by cancer can invade the bronchial wall at the lobar bronchial margin, and resection of a portion of the main bronchus is required. Resections for second primary lung cancers require conservation of lung tissue, and a sleeve lobectomy can avoid pneumonectomy.

Additional indications for sleeve lobectomy are patients over the age of 70 and patients with compromised cardiopulmonary function. Sleeve lobectomy avoids a pneumonectomy; the mortality rate is lower with a sleeve procedure, and postoperative quality of life is enhanced. A postoperative predicted forced expiratory volume in 1 second (FEV1) of less than 50% indicates a likelihood of complications following pneumonectomy, and preservation of lung tissue is of benefit. Patients with cardiac disease or other comorbidities always benefit from preservation of lung tissue.

Typical carcinoid tumors are ideally suited for sleeve resections. They frequently have a limited base of invasion into the bronchus, and margins of resections can be relatively close. Long-term results free of disease approach 100%. Patients with mucoepidermoid and adenoid cystic carcinomas are candidates for sleeve resections; a complete resection with accompanying lymph nodes must always be achieved for these lesions.

Kato and associates (1993) reported on various types of sleeve resection for tuberculous bronchial stenosis. Blunt chest trauma can cause bronchial disruption, and if not diagnosed acutely, the patient can present months or years later with a benign stricture. These strictures are located adjacent to a lobar bronchus or in a main-stem bronchus and

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are ideal for sleeve resection. Major bronchial disruption as a result of penetrating or blunt chest trauma requires d bridement of the torn bronchus and reapproximation of viable tissue. Sleeve lobectomy may be required to reconstruct the airway in association with traumatized lung parenchyma.

Fig. 28-1. Location of tumors for which standard sleeve lobectomies can be accomplished.

Benign tumors that require conservation of lung tissue include hamartomas, large lipomas, schwannomas, and granular cell myoblastomas. Metastatic carcinomas can extend to a main-stem bronchus, and sleeve lobectomy is indicated. This pathologic situation can be particularly applicable to metastatic breast cancer, hypernephromas, or metastatic sarcoma. The one major contraindication to a sleeve lobectomy is when a complete resection cannot be achieved with the sleeve procedure. The positive involvement of N2 nodes in a patient with primary bronchial carcinoma as a contraindication to sleeve lobectomy remains controversial.

DIAGNOSTIC EVALUATION

A standard chest radiograph will identify the site of pathology, and a computed tomographic (CT) scan with and without infusion is then obtained. The CT scan will determine the size, anatomic location, and extent of mediastinal invasion. Compression or invasion of the main pulmonary artery is carefully detailed on the infusion scan. Lobar compression is noted, and polypoid tumors in a main-stem or lobar bronchus can sometimes be clearly identified. Bronchial

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strictures can be seen but cannot be well measured for length or diameter. Mediastinal and hilar lymph nodes are carefully assessed for size and location. A nodal diameter of 1 cm is considered the upper limit of normal, as reported by Glazer and associates (1985). However, the sensitivity of the CT scan in defining metastatic cancer in regional lymph nodes is too low to be more than an adjunct to invasive sampling.

Fig. 28-2. A. Right upper lobe sleeve lobectomy. B. Left upper lobe sleeve lobectomy. C. Left lower lobe sleeve lobectomy.

Positron emission tomography (PET) is an important modality in the staging of lung cancer. The PET scan is more sensitive and specific than CT scanning in identifying metastatic disease in normal-size nodes and in the differentiation of enlarged benign nodes from nodes with metastatic disease. Valk and co-workers (1995) noted that PET increased or decreased nodal staging as determined by CT in 24% of presurgical patients. PET does have a high positive predictive value, but false-positive results can occur with infection and inflammation. Therefore, mediastinoscopy should be done if there is increased nodal uptake in the mediastinum. A negative CT scan for enlarged mediastinal lymph nodes coupled with a negative PET indicates that mediastinoscopy is unnecessary. The PET scan will alert the surgeon to positive hilar adenopathy and has high sensitivity in the detection of metastasis to the liver, adrenal glands, and bone. PET is an excellent screening modality for lung cancer; its only drawback is availability and cost.

Bronchoscopy is done to define the extent of the pathologic changes in the bronchus and to define histology, as noted by the author (1995). Pertinent findings indicating a probable sleeve resection include tumor in the lobar orifice, thickening of lobar spurs, exophytic tumors in a main-stem bronchus, and submucosal vascularity indicating cancer extension. Bronchial carcinoids do not bleed significantly with biopsy through the flexible fiberoptic bronchoscope, and histologic confirmation is necessary to plan resection margins. Bronchial carcinoids frequently can be pushed aside for evaluation of the distal airway to define the origin of the tumor. This is of significant help in planning the site of possible bronchotomy and resection.

Complete pulmonary function studies are obtained to assess the need for conservation of lung tissue; if there is any question regarding the patient's ability to tolerate a pneumonectomy, quantitative ventilation-perfusion lung scans are done. Full cardiac evaluation is accomplished if symptomatology is present; this includes echocardiogram, stress test, and possible coronary angiography. Magnetic resonance (MR) imaging has not proven to be of benefit in evaluating the hilum or pulmonary vasculature.

The finding of positive mediastinal nodes at mediastinoscopy indicates a need for reassessment of the planned surgical procedure. Positive N2 disease worsens the prognosis. Tronc and associates (2000) reported an 8% survival rate for sleeve lobectomy patients with N2 nodes at 5 years, and no survivors at 7 years. Ghiribelli and colleagues (2002) noted a 5-year survival of 12.5% in sleeve lobectomy patients, and Van Schil and associates (1996) reported significantly lower long-term survival in patients with N1 and N2 disease undergoing sleeve lobectomy for lung cancer. However, Naruke (1989) reported more favorable survival in patients with N2 disease, and Okada and colleagues (2000) reported a 5-year actuarial survival of 21% for patients who underwent sleeve lobectomy with N2 disease. The majority of reports show unfavorable long-term prognosis with N2 disease; these patients can be considered for a program of neoadjuvant therapy, as reported by Bonomi and the author (1993). Nonrandomized studies indicate improved survival for patients receiving neoadjuvant therapy for N2 disease, and phase III studies are soon to be reported. Until definitive results are known, each individual surgeon must decide on the program of therapy for patients with lung cancer and N1 and N2 disease who are possible candidates for sleeve lobectomy.

When planning a sleeve lobectomy, it is critical to keep in mind that pneumonectomy may be required because of technical problems or tumor extension; the surgeon must prepare the patient and family for this possibility. The patient's acceptance of, and ability to withstand, removal of an entire lung must be clearly defined. Sleeve lobectomy can be planned, but pneumonectomy may be required at the time of operation.

SURGICAL TECHNIQUE

The standard double-lumen tube is the endotracheal tube of choice for the required one-lung anesthesia. Endobronchial balloon blockers can be used for one-lung anesthesia, but bronchoscopy is required for proper positioning and the balloon blockers can be difficult to maneuver. Accurate positioning and tendency to migrate present intraoperative problems. Hypoxia can occur because of the shunting of unoxygenated blood through the nonventilated lung. The use of increased Fio2 and increased minute ventilation minimizes hypoxia, and occlusion of the main pulmonary artery on the operated side to minimize the shunt is not necessary. Techniques to improve arterial oxygenation include jet ventilation or continuous positive airway pressure (CPAP) of the operated lung combined with intermittent positive-pressure ventilation of the dependent lung. The anesthesiologist must be familiar with all of these techniques.

The posterolateral thoracotomy is a favorite incision for sleeve lobectomy, but the lateral or vertical axillary thoracotomy is the preferred incision of some. Entrance into the chest through the fifth intercostal space is satisfactory for bronchial sleeve procedures.

The initial dissection deals with the lobar branches of the pulmonary artery to ensure that the resection can be accomplished. If the tumor is in close proximity to lobar branches, proximal control of the main pulmonary artery is recommended. Neoadjuvant therapy can create significant fibrosis with obliteration of the normal tissue planes of dissection. The tumor may invade the wall of the pulmonary

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artery or involve the origin of a large lobar branch (Fig. 28-3) In this situation, it may be necessary to carry out a concomitant sleeve resection or patch angioplasty of the pulmonary artery as described by Schirren and co-workers (1999).

Fig. 28-3. Cancer invading the left main pulmonary artery at the origin of the first branch to the left upper lobe.

Careful dissection is necessary to preserve the bronchial blood supply. Funami and associates (1996) have clearly described the anatomic course of the bronchial arteries in both the left and right hilum. Preservation of bronchial arteries is also important when carrying out the associated lymphadenectomy. It is preferable to accomplish the lymph node dissection prior to the bronchial sleeve procedure to avoid traction on or manipulation of the anastomosis. Lymph nodes at stations 5, 6, and 7 are in close association with bronchial arteries that are preserved whenever possible.

The proximal and distal areas of the main bronchi are then circumferentially dissected free of adjacent tissue. A tumor-free margin is selected, and the bronchus is transected with a knife to ensure clean and straight margins (Fig. 28-4). No attempt is made to cut in any specific area of the membrane or cartilage ring. A straight transection of the main bronchus and associated distal bronchus provides the best opportunity for a complication-free anastomosis. After the specimen is removed (Fig. 28-5), frozen section analysis of both the proximal and distal ends of the bronchus is done to determine the adequacy of cancer resection. A margin positive for microscopic cancer indicates that more bronchus must be resected. Further bronchial resection can create technical problems of anastomotic tension or compromise of a distal bronchus. Careful judgment is necessary, because it may be more appropriate to carry out a pneumonectomy than risk a failed anastomosis with resultant postoperative complications that may be fatal. Techniques to minimize tension on the anastomosis include transection of the inferior pulmonary ligament and also a semicircular transection of the pericardium as described by Vogt-Moykopf and associates (1991).

Fig. 28-4. A knife transects the left main-stem bronchus for a left lower lobe sleeve lobectomy. The left upper lobe bronchus has already been cut.

The anastomosis is accomplished with 4-0 polyglycolic suture material, as described by the author (1993). Two or three through-and-through sutures are placed inferiorly to approximate the dependent and medial cartilages. These are tied with the knots outside to alleviate tension and provide accurate placement of the remaining sutures. Posterior sutures can be difficult to place and tie with the knots on the outside, and three or four sutures can be conveniently placed with the knots on the inside. The knots create minimal obstruction and are readily absorbed with little reaction. The remaining sutures are placed to achieve cartilage-to-cartilage approximation with the knots on the outside. Sutures are placed at equal depth and at an equal distance apart, because oblique placement of sutures to achieve a decrease in lumen disparity results in bronchial distortion or tearing of the cartilage due to excessive tension.

Lumen disparity is corrected by stretching the membrane of the smaller bronchus and crimping the membrane of the

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larger bronchus. The final four or five sutures are not tied until all have been placed, to ensure proper visualization of their placement. The anastomosis is covered with a pleural flap or with a pedicled anterior mediastinal fat pad. This tissue separates the pulmonary artery from the bronchial anastomosis and minimizes the complication of a bronchial arterial fistula. Tissue coverage can minimize the complication of a small bronchial disruption (Fig. 28-6).

Fig. 28-5. Right upper sleeve lobectomy specimen. Frozen section is accomplished on bronchial resection margins.

Fig. 28-6. A. Initial suture approximates dependent cartilages. B. Additional sutures are placed in a circumferential manner. Membrane reapproximation corrects lumen disparity. Pleural flap surrounds the anastomosis.

Another preferred anastomosis is to place all the sutures circumferentially before they are tied (Fig. 28-7). Kutlu and Goldstraw (1999) described the use of a continuous suture of 3-0 polypropylene in 66 sleeve lobectomies. Results were comparable with others reporting interrupted suture techniques. A smaller distal bronchus can be telescoped into the larger proximal lumen. This technique can be readily applied when performing upper and lower sleeve bilobectomies and reimplantation of the middle lobe or upper lobe into the main-stem bronchus, as described by Hollaus and associates (2003). In 15 patients with a significant bronchial lumen disparity, there was one anastomotic dehiscence and no long-term stenosis. Following completion of the anastomosis, the lung is inflated and the saline-covered bronchus is observed for any evidence of air leak at 20 to 30 cm of airway pressure. Small needle-hole air leaks are of no

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concern, but an air leak between the edges of the bronchi may require an additional suture of 5-0 polyglycolic suture. The lung should inflate and deflate readily, indicating a widely patent anastomosis. Failure of the lung to deflate can indicate anastomotic distortion or narrowing.

Fig. 28-7. Placement of all of the bronchial anastomotic sutures prior to their being tied for left lower lobe sleeve lobectomy. From Faber LP: Sleeve lobectomy. Chest Surg Clin N Am 5:233, 1995. With permission.

Fig. 28-8. A. Elliptical portion of pulmonary artery is resected. B. Linear closure without lumen compromise of pulmonary artery.

Flexible bronchoscopy is necessary to visualize the anastomosis and clear the distal airway of any bloody secretions. If the anastomosis is distorted or significantly narrowed, it may be necessary to remove some sutures and reconfigure a portion of the anastomosis. It is usually not necessary to redo the entire anastomosis.

Angioplasty is readily accomplished in conjunction with sleeve lobectomy. Rendina and co-workers (2000) described pulmonary artery reconstruction in 40 patients with bronchial sleeve lobectomy or bilobectomy. Linear resection and closure of the main artery can be done, but the surgeon must be certain that the arterial lumen is not significantly narrowed (Fig. 28-8). It is usually more appropriate to carry out a patch angioplasty with a piece of pericardium or bovine pericardium to ensure lumen patency (Fig. 28-9). A sleeve resection of the pulmonary artery can be done in conjunction with the sleeve lobectomy, and the arterial anastomosis is accomplished with fine monofilament suture in a continuous fashion (Fig. 28-10). The arterial anastomosis is done after the bronchial anastomosis has been completed to minimize retraction and handling of the vascular anastomosis, and the transected artery permits excellent exposure for the bronchial anastomosis. On occasion, an extended arterial defect does not permit reanastomosis, and a graft of autologous pericardium is constructed as described by Rendina and co-workers (2000) (Fig. 28-11). Prosthetic material can also be utilized for the pulmonary artery conduit. Heparin (5,000 units) is given prior to a sleeve resection of the pulmonary artery, and subcutaneous heparin is maintained for 7 to 10 postoperative days. Long-term anticoagulation is not necessary.

Fig. 28-9. Pericardial patch repair of defect in main pulmonary artery. From Faber LP: Sleeve resections for lung cancer. Semin Thorac Cardiovasc Surg 5:238, 1993. With permission.

Fig. 28-10. Sleeve resection of pulmonary artery. From Faber LP: Sleeve resections for lung cancer. Semin Thorac Cardiovasc Surg 5:238, 1993. With permission.

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POSTOPERATIVE MANAGEMENT AND COMPLICATIONS

Many patients with lung cancer have comorbidities, which can influence the postoperative complication rate. Hollaus and colleagues (2003) evaluated the risk factors for the development of postoperative complications in 108 patients undergoing bronchoplastic procedures for bronchial malignancy. Two pulmonary risk factors coupled with coronary artery disease were predictive for septic complications. Peripheral artery disease, extended resections, and chronic obstructive pulmonary disease were predictive for aseptic complications. Preoperative efforts to minimize these risk factors should always be considered and undertaken.

In a survey of 1,125 sleeve lobectomies performed in various centers, Tedder and associates (1992) noted that pneumonia and atelectasis occurred in approximately 6.7% and 5.4% of patients, respectively. This relates to an accumulation of secretions and blood at the anastomosis due to mucosal damage and loss of ciliary function. Bronchoscopy in the operating room immediately after completion of the anastomosis can minimize this problem. The clinical indication for postoperative bronchoscopy includes a persistent coarse wheeze at the anastomosis, continuing loss of volume noted on the chest radiograph, lobar consolidation, or a persistent air leak at 7 days postoperatively. Excessive secretions can be managed by minitracheostomy, if daily bronchoscopy is necessary. If the clinical course of the patient is satisfactory and the residual lung is well expanded, routine postoperative bronchoscopy prior to discharge is not done. Follow-up bronchoscopy to inspect the anastomosis at 3 months is at the discretion of the surgeon.

Fig. 28-11. Conduit reconstruction of pulmonary artery after tumor resection. A proximal vascular clamp does not compromise the lumen for anastomosis.

A persistent air leak at 7 to 10 days postoperatively may indicate partial anastomotic dehiscence, and the anastomosis should be inspected with the flexible bronchoscope. Bronchial necrosis is indicated by a gray-white discoloration of the mucosa; a to-and-fro motion of secretions through a partial dehiscence can be identified. A dehiscence of 4 to 5 mm can be observed and treated conservatively with prolonged chest tube drainage. This is particularly true if tissue has been placed over the bronchial anastomosis. The development of an air space and increasing volume of air leak indicate further dehiscence requiring completion pneumonectomy. An anastomotic dehiscence greater than 10 mm requires consideration of completion pneumonectomy. The surgeon must proceed with caution if suture anastomotic reapproximation is done and fresh tissue coverage with a muscle flap is required. Careful judgment is necessary because the patient must be able to tolerate the pneumonectomy procedure.

Tedder and colleagues (1992) reported a 3.5% incidence of bronchopleural fistula (42 in 1,186 patients). Completion pneumonectomy carries a mortality rate of 15% to 20%, as reported by Kawahara (1994) and Van Schil (1996) and their associates. Schirren and colleagues (1999) reported a 7.4% incidence of bronchopleural fistula in their series of complex bronchoplastic procedures in association with many angioplastic repairs. Tronc and associates (2000) reported a fistula rate of 1.1% (2 of 184) in patients undergoing sleeve lobectomy for lung cancer. Both patients were

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managed conservatively, and this excellent result relates to precise preoperative evaluation and technical experience. Kawahara and co-workers (1994) reported a 5.6% fistula rate (6 of 112 patients). However, in 24 patients with anastomotic complications, 19 were stage IIIA or IIIB, and pulmonary artery angioplasty was performed in 37 patients, indicating the advanced stage of disease in these patients. I (1993) reported six patients who required completion pneumonectomy because of anastomotic complications.

Improved surgical technique has minimized the late complication of bronchial stenosis or the early complication of bronchial kinking. The development of bronchial stenosis is successfully managed by bronchial dilation and stenting techniques, as described by Kutlu and Goldstraw (1999).

Hemoptysis in the postoperative period is of significant concern and can herald the development of an impending bronchial arterial fistula. Immediate bronchoscopy is required to assess the anastomosis and attempt to define the area of bleeding. Completion pneumonectomy is usually required to avoid this fatal complication.

Function of the reimplanted lung is decreased in the early postoperative period and relates to decreased bronchial arterial flow, damaged lymphatics, and transected parasympathetic nerves. Decreased perfusion may last for 2 to 3 weeks. Khargi and associates (1994) evaluated the preoperative and postoperative pulmonary function of 109 sleeve lobectomy patients and demonstrated that there was complete recovery of function of the reimplanted lobe at 4 months. Deslauriers and colleagues (1986) studied the functional results of sleeve lobectomy and determined that the reimplanted lung contributes significantly to pulmonary function with minimal change in ventilation or perfusion. Preoperative and postoperative lung function assessment was carried out by Gaissert and colleagues (1996). Their findings clearly demonstrated that the operated lung carried out expected proportional function.

RESULTS OF SLEEVE RESECTION FOR LUNG CANCER

The mean age of patients is 60 to 65 years, the ratio of men to women is approximately 5 to 1, and the majority of patients have squamous cell carcinoma, as described by Tronc (2000), Fadel (2002), and Terzi (2002) and their associates. The majority of sleeve resections for lung cancer are the standard lobar type, but can vary with the ingenuity of the operating surgeon. My (1993) experience with sleeve lobectomy is depicted in Fig. 28-12. Other procedures accomplished in this series were six sleeve segmentectomies, with four on the left and two on the right. Other sleeve procedures that can be accomplished include right upper and middle lobectomy, right middle lobectomy and superior segmentectomy, right lower lobectomy with reimplantation of the right middle lobe, right middle and lower lobectomy, and reimplantation of basal segments to a main-stem bronchus. More variations have been described by Vogt-Moykopf and co-workers (1994), including lobar transposition.

Mortality

Mortality varies in reported series from 1.0% to 12%. Vogt-Moykopf and colleagues (1994) reported an overall mortality of 8% in 502 patients who underwent varying types of sleeve resections, and patients undergoing combined angioplasty and bronchial sleeve procedures had a mortality of 10%. Tronc and colleagues (2000) reported an operative mortality of 1.6% (3 of 184 patients). Fadel and associates (2002) noted a mortality of 2.9% (4 of 139 patients) in sleeve lobectomy for non small cell lung cancer (NSCLC). Mortality reported by the author (1995) was 2% (3 of 153). Watanabe and colleagues (1990) reported a 1.3% mortality rate in 79 sleeve procedures, and Tedder and

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co-workers (1992) in their review reported a mortality rate of 5.5% (62 of 1,125). However, Terzi and associates (2002) noted an overall mortality of 12% (18 of 151 patients) in sleeve lobectomy for lung cancer. Univariate analysis showed that mortality was higher in patients over age 70 and in patients who were functionally compromised. These results have modified their selection of patients for sleeve lobectomy with these comorbidity factors. A sleeve lobectomy for lung cancer should be accomplished with a mortality rate under 5%.

Fig. 28-12. Rush-Presbyterian-St. Luke's experience with sleeve lobectomy from lung cancer. From Faber LP: Sleeve resections for lung cancer. Semin Thorac Cardiovasc Surg 5:238, 1993. With permission.

Long-Term Survival

The reporting of long-term results following sleeve lobectomy is variable because the methods of clinical staging may or may not include mediastinoscopy, neoadjuvant therapy, and postoperative adjuvant therapy. Tronc and co-workers (2000) reported complete follow-up in 184 patients who underwent sleeve resection for lung cancer. There were nine carcinoid tumors in this group. Resection was complete in 161 patients (87%), and residual carcinoma was identified in the resected bronchial margin in 12 patients. Mediastinoscopy with complete lymph node sampling was done in 160 patients. Neoadjuvant chemotherapy was given in 3 patients with N2 disease documented at mediastinoscopy. The 5-year survival for patients with N0 disease was 63%; with N1 disease, 48%; and with N2 disease, 8%. The actuarial survival rate for the 184 patients was 52% at 5 years and 34% at 10 years. No patients with N2 disease survived 10 years, and these survival figures are statistically significant. This is a large series of clinically well-staged patients and indicates the results that can be achieved with careful patient selection.

Van Schil and associates (1996) reported an actual 5-year survival rate of 46% in 145 patients undergoing bronchial sleeve resection for NSCLC. The 5-year survival was 62% for patients with N0 disease and 31% for 58 patients with N1 disease. For the 16 patients with N2 disease, 5-year and 7-year survival rates were 31% and 13%, respectively. There was no statistically significant difference in survival between patients with N1 and N2 disease. Multivariate analysis showed that nodal stage and patient age were significant factors in relation to survival.

Schirren and colleagues (1999) reported a 51% survival at 5 years in patients with stage I disease, a 41% 5-year survival in patients with stage II disease, and a 25% 5-year survival in patients with stage IIIA disease. Many of these patients had angioplastic resections in conjunction with the sleeve lobectomy and the disease was more clinically advanced than in other reported series.

Mezzetti and co-workers (2002) reported the results in 83 patients who underwent sleeve lobectomy for primary lung cancer. The 5-year overall survival rate was 43%. For N0 disease it was 61%; N1 disease, 39%; and N2 disease, 9%. Survival difference was statistically significant between patients with N0 and N1 or N2 disease.

Fadel and associates (2002) carried out sleeve lobectomy for NSCLC in 139 patients. Overall 5-year survival was 52%; survival of patients with N0 disease at 5 years was 55%, and for N1 disease 68%. There were no 5-year survivors in the patients with N2 disease. Resection was incomplete in 7 patients who would not tolerate pneumonectomy. Multivariate analysis identified that nodal status and microscopic invasion of the bronchial stump influenced long-term survival.

Terzi and associates (2002) reported on 151 patients undergoing sleeve lobectomy for lung cancer. Overall 5-year survival was 38.8%. Survival for N0 disease at 5 years was 57%; N1 disease, 33%; and N2 disease, 19%. There was statistically significant difference in survival between N0 and N1 or N2 disease.

I (1995) reported the results in 153 patients, with 86 receiving some form of neoadjuvant therapy, primarily radiation. The overall survival was 35% at 5 years; patients who did not receive neoadjuvant therapy had a survival rate of 43% at 5 years, and those with neoadjuvant therapy had a 5-year survival rate of 24%. Not all patients underwent mediastinoscopy, and clinical staging was based on lymph node size defined by CT scan and the finding of positive nodes in the pathologic specimen.

It becomes obvious that survival following sleeve lobectomy for NSCLC is related to stage of disease and a complete resection.

Local and Regional Recurrence Rate

A major indication for resection of primary lung cancer is to eradicate local disease. Local recurrence is therefore of concern when carrying out a lung-sparing operative procedure. There is variability in the reporting of local recurrence following sleeve resections for lung cancer. Some authors report only recurrence at the suture line, and others report recurrence anywhere in the operated chest. Tronc and colleagues (2000) reported an overall local recurrence rate of 22% (41 of 184 patients); cervical mediastinoscopy had been done in 160 patients. Recurrence rate varied by nodal status and was 14% in patients with N0 disease (14 of 97), 23% in patients with N1 disease (19 of 68), and 42% in patients with N2 disease (8 of 19). There was statistical significance of recurrence between patients with N0 versus N2 disease (p = 0.005). Combining local and distant recurrence, the rates were 22%, 41%, and 63% for N0, N1, and N2 nodal groups, respectively. In patients who had a complete resection, 16% had local recurrence, while 65% (15 of 23) had local recurrence after an incomplete resection.

In 139 sleeve lobectomy resections for NSCLC, Fadel and co-workers (2002) reported a local and regional recurrence rate of 15% (21 of 139 patients). Van Schil and co-workers (1996) reported a local recurrence rate of 20% (29 of 145).

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Only 5 patients were candidates for completion pneumonectomy, and 3 of 29 patients were alive without evidence of disease. These results indicate that local regional recurrence can be a devastating complication.

Frist and co-workers (1987) reported a local recurrence rate of 6% (2 of 33) in patients undergoing sleeve resection for NSCLC. Local and regional recurrence was reported in 10 patients by Gaissert and colleagues (1996), for a rate of 14% (10 of 69). This report included tumor recurring in the mediastinum in 7 patients and in the ipsilateral lung in 2. Only 1 patient had a confirmed suture line recurrence. Local relapse in the site of the anastomosis occurred in 20% of lung cancer sleeve lobectomy resections as reported by Mezzetti and co-workers (2002).

Incomplete resections and stage of disease relate to local and regional recurrence following sleeve lobectomy, but this occurrence appears to be no more frequent in a similar group of patients undergoing the alternative operation of pneumonectomy. Yoshino and associates (1997) reported a higher incidence of local recurrence in pneumonectomy patients than in a similar group of sleeve lobectomy patients. Local recurrence was evaluated by Okada and colleagues (2000) in a similar group of patients undergoing sleeve lobectomy or pneumonectomy for lung cancer and was 8% and 10%, respectively. The pattern of failure for sleeve lobectomy for NSCLC is certainly no worse than the 20% intrathoracic recurrence rate following standard resections reported by the Ludwig Lung Cancer Study Group (1987).

Results of Combined Sleeve Resection and Arterial Reconstruction

Sleeve lobectomy in conjunction with pulmonary artery reconstruction is a viable procedure for NSCLC (Fig. 28-13). The many variations of this type of procedure are well described by Rendina and co-workers (2000), as they have described a sleeve resection of the bronchus in conjunction with angioplasty in 40 patients. There were 14 complete pulmonary artery sleeve resections, 25 patch repairs of the pulmonary artery, and 1 conduit. There was one pulmonary artery thrombosis that required completion pneumonectomy and one postoperative death related to sepsis. The reported 5-year survival rate was 38.6% for their combined pulmonary artery and bronchial reconstruction patients. Vogt-Moykopf and co-workers (1991, 1994) reported a 35% 5-year survival rate in 108 patients with stage I and II disease who had a combined bronchial and pulmonary artery reconstruction for lung cancer.

In 110 patients who underwent sleeve lobectomy, Icard and co-workers (1999) performed an associated pulmonary arterial resection in 16 patients. A sleeve of the pulmonary artery was done in 4 cases, and tangential closure with partial resection in 12. The 5-year actuarial survival was 9%. This finding led these authors to recommend pulmonary artery angioplastic resection only in patients who could not tolerate pneumonectomy. Most authors believe that sleeve lobectomy in conjunction with pulmonary artery angioplasty is a viable and curative procedure.

Fig. 28-13. A. Computed tomographic (CT) scan shows left upper lobe squamous cell cancer invading the pulmonary artery. B. Postoperative CT scan illustrates normal pulmonary arterial flow to residual left lower lobe following pulmonary artery angioplasty and left upper lobe sleeve lobectomy.

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Sleeve Resection in Patients with N2 Disease

Sleeve resection in patients with positive N2 disease remains controversial. There were no 5-year survivors in 24 patients with N2 disease reported by Fadel and associates (2002) who had a sleeve lobectomy for lung cancer. An 8% survival rate in 19 patients with N2 disease at 5 years was reported by Tronc and associates (2000), and a 17% survival by Watanabe and co-workers (1990). Van Schil and associates (1996) noted 5- and 7-year survival rates of 31% and 13%, respectively, for 16 patients with N2 disease. Neoadjuvant therapy can be considered for these patients, as reported by Stamatis and co-workers (2002). They accomplished 37 sleeve lobectomies after concurrent chemoradiotherapy. Morbidity, mortality, and survival were similar to other reported series. The author (1995) described 86 patients who received primarily radiation therapy prior to sleeve lobectomy. Actual survival was 24% at 5 years, with no significant increase in morbidity or mortality (Fig. 28-14).

The finding of positive regional lymph nodes at the time of the surgical procedure is not a contraindication to resection. Sleeve lobectomy provides access to all lymph node stations, and mediastinal lymphadenectomy can be as complete as if pneumonectomy were carried out. Matted lymph nodes in a major fissure usually contraindicate sleeve resection; pneumonectomy is the procedure of choice in this case.

Sleeve lobectomy for NSCLC is the procedure of choice when technically feasible. When compared with the alternative procedure of pneumonectomy, sleeve lobectomy has comparable long-term results, decreased mortality and morbidity, and improved quality of life. Thus, it is a procedure of choice, not a procedure of compromise.

Fig. 28-14. A. Right upper lobe squamous carcinoma invading mediastinum and level 4 lymph nodes. B. CT scan of similar area depicting shrinkage of tumor following chemoradiation therapy and right upper lobe sleeve lobectomy.

SLEEVE RESECTION FOR OTHER TUMORS

Bronchial carcinoids frequently obliterate a lobar bronchus; these neoplasms are most suitable for a bronchoplastic resection. Margins can be in close proximity to the tumor, and long-term results are very good. Lowe and associates (1995) reported results of bronchoplastic procedures for carcinoid tumors in 112 patients; 100 patients (96%) survived 5 years. One hundred percent 5-year survival for sleeve resection of carcinoid tumors was reported by Fadel and associates (2002). There were 25 typical carcinoids and 5 atypical carcinoid tumors in this group. Twenty-two patients had stage I disease, and 8 had stage II disease. One patient died of myocardial infarction at 78 months, and the other 29 patients were free of disease at 10 years.

The atypical carcinoid lesion is a more aggressive tumor, and complete lymphadenectomy is always accomplished in association with the sleeve procedure. Sleeve resections are also indicated for mucoepidermoid and adenoid cystic carcinomas of the bronchus. Long-term results relate to grading of the tumor and involvement of regional lymph nodes, as described by Breyer and colleagues (1980).

BENIGN LESIONS

Sleeve resections are important in resecting benign lesions of the tracheobronchial tree because they afford the opportunity to conserve lung tissue. Motor vehicle accidents are associated with traumatic disruption of the main-stem bronchus at the origin of the lobar bronchus, and sleeve resection is often indicated. Bronchial edges are transected to provide viable tissue for anastomosis, and it is important to achieve a tension-free anastomosis. Late bronchial stenosis

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may occur in a distal main-stem bronchus or compromise a lobar bronchus. In this instance, sleeve lobectomy will preserve the distal lung tissue, and, if infection free, it will function normally in the postoperative period.

Tuberculosis is rare, but an occasional patient may develop a stricture related to this inflammatory process. Antituberculosis therapy preoperatively is mandatory, and inflammation at the site of the stricture must be minimized. Patients with Wegener's granulomatosis and sarcoidosis can also present with lobar or bronchial compromise and can be candidates for sleeve resection.

Techniques for benign lesions are similar to those described for neoplasms, and results are most satisfactory.

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General Thoracic Surgery. Two Volume Set. 6th Edition
General Thoracic Surgery (General Thoracic Surgery (Shields)) [2 VOLUME SET]
ISBN: 0781779820
EAN: 2147483647
Year: 2004
Pages: 203

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