Safety and efficacy of bronchovascular reconstruction after induction chemotherapy for lung cancer

Development of postoperative bronchopleural fistula after neoadjuvant immunochemotherapy in non-small cell lung cancer: case reports and review of the literature

BACKGROUND

The advent of immune checkpoint inhibitors has dramatically changed the treatment paradigm for advanced non-small-cell lung cancer (NSCLC). Due to the complexity and diversity of stage III disease, the inclusion of immune checkpoint inhibitors (ICIs) in neoadjuvant treatment regimens is also required. However, immune-related adverse events (irAEs) limit the application of ICIs to a certain extent. Bronchopleural fistula (BPF) is a serious and fatal complication after pneumonectomy that is rarely reported, especially in patients who accept neoadjuvant immunotherapy or chemoimmunotherapy.

CASE PRESENTATION

Herein, we reported four patients with postoperative BPF who received a neoadjuvant regimen of sintilimab plus chemotherapy. Postoperative BPF occurred in the late stage in three patients; one patient underwent bronchoscopic fistula repair, and the fistula was closed well after surgery, and the other two patients gradually recovered within 1-2 months after symptomatic treatment with antibiotics. One patient with BPF after left pneumonectomy died of respiratory failure due to pulmonary infection. We also reviewed the literature on the development of postoperative BPF in patients receiving immuno-neoadjuvant therapy to discuss the clinical process further, postoperative pathological changes, as well as risk factors of BPF patients.

CONCLUSIONS

Central type lung cancer with stage III may be the risk factors of BPF in cases of neoadjuvant immunochemotherapy for lung cancers patients.

Ex Vivo Comparison of the Elastic Properties of Vascular Substitutes Used for Pulmonary Artery Replacement

INTRODUCTION

Study aims were to evaluate the elastic properties of vascular substitutes frequently used for pulmonary artery (PA) replacement, and then to compare their compliance and stiffness indexes to those of human PA.

METHODS

A bench-test pulsatile flow experiment was developed to perfuse human cadaveric vascular substitutes (PA, thoracic aorta, human pericardial conduit), bovine pericardial conduit, and prosthetic vascular substitutes (polytetrafluorethylene and Dacron grafts) at a flow and low pulsed pressure mimicking pulmonary circulation. Intraluminal pressure was measured. An ultrasound system with an echo-tracking function was used to monitor vessel wall movements. The diameter, compliance, and stiffness index were calculated for each vascular substitute and compared to the human PA at mean pressures ranging from 10 to 50 mmHg.

RESULTS

The compliance of the PA and the thoracic aorta were similar at mean physiological pressures of 10 mmHg and 20 mmHg. The PA was significantly less compliant than the aorta at mean pressures above 30 mmHg (P = 0.017). However, there was no difference in stiffness index between the two substitutes over the entire pressure range. Compared to the PA, human pericardial conduit was less compliant at 10 mmHg (P = 0.033) and stiffer at 10 mmHg (P = 0.00038) and 20 mmHg (P = 0.026). Bovine pericardial conduit and synthetic prostheses were significantly less compliant and stiffer than the PA for mean pressures of 10, 20, and 30 mmHg. There were no differences at 40 and 50 mmHg.

CONCLUSIONS

Allogenic arterial grafts appear to be the most suitable vascular substitutes in terms of compliance and stiffness for PA replacement.

Anastomosis Complications after Bronchoplasty: Incidence, Risk Factors, and Treatment Options Reported by a Referral Cancer Center

BACKGROUND

Sleeve lobectomy with bronchoplasty is a safe surgical technique for the management of lung cancer and endobronchial localization of extrapulmonary cancers. However, anastomotic complications can occur, and treatment strategies are not standardized.

METHODS

Data from 280 patients subjected to bronchoplasty were retrospectively analyzed, focusing on surgical techniques, anastomotic complications, and their management. Multivariate analysis was performed, and Kaplan-Meier curves were used to determine survival.

RESULTS

Ninety percent of 280 surgeries were for lung cancer. Anastomotic complications occurred in 6.42% of patients: late stenosis in 3.92% and broncho-pleural fistula in 1.78%. The median survival was 65.90 months (95% CI = 41.76-90.97), with no difference (p = 0.375) for patients with (51.28 months) or without (71.03 months) anastomotic complications. Mortality at 30 days was higher with anastomotic complications (16.7% vs. 3%, p = 0.014). Multivariable analysis confirmed pathological stage (N+) as a risk factor for anastomotic complications (p = 0.016). Our mortality (3.93%) and morbidity rate (41.78%) corresponded to recent series results.

CONCLUSIONS

In our experience, surgery is preferred to avoid life-threatening complications in bronchopleural fistulas. Bronchoscopic balloon dilatation is preferred for benign strictures. The nodal stage is related to complications (p = 0.0014), reflecting the aggressiveness of surgery, which requires extended radical lymphadenectomy.

Double sleeve resections

Double sleeve lung resections are complex surgical procedures that require specialized surgical expertise and careful patient selection. These procedures allow for the preservation of lung tissue while still achieving complete tumor resection for central tumors. Although initially considered high-risk operations, double sleeve lung resections have become a viable option for central tumors. Recent studies have shown that double sleeve lung resections are associated with lower morbidity and mortality rates than pneumonectomy. Furthermore, double sleeve lung resections may be associated with similar or even better long-term oncological outcomes compared to pneumonectomy, with the added benefit of preserving lung parenchyma and reducing the incidence of postoperative complications.

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.

The outcomes of margin status after sleeve lobectomy for patients of non-small cell lung cancer

Background

Sleeve lobectomy is recognized as an alternative surgical operation to pneumonectomy because it preserves the most pulmonary function and has a considerable prognosis. In this study, we aimed to investigate the implications of residual status for patients after sleeve lobectomy.

Methods

In this retrospective cohort study, we summarized 58 242 patients who underwent surgeries from 2015 to 2018 in Shanghai Chest Hospital and found 456 eligible patients meeting the criteria. The status of R2 was excluded. The outcomes were overall survival (OS) and recurrence‐free survival (RFS). We performed a subgroup analysis to further our investigation.

Results

After the propensity score match, the baseline characteristic was balanced between two groups. The survival analysis showed no significant difference of overall survival and recurrence‐free survival between R0 and R1 groups (OS: p = 0.053; RFS: p = 0.14). In the multivariate Cox analysis, we found that the margin status was not a dependent risk factor to RFS (p = 0.119) and OS (p = 0.093). In the patients of R1, N stage and age were closely related to OS, but we did not find any significant risk variable in RFS for R1 status. In the subgroup analysis, R1 status may have a worse prognosis on patients with more lymph nodes examination. On further investigation, we demonstrated no differences among the four histological types of margin status.

Conclusion

In our study, we confirmed that the margin status after sleeve lobectomies was not the risk factor to prognosis. However, patients with more lymph nodes resection should pay attention to the margin status.

Technical aspects of uniportal video-assisted thoracoscopic double sleeve bronchovascular resections

Double sleeve, bronchial and vascular reconstructions are challenging procedures indicated for centrally located tumours to avoid pneumonectomy. Traditionally, these resections have been performed by thoracotomy, but thanks to advances in imaging systems, better surgical instruments and the gained experience in video-assisted thoracic surgery (VATS), the scenario now is different. During the last decade, we have seen a rapid evolution of the uniportal VATS technique from simple lobectomies to advanced double sleeve bronchovascular procedures and carinal resections. The advantages of VATS over open surgery for major lung resections in terms of postoperative pain and morbidity, length of hospital stay and quality of life have prompted experienced surgeons to adopt uniportal VATS for cases requiring a sleeve resection. However, when a double bronchial and vascular sleeve resection is required, the adoption rate of minimally invasive surgery is still very low even for very experienced VATS surgeons. The difficulty of tumour mobilization, complexity of the suturing technique and the concern about possible uncontrolled massive bleeding during VATS are the main reasons for this low rate of adoption. In this article, we describe the technical aspects and tricks of this procedure when it is done by the uniportal VATS approach.

Sleeve lobectomy after neoadjuvant chemoimmunotherapy/chemotherapy for local advanced non-small cell lung cancer

Background

Sleeve lobectomy has been reported to be a safe procedure after neoadjuvant chemotherapy. We aim to evaluate the oncological and surgical outcomes of neoadjuvant chemoimmunotherapy (IO+C) for local advanced non-small cell lung cancer (NSCLC) patients who underwent sleeve lobectomy.

Methods

NSCLC patients that underwent sleeve lobectomy between December 2016 and December 2019 were retrospectively included. Patients were divided into two groups: neoadjuvant IO+C and chemotherapy. Oncological, intraoperative and postoperative variables were compared.

Results

In total, 20 patients underwent sleeve lobectomy after neoadjuvant IO+C (n=10) or chemotherapy (n=10). In the neoadjuvant IO+C group, 8/10 (80%) patients achieved a partial response (PR), 1/10 (10%) patients had a complete pathological response (CPR), and 5/10 (50%) patients achieved a major pathological response (MPR). In the neoadjuvant chemotherapy group, only 3/10 (30%) patients had PR, and 3/10 (30%) patients achieved MPR. No complications were found in the neoadjuvant IO+C group, 1 chylothorax occurred in the neoadjuvant chemotherapy group. Other peri- and postoperative outcomes were similar: bleeding volume (365.00 vs. 347.50 mL; P=0.267), operation time (291.88 vs. 287.50 min; P=0.886), chest tube duration (5.40 vs. 5.00 day; P=0.829), total drainage volume (815.50 vs. 842.50 mL; P=0.931) and the length of hospital-stay (7.00 vs. 6.56 day; P=0.915). In addition, less N1 (average number 4.70 vs. 7.40) and N2 (average number 9.80 vs. 20.10) lymph nodes were acquired in the neoadjuvant IO+C group than the neoadjuvant chemotherapy group. The number of lymph nodes positive for tumor cells was also less in the neoadjuvant IO+C group than the neoadjuvant chemotherapy group, both in N1 (0.40 vs. 1.60) and N2 (0.10 vs. 1.30). The positive lymph node ratio (LNR) was lower in the neoadjuvant IO+C group, both in N1 (0.05 vs. 0.15) and N2 (0.01 vs. 0.09). A greater destruction on elastic fiber of the blood vessels, vascular wall degeneration, fibrinoid necrosis and fibrosis, and greater pulmonary interstitial exudation were found in neoadjuvant IO+C patients compared to the neoadjuvant chemotherapy patients.

Conclusions

Sleeve lobectomy for advanced NSCLC following IO+C is feasible, although the operations become more complex, neoadjuvant IO+C did not delay postoperative recovery.

Impact of Neoadjuvant Chemoradiation on Adverse Events After Bronchial Sleeve Resection

BACKGROUND

We analyzed the association between neoadjuvant chemoradiation in patients undergoing bronchial sleeve resection with the incidence of postoperative pulmonary and airway complications.

METHODS

After instructional review board approval we performed a retrospective review of a prospectively maintained database of 136 patients who underwent sleeve resection in our institution between January 1998 and December 2016. Administration of neoadjuvant chemoradiation treatment was the studied exposure. Outcomes of interest were rates of postoperative pulmonary and airway complications. Nonparametric testing of demographic, surgical, and pathologic characteristics and morbidity was performed. Logistic regression models evaluated postoperative pulmonary complications and airway complications. Analysis was performed using Stata/IC 15.

RESULTS

We analyzed 136 patients (18 underwent neoadjuvant chemoradiation), 77 (57%) of whom had non-small cell lung cancer. Postoperative pulmonary complications were observed in 44 of 136 patients (32%). Incidences of pulmonary complications were higher in the neoadjuvant chemoradiation group compared with the non-neoadjuvant radiation group (15/18 patients [83%] vs 29/118 patients [25%], respectively; P < .001). Likewise, rates of pneumonia, atelectasis, respiratory insufficiency, bronchial stenosis, prolonged air leak, bronchopleural fistula, and completion pneumonectomy (2/18 [11%]) were higher in the neoadjuvant chemoradiation group, reaching statistical significance in all cases except bronchial stenosis and prolonged air leak. Only neoadjuvant chemoradiation therapy remained significant for postoperative pulmonary and airway complications on logistic regression (both P < .05) CONCLUSIONS: Patients who undergo neoadjuvant chemoradiation before sleeve resection are at an increased risk of pulmonary and airway complications.

Does Induction Therapy Increase Anastomotic Complications in Bronchial Sleeve Resections?

BACKGROUND

Sleeve lobectomy represents a safe and effective treatment for central NSCLC to avoid the risks of pneumonectomy. Induction therapy (IT) may be indicated in advanced stages; however, the effect of IT on bronchial anastomoses remains uncertain. The purpose of the study was to evaluate the impact of IT on the complications of the anastomoses.

METHODS

Between 2000 and 2012, 159 consecutive patients were submitted to sleeve lobectomy for NSCLC at our Institution. We retrospectively compared the results of patients who underwent IT before operation with those who received upfront surgery.

RESULTS

In the study period, 49 (30.8%) patients received IT (37 chemotherapy, 1 radiotherapy and 11 chemo-radiotherapy) and 110 (69.2%) patients were directly submitted to surgery (S). The two groups were comparable for sex, age, comorbidities, ASA score, pulmonary function, side, type of procedure and histology. Pathological stage was statistically higher for IT group (p = 0.001). No differences between IT and S groups were observed in terms of post-operative mortality (2% vs 0%, p = NS), morbidity (45% vs 38%, p = NS), including early (6% vs 9%, p = NS) and long-term (16% vs 14%, p = NS) bronchial complication rates. Patients undergoing induction mediastinal radiotherapy, however, are at higher risk of bronchial complications.

CONCLUSION

In our experience, the use of induction chemotherapy did not significantly increase mortality and morbidity rates, in particular, neither for early nor for late anastomotic complications. We, therefore, conclude that sleeve lobectomy after induction chemotherapy is safe and reliable procedure for the treatment of locally advanced NSCLC.

Transplanted fibroblasts proliferate in host bronchial tissue and enhance bronchial anastomotic healing in a rodent model

INTRODUCTION

Healing of airway anastomoses after preoperative irradiation can be a significant clinical problem. The augmentation of bronchial anastomoses with a fibroblast-seeded human acellular dermis (hAD) was shown to be beneficial, although the underlying mechanism remained unclear. Therefore, in this study we investigated the fate of the fibroblasts transplanted to the scaffold covering the anastomosis.

MATERIAL AND METHODS

32 Fisher rats underwent surgical anastomosis of the left main bronchus. In a 2 × 2 factorial design, they were randomized to receive preoperative irradiation of 20 Gy and augmentation of the anastomosis with a fibroblast-seeded transplant. Fibroblasts from subcutaneous fat of Fischer-344 rat were transduced retrovirally with tdTomato for cell tracking. After 7 and 14 days, animals were sacrificed and cell concentration of transplanted and nontransplanted fibroblasts in the hAD as well as in the bronchial tissue was measured using RT-PCR.

RESULTS

Migration of transplanted fibroblasts from dermis to bronchus were demonstrated in both groups, irradiated and nonirradiated. In the irradiated groups, there was a cell count of 7 × 104 ± 1 × 104 tomato+-fibroblasts in the bronchial tissue at day 7, rising to 1 × 105 ± 1 × 104 on day 14 (p <0.0001). Tomato+-cell concentration in hAD increased from 6 × 103 ± 1 × 103 at day 7 to 6 × 104 ± 1 × 104 at day 14 (p <0.0001). In the nonirradiated groups, tomato+-cell concentration in bronchus was 4 × 103 ± 1 × 103 on day 7 and 4 × 103 ± 1 × 103 at day 14. In the hAD tomato+ cell concentration rising from 1 × 104 ± 1 × 103 at day 7 to 2 × 104 ± 3 × 103 cells at day 14 (p = 0.0028).

CONCLUSIONS

Transplanted fibroblasts in the irradiated groups proliferate and migrate into the irradiated host bronchial tissue, but not in the nonirradiated groups.

Bronchial and arterial sleeve resection for centrally-located lung cancers

The use of bronchial and arterial sleeve resections for the treatment of centrally-located lung cancers, when available, has become the option of choice in comparison with pneumonectomy (PN). Technical expertise, in particular in vascular reconstruction, and perioperative management improved over time allowing excellent short-term and long-term results. This is even truer if considering literature data from the main experiences published in the last years. These evidences have given to such lung sparing reconstructive procedures more and more acceptance among the surgical community. This article focuses on the main technical aspects and literature data regarding bronchovascular sleeve resections.

Evolution of a Lung-Sparing Strategy with Sleeve Lobectomy and Induction Therapy for Non-small Cell Lung Cancer: 20-Year Experience at a Single Institution

Background

To elucidate the evolution of a lung-sparing strategy with sleeve lobectomy (SL) and induction therapy for non-small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed 205 patients with NSCLC who underwent pneumonectomy (PN, n = 54) or SL (n = 151) from 1994 to 2013. The study period was divided into four 5-year periods, and surgical trends were analyzed, focusing on the PN:SL ratio.

Results

PN was associated with a significantly advanced pathological stage, a larger tumor size and less pulmonary function compared with SL. The PN group had higher 30-day (3.7 vs. 0 %, p = 0.018) and 90-day (13.0 vs. 1.3 %, p = 0.0003) mortality than the SL group. The overall 5-year survival rate was significantly higher with SL (71.5 %) versus PN (42.8 %, p = 0.011) for patients with pN0–1. The ratio of PN among total surgeries decreased significantly over the four periods (1994–1998, 1999–2003, 2004–2008, and 2009–2013) from 5.63 % to 3.17, 1.40, and 1.38 %, respectively (p < 0.0001); in contrast, the PN:SL ratio increased significantly from 1.64 to 2.50, 3.71, and 5.44, respectively (p = 0.041). During the last period, when we introduced induction therapy, 38 of 651 who received surgery underwent induction therapy. The PN:SL ratios of those who did and did not undergo induction therapy were 15 (PN: 1, SL: 15) and 4.25 (PN: 8, SL: 34), respectively.

Conclusions

A lung-sparing strategy with SL for NSCLC can decrease the PN rate to less than 2 % with less mortality. Induction therapy may facilitate SL and increase the PN:SL ratio.

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.

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.

Surgical Treatment of Lung Cancer

In this chapter, we discuss the preoperative evaluation that is necessary prior to surgical resection, stage-specific surgical management of lung cancer, and the procedural steps as well as the indications to a variety of surgical approaches to lung resection.

Bronchopleural Fistula and Empyema After Anatomic Lung Resection

Empyema after anatomic lung resection is rare but causes serious morbidity, particularly if associated with a bronchopleural fistula. Careful assessment of preoperative risk factors and proper surgical technique can minimize risks. Empyema after segmentectomy or lobectomy may respond to simple drainage and antibiotics, or may require decortication with or without muscle transposition. After pneumonectomy, treatment principles include initial drainage of the intrathoracic space, closure of the fistula if present, and creation of an open thoracostomy, which is packed and later closed. Success rates can exceed 80%.

Bronchial and arterial sleeve resection after induction therapy for lung cancer

Lobectomy with reconstruction of the bronchus and pulmonary artery is a viable therapeutic option for patients with centrally located non-small cell lung cancer. Preoperative chemotherapy or chemoradiotherapy may represent an additional risk factor for postoperative complications because of increased difficulty in surgical dissection and potential impairment of bronchial healing. Although limited data are available in the literature in this setting, a few published studies have reported the possibility of performing even complex bronchovascular reconstructions after neoadjuvant treatment with no increased morbidity and mortality. This article discusses the main technical details and data from the literature.

Advances in the use of video-assisted thoracoscopic lobectomy in lung cancer: sleeve bronchoplasty and arterioplasty

SUMMARY 

This article focuses on the technical strategies for performing sleeve bronchoplasty and pulmonary arterioplasty as advances in the application of video-assisted thoracoscopic surgery (VATS) as lobectomy with bronchovascular reconstruction is a favorable alternative to pneumonectomy in terms of the pulmonary function. When performing VATS sleeve bronchoplasty or arterioplasty, several technical issues should be discussed, including how to reduce the anastomotic tension of the airway, perform bronchial anastomosis, and clamp the pulmonary artery and select the type of vascular clamp. The traction device technique and continuous suture technique are thought to help surgeons perform VATS sleeve bronchoplasty, while cross-clamping of the pulmonary artery using thoracoscopic instruments aids in carrying out VATS arterioplasty.

Is pneumonectomy using video-assisted thoracic surgery the way to go? Study of data from the Japanese Association for Thoracic Surgery

BACKGROUND

The number of pneumonectomies performed has been decreasing every year. That decrease is the result of changes in distribution of histological type, stage, and tumor location. To investigate the results of pneumonectomies performed on lung cancer patients in Japan over a period of 15 years, data reported by the Japanese Association for Thoracic Surgery were analyzed.

METHODS

All data shown in the table were derived from official records reported in Japan. Mortality refers to hospital death rather than 30-day death, to more precisely evaluate the safety of the operations.

RESULTS

(1) The number of sleeve lobectomies did not increase. (2) The operative mortality rate with pneumonectomies did not fall. In 2011, the rate of hospital deaths among pneumonectomy patients rose to 3.9% and worsened to 5.3% in 2012, which was more than twice that of 30-day death, despite an improvement in results as a whole. (3) The incidence of lethal bronchopleural fistula showed very little improvement, declining from 11.7 to 9.6%. (4) In 2012, VATS was used in 13.1% of all pneumonectomy patients. That figure stood at only 0.5% in 1997.

CONCLUSION

Regarding pneumonectomies performed in Japan during the period analyzed, use of the less-invasive approach increased but bronchopleural fistula was still a major complication. The rate of hospital deaths among pneumonectomy patients worsened 2 years in a row. What is of critical importance is not the choice of approach--VATS or open thoracotomy--but the surgeon's efforts to find a chance to perform lung-saving surgery.

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.

Sleeve lobectomy compared with pneumonectomy after induction therapy for non-small-cell lung cancer

BACKGROUND

We compared morbidity, mortality, and oncological results of bronchial and/or vascular sleeve lobectomy (SL) with those of pneumonectomy (PN) after induction therapy for lung cancer.

METHODS

Between 1998 and 2011, 82 patients receiving induction therapy (chemo or chemo-radiotherapy) for non-small-cell-lung-cancer underwent sleeve lobectomy (n = 39) or pneumonectomy (n= 43). Only patients undergoing preoperative chemotherapy (39 in the SL group and 39 in the PN group) were included in the study. SL was bronchial in 21, vascular in 12, and broncho-vascular in six cases, respectively. Clinical stage before induction therapy was IIb in seven patients (1 in PN group; 6 in SL group), IIIa in 66 (36 in PN group; 30 in SL group), and IIIb in five patients (2 in PN group; 3 in SL group), respectively. N3 patients were not included in this series.

RESULTS

The rate of downstaged patients (pathological complete response and stage I-II) was 79.5% in the SL group and 53.8% in the PN group (p = 0.01).Postpneumonectomy mortality rate was 2.6 %. There was no postoperative mortality after SL. Complications occurred in 12 patients (30.8%) after PN and in 11 patients (28.2%) after SL (p = 0.6). Three-year and 5-year survival rates were 68 ± 3% and 64 ± 8% in the SL group; and 59.5 ± 5% and 34.5 ± 8% in the PN group (p = 0.02). The difference in terms of recurrence rate (locoregional and distant) between the two groups was not significant (p = 0.2).

CONCLUSIONS

SL represents a valid therapeutic option even after induction chemotherapy, providing better long-term survival than PN, with no increase of postoperative complications or recurrence rate. Pathological downstaging is a favorable prognostic factor.

A new classification of bronchial anastomosis after sleeve lobectomy

OBJECTIVE

Ischemia and infection of the distal part of the tracheobronchial anastomosis are the leading causes of bronchial anastomotic leakage with a high morbidity and mortality. To improve interpretation of healing of the anastomosis and the consequences, we have developed a classification scheme that allows quality control and defines early and standardized treatment of complications.

PATIENTS AND METHOD

We conducted a retrospective analysis of the records of 202 patients treated in our institution between January 1, 2006 and December 31, 2010 after sleeve lobectomy. All patients received prophylactic inhalation with tobramycin 80 mg twice a day. Neoadjuvant treatment was given in 21% of the patients. Routine bronchoscopy on day 7 was performed with classification of the anastomosis as follows: X, unknown; 1, healing well with no fibrin deposits; 2, focal fibrin deposits and superficial (mucosal) necrosis; 3, circular fibrin deposits, superficial (mucosal) necrosis, and/or ischemia of the distal mucosa; 4, transmural necrosis with instability of the anastomosis; and 5, perforation, necrosis of the anastomosis, and insufficiency.

RESULTS

The anastomosis was graded as satisfactory (1 and 2) in 86% of the patients. In 14%, it was regarded as critical (≥3-5) leading to systemic antibiotic treatment and control bronchoscopy. The overall 30-day mortality was 1%.

CONCLUSIONS

Quality control of the tracheobronchial anastomosis comprised bronchoscopy performed before patients were dismissed. Inasmuch as postoperative bronchoscopy is not always performed by the operating surgeon, this classification is an aid to improve the description of endobronchial healing and to commence treatment of critical bronchial healing.

Sacrificing the pulmonary arterial branch to the spared lobe is a risk factor of bronchopleural fistula in sleeve lobectomy after chemoradiotherapy

OBJECTIVES

A sleeve lobectomy is a widely accepted procedure for enabling the pulmonary parenchyma to be spared. Induction chemoradiotherapy (CRT) followed by surgery is one treatment option for locally advanced non-small cell lung cancer (NSCLC), but CRT is considered to have a negative effect on subsequent surgery, especially for anastomotic healing. In this study, we describe our experience performing sleeve lobectomies and the associated anastomotic complications after induction CRT.

METHODS

The medical records of NSCLC patients who underwent surgery after receiving CRT were reviewed. The relationships between anastomotic complications and clinicopathological factors were examined.

RESULTS

Between December 1998 and October 2011, a total of 104 patients received CRT followed by surgery. Among them, 14 NSCLC patients underwent a bronchial sleeve resection: nine patients underwent a right upper lobe resection, two patients underwent a left lingular division and lower lobe resection and one patient each underwent a right lower lobe, a right upper and middle lobe and a right middle and lower lobe resection. A bronchopleural fistula at the anastomosis occurred in two patients. A pulmonary arterial (PA) branch to the spared lobe had been sacrificed in both of these patients because of tumour involvement. In contrast, the PA branches to the spared lobes were preserved in 11 of the 12 patients who did not exhibit anastomotic complications (P = 0.033).

CONCLUSIONS

Our experience strongly suggests that the sacrifice of the PA branch to the spared lobe is a possible risk factor for anastomotic complications for a sleeve lobectomy after induction CRT.

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.

Sleeve lobectomy after induction chemoradiotherapy

OBJECTIVES

The effect of induction chemoradiotherapy (CRT) on bronchial anastomoses remains uncertain. This prospective study aimed to assess the impact of neoadjuvant CRT on mortality, morbidity and survival following circular sleeve lobectomy (SL).

METHODS

All consecutive patients undergoing SL between June 2005 and December 2010 were prospectively included. Clinico-demographic variables were sex, age, clinical and pathologic TNM staging, comorbidities, pulmonary function, SL type, complications, neoadjuvant CRT and mortality.

RESULTS

Of 79 patients, who underwent SL during this period, 53 (67%) patients were directly assigned to surgery and 26 (33%) patients had pre-induction treatment for N2 pathologically confirmed. Induction treatment (CRT) was based on platinum-based chemotherapy and radiation (range 45-60 Gy). Twenty-one (80%) patients of the CRT group achieved a complete mediastinal pathological response. Mortality occurred in only three cases in the non-CRT [bronchovascular fistula, pulmonary artery thrombosis (reoperation and pneumonectomy and exitus due to pneumonia) and ADRS]. There were no differences with respect to complication rate between the non-CRT and CRT patients (33 versus 37%, P > 0.05), and overall 5-year survival was 69 and 33%, respectively (P = 0.017). Overall survival in the subgroup of CRT patients with mediastinal complete response after induction resulted significantly worse than the non-CRT group (43 versus 69%, P < 0.01). The rate of distant metastases was similar in both groups and only one patient experienced local recurrence.

CONCLUSIONS

Neoadjuvant CRT does not increase surgical morbidity, anastomotic complications or mortality in SL. Complete mediastinal response after induction therapy overcomes a significant independent prognostic factor for better survival. Although SL following induction CRT carries a good prognosis, the long-term results shows significantly lower survival compared with SL without induction CTR. In addition, patients who had complete pathological responses have a better prognosis than non-responders. SL appears to be safe and reliable after neoadjuvant concurrent CRT and can be considered the primary surgical option to save the complications related to pneumonectomy in central tumours.

Long-term results of sleeve lobectomy in the management of non-small cell lung carcinoma and low-grade neoplasms

BACKGROUND

The objective of this study was to evaluate the operative mortality, morbidity, and long-term survival of sleeve lobectomy for non-small cell lung cancer and low-grade neoplasms. We evaluated the effects of neoadjuvant therapy on the bronchial anastomotic complication rate and determined whether sleeve lobectomy performed in patients with N1 disease resulted in decreased overall survival.

METHODS

This study is a retrospective review of 196 patients who underwent sleeve lobectomy. One hundred twenty-five patients had non-small cell lung cancer. There were 117 men (59.7%) and 79 women (40.3%) with a mean age of 54 years. Sixteen patients (13%) received neoadjuvant therapy. Fifty-six patients with N1 disease underwent sleeve lobectomy.

RESULTS

There were 4 (2.0%) postoperative deaths. The postoperative morbidity rate was 36.7%. Four patients (2.0%) experienced bronchopleural fistulas. Multivariate analysis demonstrated that age older than 70 years (p = 0.02) and the diagnosis of non-small cell lung cancer (p = 0.0002) were risk factors for postoperative complications. Multivariate analysis also demonstrated that neoadjuvant therapy predicted anastomotic complications (p = 0.01). For non-small cell lung cancer patients, the 5-year survival rate was 44%. The 5-year survival rates for patients with pathologic N0 disease and N1 disease were 52.6% versus 39.3%, respectively (p = 0.205).

CONCLUSIONS

Sleeve lobectomy can be performed with minimal bronchial anastomotic complications and low postoperative mortality. In our study, neoadjuvant therapy for non-small cell lung cancer adversely influenced the rate of anastomotic complications. Performing sleeve lobectomy for patients with N1 disease was not associated with decreased overall survival rates.

Carinaplasty airway closure: a technique for right pneumonectomy

BACKGROUND

Bronchopleural fistula remains a significant source of morbidity and mortality after right pneumonectomy. We reviewed our initial experience with a novel "carinaplasty" airway closure technique aimed at reducing the risks of bronchopleural fistula.

METHODS

Since 2003, 51 consecutive patients who required right pneumonectomy at our institution underwent carinaplasty airway closure. Malignancy was the indication for pneumonectomy in all but 2 patients. Eighteen patients received preoperative radiation therapy, including 5 patients who received 6000 cGy or more. Postoperatively, 17 patients required mechanical ventilation for an average of 13 days (range, 3 to 42 days).

RESULTS

Six operative deaths occurred, four (8.6%) of which were in the 46 patients who did not receive preoperative bleomycin. All deaths were secondary to respiratory failure. None of these patients demonstrated bronchopleural fistula despite mechanical ventilation for up to 30 days. In 2 patients, a small (< or = 2 mm) bronchopleural fistula developed at 3 and 4 months after operation, respectively. Both patients presented with minor symptoms and spontaneously healed within 1 month after open drainage.

CONCLUSIONS

These data suggest that the carinaplasty airway closure may reduce the morbidity and mortality of bronchopleural fistula after right pneumonectomy. We speculate mechanisms include elimination of the bronchial stump diverticulum in combination with more submucosal blood supply at the suture line compared with the standard bronchial closures. We currently consider carinaplasty airway closure the technique of choice at our institution and plan continued evaluation.

Morbidity, mortality, and long-term survival after sleeve lobectomy for non-small cell lung cancer

OBJECTIVE

Sleeve lobectomy is a widely accepted procedure for central tumors for which the alternative is pneumonectomy. The purpose of this study is to assess operative mortality, morbidity, and long-term results of sleeve lobectomies performed for non-small cell lung carcinoma (NSCLC).

METHODS

A retrospective review of 218 patients who underwent sleeve lobectomy for NSCLC between 1981 and 2005 was undertaken. There were 186 (85%) men and 32 women with a mean age of 61.9 years (range, 19-82 years). Eighty patients (36.6%) had a preoperative contraindication to pneumonectomy. Right upper lobectomy was the most common operation (45.4%). Vascular sleeve resection was performed in 28 patients (12.8%) and was commonly associated with left upper lobectomy (n=20; 9.1%; p=0.0001). The histologic type was predominantly squamous cell carcinoma (n=164; 75%), followed by adenocarcinoma (n=46; 21%). Resection was incomplete in nine (4.1%) patients.

RESULTS

There were nine operative deaths; the operative mortality and the morbidity rates were 4.1% and 22.9%, respectively. A total of 14 (6.4%) patients presented with bronchial anastomotic complications: two were fatal postoperatively, seven patients required reoperation, three required a stent insertion, and two were managed conservatively. Multivariate analysis showed that compromised patients (p=0.001), current smoking (p=0.01), right sided resections (p=0.003), bilobectomy (p=0.03), squamous cell carcinoma (p=0.03), and presence of N1 or N2 disease (p=0.01) were risk factors for mortality and morbidity. Follow-up was complete in 208 patients (95.4%). Overall 5-year and 10-year survival rates were 53% and 28.6%, respectively. After complete resection, recurrence was local in 10 patients, mediastinal in 20, and distant in 25. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0-N1 vs N2; p=0.01) and the stage of the lung cancer (stage I-II vs III, p=0.02).

CONCLUSIONS

For patients with NSCLC, sleeve lobectomy achieves local tumor control, even in patients with preoperative contraindication to pneumonectomy and is associated with low mortality and bronchial anastomotic complication rates. Postoperative complications are higher in compromised patients, smokers, N disease, right sided resections, bilobectomies, and squamous cell cancers. The presence of N2 disease and stage III significantly worsen the prognosis.

[Postoperative risk after induction treatment on surgery in non-small cell lung cancer]

Induction treatments in non-small cell lung cancer are usually discussed. Long-term survival after surgery and resecability are enhanced in locally advanced cancers. Morbidity and mortality observed after surgery limit the use of these treatments, despite they depend on many other factors: comorbidities in patient, smoking status, cancer staging, and type of surgery. Right pneumectomy enhances this risk more than left pneumectomy or other limited resections allowed by neoadjuvant treatments, especially in case of downstaging.

Reconstruction of the Pulmonary Artery

Sleeve resection and prosthetic reconstruction of the pulmonary artery have progressively gained acceptance as an alternative to pneumonectomy in lung cancer surgery. Previous concern was mainly related to technical difficulties, intraoperative and postoperative complications, lack of long-term survival, and impact on cardiopulmonary function. For this reason it was not until very recently that lobectomy associated with resection and reconstruction of the pulmonary artery, associated or not to a sleeve resection of the bronchus, has been demonstrated to be an advantageous alternative. The concern about an increased complication rate has been proven to be excessive; in fact, pulmonary artery reconstruction can be performed safely and effectively with the correct indications and technique. We hereby report our experience, along with a review of the indications, the surgical technique, and outcome of pulmonary artery reconstruction.

Sleeve Lobectomy in Lung Cancer

Sleeve lobectomy for lung cancer is now commonly performed around the world for central lung cancers that are anatomically suitable regardless of lung function. The morbidity and mortality are low, especially when compared with pneumonectomy. Bronchial complications are quite low. Local control seems to be at least as good as that obtained with pneumonectomy. Survival in most series is better with sleeve lobectomy than with pneumonectomy. Although there is still controversy with the use of sleeve lobectomy in patients with N1 disease, several recent series suggest better survival compared with pneumonectomy. Sleeve lobectomy can be safely performed after induction therapy. Quality of life is better with sleeve lobectomy compared with pneumonectomy.