Lung conservation techniques: bronchial sleeve resection and reconstruction of the pulmonary artery

Parenchymal Sparing Surgery for Lung Cancer: Focus on Pulmonary Artery Reconstruction

Reconstruction of the pulmonary artery (PA) associated with lobectomy for the radical resection of lung cancer has been progressively gaining diffusion in lung cancer surgery as a safe and effective therapeutic option that may allow radical resection when lobectomy is not technically feasible, avoiding pneumonectomy. There are some controversial aspects concerning the intraoperative and perioperative management of a sleeve resection with PA reconstruction that may influence the outcome. In the present article, the authors have analyzed some of the main technical and oncological aspects to take stock of what they have learned from their lung-sparing operations experience over time. PA reconstruction may require prosthetic materials including different options with variable cost. A main concern in vascular reconstructive procedures is avoiding tension on the anastomosis. When PA reconstruction is required, appropriate anticoagulation management is crucial. Results from the main literature data confirm the reliability of lobectomy associated with PA reconstruction in terms of perioperative morbidity and long-term survival. Sleeve lobectomy and PA reconstruction can be performed safely and effectively even after induction therapy.

Outcomes of minimally invasive sleeve resection

Background

Sleeve resection allows for preservation of lung parenchyma and improved long-term outcomes when compared with pneumonectomy. Little is known about minimally invasive sleeve resection, especially indications, feasibility, technical aspects, complications, and outcomes. We reviewed our institutional experience with sleeve resections via a minimally invasive approach.

Methods

We performed a retrospective review of a prospectively maintained database from 01/01/2010 to 11/01/2017. Indications, operative details, pathology, postoperative complications were reviewed and longer-term follow-up was reviewed.

Results

Fifteen patients were identified (5 males, 10 females). Details are presented in Table 1. Patients ranged in age from 7 to 82 years (median, 57 years). Approaches included video-assisted thoracoscopic surgery (VATS) and robotic. Airway sleeve resection was performed in all patients with an additional arterioplasty in 4, one patient having a double sleeve. Length of stay ranged from 3 to 10 days (median, 5 days). Indication for surgery included carcinoid in 5 (1 atypical), NSCLC in 6, and 4 additional pathologies. Complications occurred in 6 patients: air leak [2], pericardial effusion [1], transient brachial plexopathy [1], and atrial fibrillation [2]. There were no anastomotic complications. Median follow-up was 4.2 years. There were no anastomotic strictures.

Conclusions

In experienced centers, sleeve resection via a minimally invasive approach is feasible with acceptable morbidity and mortality. Results in this small series appear comparable with the open approach.

Lobectomy with angioplasty: which is the best technique for pulmonary artery reconstruction?

Lobectomies with bronchial and/or vascular reconstruction are conservative procedures aimed at managing locally advanced lung cancer, avoiding a pneumonectomy. Considering morbidity, mortality and the functional consequences of a pneumonectomy, such procedures must be in the technical armamentarium of every thoracic surgeon. Vascular reconstruction of the pulmonary artery (PA) is seldom performed with or without the bronchial sleeve resection. Both functional and oncologic outcomes have been reported to be better than after a pneumonectomy. Different technical options are now available but some aspects and technical details are not standardized. Indications, possible complications, planning and even definitions need to be more solid to allow for definitive improvement in such procedures. This analysis is aimed at assessing the acquired technical data with special emphasis on the PA reconstruction with autologous tissues.

Lung Abscess as Delayed Manifestation of Pulmonary Arterial Narrowing After Sleeve Resection

A patient who had undergone right upper bilobectomy because of a carcinoid experienced lung abscesses 17 months after operation. After recurrences, despite different antibiotic agents, dual-energy computed tomography showed subtotal stenosis of the right lower lobe pulmonary artery with marked pulmonary perfusion-reduction. Rare causes of lung-abscesses should be considered.

Translocation of left inferior lobe pulmonary artery to the pulmonary artery trunk for central type non-small cell lung cancers

BACKGROUND

The purpose of this study was to report on a technique for translocation of the left inferior lobar pulmonary artery (PA) to the PA trunk associated with bronchial sleeve resection of the left superior lobe in the treatment of bronchogenic cancer.

METHODS

The clinical data of four non-small-cell lung cancer (NSCLC) patients with translocation of the left inferior lobar PA to the PA trunk associated with bronchial sleeve resection of the left superior lobe was retrospectively reviewed between June 13, 2014 and June 8, 2015. A reconstruction of the left pulmonary arteries was performed by translocating the left inferior lobar PA to the PA trunk with end-to-side anastomosis, sleeve resection of bronchus, and systemic lymphadenectomy.

RESULTS

Histology confirmed squamous carcinoma in these four cases. Stage pT3N2M0-IIIA was confirmed in 2 cases, pT3N1M0-IIIA in 1 case, and pT3N0M0-IIB in 1 case. No perioperative deaths or complications were observed. Four patients underwent postoperative chemotherapies, and the end of follow-ups date was Oct. 21, 2015.

CONCLUSIONS

Translocation of the left inferior lobar PA to the PA trunk is practicable as a lung-sparing procedure, despite being technically challenging.

Glasses-free three-dimensional endoscopic bronchoplasty, arterioplasty, and angioplasty of the superior vena cava for the radical treatment of right middle upper lung cancer

The role of video-assisted thoracoscopic surgery (VATS) radical resection in the treatment of lung cancer has widely recognized. Studies have demonstrated that the thoracoscopic radical treatment of lung cancer can achieve similar long-term survival as that of conventional open surgeries; meanwhile, it can be applied for bronchial sleeve resection that is more challenging for most thoracic surgeons. Bronchial sleeve pneumonectomy can avoid total pneumonectomy when removing tumors, and therefore it can lower the surgery-associated mortality and improve the long-term survival by maximizing the preservation of lung function. Thus, it has become a standard procedure for central-type lung cancer. We have completed a glasses-free three-dimensional (3D) complete thoracoscopic surgery in a patient with central-type lung cancer in his right lung. During the surgery, we found the tumor had invaded the right pulmonary trunk, right main bronchus, and lateral wall of superior vena cava.

Reconstruction of the bronchus and pulmonary artery

Bronchovascular reconstructive procedures employed in order to avoid pneumonectomy (PN) in patients functionally unsuitable have provided, over time, excellent results, similar or even better than those obtained by PN. In recent years, new successful techniques have been developed that pertain in particular the prevention of major complications and the reconstruction of the pulmonary artery (PA). Encouraging data from increasing number of published experiences support the choice of parenchymal sparing procedures for lung cancer also in patients with good functional reserve. This is even more true if considering trials published in the last 10 years, thus indicating that improved outcome can be achieved with increased experience in reconstructive techniques and perioperative management. This article discusses the main technical aspects and results of literature.

Uniportal video-assisted thoracoscopic bronchoplastic and carinal sleeve procedures

Despite of the recent advanced with the video-assisted thoracoscopic surgery (VATS), the most common approach for bronchial and carinal resection is still the open surgery. The technical difficulties, the steep learning curve and the concerns about performing an oncologic and safe reconstruction in advanced cases, are the main reasons for the low adoption of VATS for sleeve resections. Most of the authors use 3-4 incisions for thoracoscopic sleeve procedures. However these surgical techniques can be performed by a single incision approach by skilled uniportal VATS surgeons. The improvements of the surgical instruments, high definition cameras and recent 3D systems have greatly contributed to facilitate the adoption of uniportal VATS techniques for sleeve procedures. In this article we describe the technique of thoracoscopic bronchial sleeve, bronchovascular and carinal resections through a single incision approach.

Techniques of protection and revascularization of the bronchial anastomosis

Airway anastomosis has been traditionally considered at risk for the onset of complications, particularly dehiscence with consequent infection and erosion in the adjacent vessels. Although the modifications and improvements of the surgical technique has contributed to reduce the incidence of complications, the protection and revascularization of the anastomotic site is still considered mandatory at many centers Many techniques have been proposed for encircling the bronchial anastomosis.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

Bronchovascular right upper lobe reconstruction by uniportal video-assisted thoracoscopic surgery

Lung cancer requiring double bronchial and vascular reconstruction of the pulmonary artery is a challenging procedure usually performed by thoracotomy. However, recent development of video-assisted thoracoscopic techniques allows experienced and skilled surgeons to perform these cases through a minimally invasive approach. Most of these complex thoracoscopic resections are performed by using 3 to 4 incisions. We present the first report of a right side combined vascular reconstruction and bronchoplasty performed through a single-incision video-assisted thoracoscopic surgery (VATS) technique.

Long-term results after resection of bronchial carcinoid tumour: evaluation of survival and prognostic factors

OBJECTIVES

We retrospectively analysed morbidity, mortality and oncological results of patients who had undergone surgery for bronchial carcinoid tumours.

METHODS

Between 2002 and 2012, 65 patients with bronchial carcinoids underwent lobectomy (n = 34), sublobar resection (segmentectomy/wedge) (n = 18), sleeve lobectomy (n = 5) (reconstruction of the pulmonary artery was associated in 1 case), sleeve resection of the main bronchus (n = 4) or pneumonectomy (n = 4) (reconstruction of the carina was associated in 1 case).

RESULTS

Resection was radical with histologically negative margins in all patients (R0). Histology showed typical carcinoid (TC) in 55 (84.6%) patients and atypical carcinoid (AC) in 10 (15.4%) patients. Final pathological stages were Stage I in 42 (64.6%) patients, Stage II in 18 (27.7%) and Stage III in 5 (7.7%). No postoperative mortality was observed. The postoperative morbidity rate was 15.4% (no bronchial and/or vascular reconstructive-related complications occurred). The median follow-up was 58 (range 2-121) months. The overall recurrence rate was 12.3% (n = 8). The survival rate at 5 years was 100% for TC and 87% for AC. Disease-free survival rates at 3 and 5 years were 95 and 93% for TC and 78 and 44% for AC, respectively (P = 0.004). Pathological nodal involvement (pN1-N2) did not affect overall survival or recurrence.

CONCLUSIONS

The surgical treatment of bronchial carcinoids provides high long-term survival rates. Low postoperative morbidity and mortality can be expected even after bronchial reconstruction. The AC appears to be the main factor that determines the risk of recurrence. Bronchial reconstructive lung sparing operations are not related to an increased recurrence rate.

Bronchial and pulmonary arterial sleeve resection

This chapter deals with the indications and techniques of resection and reconstruction of the bronchi and pulmonary artery associated with sleeve lobectomy for lung cancer. The techniques of bronchial suture are described in detail, and the indications and the various techniques of pulmonary artery reconstruction, such as sleeve resection and end-to-end anastomosis, or partial resection and patch reconstruction are described and evaluated comparatively. Finally, the results of sleeve resection are reported, and a review of the literature on the subject is presented.

Reconstruction of the bronchus and pulmonary artery

Sleeve lobectomy (SL) (lobectomy associated with resection and reconstruction of the bronchus, the pulmonary artery, or both) has proved to be a suitable choice for the treatment of centrally sited non-small cell lung cancer. SL for lung cancer is indicated when a tumor or an N1 lymph node infiltrates the origin of a lobar bronchus, the origin of the lobar branches of the pulmonary artery, or both but not to the extent that a pneumonectomy is required. SL can be performed safely and effectively, even after induction therapy, without an increased complication rate.

Pulmonary sleeve resection in locally advanced lung cancer using cryopreserved allograft for pulmonary artery replacement

BACKGROUND

During lobectomy, resection of pulmonary artery, followed by reconstruction or replacement with or without concomitant sleeve bronchial resection, is feasible in selected cases. We report morbidity, mortality, and technical issues in pulmonary artery replacement using a cryopreserved arterial allograft after sleeve resection for centrally located non-small cell lung carcinoma (NSCLC).

METHODS

We reviewed clinical and pathologic data of patients who underwent arterial sleeve lobectomy with pulmonary artery replacement in our institution from 2007 to 2012.

RESULTS

Of 178 centrally located NSCLCs, sleeve resections were performed in 92 (51%), pneumonectomies in 33 (18%), and lobectomies in 53 (31%). Of the 32 (34.7%) pulmonary) reconstructions (excluding tangential suture), 20 (21.7%) were end-to-end anastomosis, 2 (2.1%) were pericardial patch reconstructions, and 10 (11%) were PA replacements. Clinical T staging was cT2a in 4 patients, cT2b in 3, cT3 in 2, and cT4 in 1. Four patients received concurrent induction chemoradiotherapy. Three patients underwent a double-sleeve right lobectomy. Cryopreserved allografts used were descending thoracic aorta (n = 3) and pulmonary arteries (n = 7). Complete resection (R0) was achieved in all patients. Final N staging was pN0 (n = 4), pN1 (n = 5), and pN2 (n = 1). There was no operative mortality. Four patients had major morbidity, including 1 early conduit thrombosis treated by pneumonectomy completion. Graft patency, assessed by contrast-enhanced computed tomography scan, was 90%. Mean follow-up was 25 ± 14 (range, 8-47) months (30% for >36 months). Overall 5-year survival was 66.7%, and the estimated median disease-free survival was 42 months.

CONCLUSIONS

In central NSCLCs, conservative surgery using a cryopreserved arterial allograft to replace the pulmonary artery after extended segmental resection could avoid pneumonectomy in selected patients.

Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined.

METHODS

The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians.

RESULTS

Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.

Triple plasty of bronchus, pulmonary artery, and superior vena cava for non-small cell lung cancer

BACKGROUND

It has been technically challenging to perform simultaneous triple plasty on the superior vena cava (SVC), pulmonary artery (PA), and main bronchus for central-type lung cancers. In the present study, the authors describe a corresponding technique and clinical outcomes of this surgical manipulation.

METHODS

Clinical data from 4 patients with non-small cell lung cancer (NSCLC) who underwent triple plastic resections and reconstructions were retrospectively reviewed. Three patients received neoadjuvant chemotherapy for pathologically proven locally advanced disease. For pulmonary arteries, sleeve resection with end-to-end anastomosis was performed in 2 patients; tangential resection was used in the other 2 patients. SVC resection with ringed polytetrafluoroethylene (PTFE) graft interposition was performed in 1 patient; the other 3 patients underwent tangential SVC resection. Sleeve resection of the bronchus was performed in all 4 patients. Systemic lymphadenectomy was accomplished in all patients.

RESULTS

There was histologic confirmation of large cell carcinoma, adenocarcinoma, squamous cancer, and adenosquamous cancer, respectively, in these 4 patients. Stage pT4N2M0-IIIB was confirmed in 2 patients, and stage T4N1M0-IIIA and stage T2aN2M0-IIIA were confirmed in the other 2 patients. There were no perioperative deaths. Postoperative atrial fibrillation and prolonged air leakage occurred in 2 patients, respectively. Four patients underwent postoperative chemotherapy and 2 patients were administered radiotherapy. Patients were followed for 21 to 38 months: Two patients had disease-free survival at their 32-month and 38-month follow-ups, and the other 2 patients died 21 and 22 months, respectively, after operation because of remote metastasis.

CONCLUSIONS

Triple plasty of bronchus, PA, and SVC is both practical and safe for patients with locally advanced NSCLC. For patients with strict indications, the long-term survival is favorable.

Extensive resections: pancoast tumors, chest wall resections, en bloc vascular resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.

The effects of anesthetic preconditioning with sevoflurane in an experimental lung autotransplant model in pigs

BACKGROUND

Ischemia-reperfusion lung injury is doubly important in thoracic surgery because of the associated ventilation damage to 1 lung. In this study we evaluated the cytoprotective effects of sevoflurane in a pulmonary autotransplant model in pigs.

METHODS

Twenty Large White pigs undergoing pneumonectomy plus lung autotransplant were divided into 2 10-member groups on the basis of the anesthetic received (propofol or sevoflurane). Proinflammatory mediators, oxidative stress, nitric oxide metabolism, and hemodynamic and blood variables were measured at 5 different time points.

RESULTS

There was an increase of oxidative stress markers and proinflammatory mediators in the propofol group, whereas the hemodynamic variables were similar in both groups.

CONCLUSIONS

We demonstrated that sevoflurane decreased the inflammatory response and oxidative stress in a live ischemia-reperfusion lung model.

Lung parenchymal sparing using cryopreserved allografts for pulmonary artery reconstruction

This chapter details the indications, technique, and pitfalls of double sleeve resection with pulmonary artery (PA) replacement by a cryopreserved allograft. Both bronchial and vascular anastomoses are explained and intraoperative and postoperative allograft management are described, along with the pros and cons of each possible conduit for PA replacement.

Surgical Techniques and Results for Partial or Circumferential Sleeve Resection of the Pulmonary Artery for Patients with Non-Small Cell Lung Cancer

BACKGROUND

We assessed our experience with partial or circumferential resection of the pulmonary artery during lobectomy.

METHODS

We retrospectively reviewed a prospective electronic database of patients who underwent pulmonary artery resection. The technique used was an R0 resection with end-to-end anastomosis only if needed, distal control of the pulmonary artery by clamping the vein (not the artery), and no postoperative anticoagulation.

RESULTS

Between October 1998 and June 6, 2006, 42 (3.2%) of 1328 patients who underwent lobectomy performed by one surgeon required resection of the pulmonary artery (38 partial, 4 circumferential) to achieve a margin-negative resection and avoid pneumonectomy. Of these, 41 had non-small cell lung cancer, and 23 (55%) had neoadjuvant chemoradiotherapy (median dose of 60 Gy). Right upper lobectomy was performed in 2 patients and a left upper lobectomy in 40. A negative bronchial and vascular margin was achieved in all. Morbidity occurred in 11 patients (atrial fibrillation in 6) and left recurrent laryngeal neurapraxia in 2. Aspiration resulted in one operative death. Follow-up (median, 48 months) showed no local recurrence on the pulmonary artery and normal blood flow through it. Five-year survival was 60%.

CONCLUSIONS

Pulmonary artery resection and reconstruction to avoid pneumonectomy can be performed safely, even in a highly irradiated field. Clamping of the remaining pulmonary vein for distal control is safe and affords more room. Circumferential resection with end-to-end anastomosis of the pulmonary artery is rarely required. Partial resection is safe, does not impede blood flow, and does not compromise local recurrence rates. Postoperative anticoagulation is not needed.

Parenchymal sparing operations for bronchogenic carcinoma

By the end of the 1950s, the principles of tracheobronchial and pulmonary artery (PA) reconstruction had been established, and their successful clinical application had taken place. It was not until very recently, however, that these techniques aroused widespread interest among thoracic surgeons as a means to achieve complete cancer resection while preserving functioning lung parenchyma. At the present time, sleeve resection of the bronchus and/or PA has a definite role in the surgical management of lung cancer. Growing interest in this field is evidenced by an increasing number of technical variations intended to adapt the basic technique to the different anatomical settings. Also pitfalls, complications, and their prevention and treatment are being extensively described. Last but not least, functional and oncological long-term results, comparing favorably with those of more extended resections, are being reported by many groups. This demonstrates that sleeve lobectomy is no longer reserved only for particularly skillful surgeons. Sleeve lobectomy has achieved its rightful position among the techniques commonly used in thoracic surgery after 40 years of improving understanding and alternating enthusiasm and legitimate doubts.

Can pneumonectomy for non-small cell lung cancer be avoided? An audit of parenchymal sparing lung surgery

BACKGROUND

Lung cancer resection rates are suboptimal in the UK. Pneumonectomy has a higher perioperative mortality risk than lobectomy. To increase resection rates and improve outcomes we have implemented a policy of parenchymal sparing surgery for tumours involving a main stem bronchus.

METHODS

In a prospective 4 year study of 119 consecutive patients operated upon by a single surgeon the perioperative course, pathology and survival were compared for 81 patients undergoing pneumonectomy and 38 patients in whom pneumonectomy was avoided by bronchoplastic+/-angioplastic procedures.

RESULTS

The rate of pneumonectomy decreased significantly with increasing experience with parenchymal sparing surgery (R(2)=0.98, P<0.001) with 21 of the last 30 patients (70%) avoiding pneumonectomy. There were no significant inter-group differences in patient characteristics, perioperative course or outcome. One-year survival was 64% after pneumonectomy and 73% after sleeve lobectomy. However the perioperative loss of respiratory function was significantly lower in the patients in whom pneumonectomy was avoided (P=0.0003).

CONCLUSIONS

Pneumonectomy can be avoided in a large proportion of patients with non-small cell lung cancer of a main stem bronchus without adversely affecting outcome but with preservation of lung function