Parenchymal sparing operations for bronchogenic carcinoma

Long-Term Survival after Extended Sleeve Lobectomy (ESL) for Central Non-Small Cell Lung Cancer (NSCLC): A Meta-Analysis with Reconstructed Time-to-Event Data

OBJECTIVE

We conducted a thorough literature search on patients with central non-small cell lung cancer (NSCLC) undergoing either extended sleeve lobectomy (ESL) or pneumonectomy (PN).

METHODS

We identified all original research studies that compared the long-term survival of ESL versus PN from 1990 to 2022. The primary endpoints were the median overall survival (OS) and disease-free survival (DFS). Complications, operative mortality, and the reoperation rate were the secondary endpoints. Regarding the primary endpoints, independent patient data were extracted from the included studies, and pooled Kaplan-Meier curves were constructed. A sensitivity analysis was performed using the leave-one-out method.

RESULTS

Nine studies were included in the qualitative and seven in the quantitative synthesis, including 431 patients. Patients in the ESL group demonstrated a significantly higher OS compared with the PN group (HR, 0.63; 95% CI, 0.46-0.87; p = 0.005). In addition, patients undergoing ESL presented a significantly higher DFS compared to the PN group (HR, 0.57; 95% CI, 0.40-0.80; p = 0.004). These findings were further validated with a sensitivity analysis. The most common complications in the ESL group were bronchopleural fistula (4.6%), stricture (3.1%), prolonged air leakage (7.3%), sputum retention (4.6%), pneumonia (7.7%), and pulmonary vein thrombosis (1.5%). ESL was associated with a low reoperation rate (1.5%) and operative mortality (1.2%).

CONCLUSIONS

The present meta-analysis indicates that ESL is associated with enhanced survival outcomes compared to PN for patients with central NSCLC. Further randomized controlled trials are necessary to validate our findings.

Complex sleeve lobectomy has the same surgical outcome when compared with conventional lobectomy in patients with lung cancer

OBJECTIVES

No significant data are available to assess whether complex sleeve lobectomy (complex-SL) can be considered comparable to conventional lobectomy (CL) in terms of surgical outcome. The purpose of this study was to compare surgical and oncological outcomes of complex-SL with CL in patients with lung cancer.

METHODS

Between 2000 and 2015, a total of 568 patients who underwent open CL (defined as resection of only 1 lobe) and 187 patients who underwent SL were analysed. The SL group was divided into 2 subgroups: standard-SL (bronchial SL, n = 106) and complex-SL (n = 81) (defined as bronchial sleeve resection together with another surgical intervention: bronchovascular SL, n = 40; vascular SL, n = 26; atypical bronchoplasty with resection of more than 1 lobe, n = 12; bronchial SL + chest wall resection, n = 3).

RESULTS

The complex-SL group had more patients with chronic obstructive pulmonary disease (COPD) (25.9% vs 12.5%, P = 0.001), neoadjuvant treatment (39.5% vs 12.0%, P < 0.001), advanced-stage non-small-cell lung cancer (53.2% vs 33.1%, P = 0.001) and low preoperative forced expiratory volume in 1 s (77.2% vs 84.3%, P = 0.004) than the CL group. The overall surgical mortality (in-hospital or 30-day) was 2.6% (n = 20); it was 2.8% for CL and 2.8% for complex-SL. Postoperative complications occurred in 34.9% of the CL group and 39.5% of the complex-SL group (P = 0.413). The pulmonary complication rate was similar between the groups (24.1% for CL, 27.2% for complex-SL, P = 0.552). The 5-year survival in the CL group was 57.1%, and in the complex-SL group it was 56.2% (P = 0.888). Multivariate analysis showed that TNM stage (P < 0.001) and N status (P < 0.001) were significant and independent negative prognostic factors for survival.

CONCLUSIONS

Complex-SL had a comparable outcome to CL, although the complex-SL group had more patients with advanced-stage NSCLC, low preoperative forced expiratory volume in 1 s and COPD.

Sleeve Lobectomy: To Wrap or Not to Wrap the Bronchial Anastomosis?

BACKGROUND

Bronchoplastic procedures have become the reference standard in the lung parenchyma-sparing treatment of centrally located bronchopulmonary tumors. Two schools of thought exist regarding performing a bronchial sleeve resection: those who wrap the anastomosis with a pedicled flap and those who leave the anastomosis unprotected. We performed a study comparing these 2 methods.

METHODS

This study was a retrospective multicenter observational analysis of 90 consecutive patients undergoing bronchial sleeve resections for neoplastic disease between June 2009 and July 2019. Group A (60 patients) underwent bronchial wrapping and group B (30 patients) did not undergo wrapping.

RESULTS

The only difference between group A, which had 5 patients (8.3%), and group B, which had 10 patients (33.3%), regarding general characteristics was the presence of diabetes (P = .003). There were no differences in surgical, postoperative, and follow-up characteristics. There was no statistically significant difference between groups (group A, 9 patients [15%]; and group B, 6 patients [20%]) in terms of anastomotic complications at 1 year (P = .425). Diabetes was an independent predictive factor for anastomotic complications at 1 year (P = .035). The number of postoperative complications (P < .001) was an independent risk factor for length of hospital stay.

CONCLUSIONS

We found no differences between groups in terms of postoperative complications and length of hospital stay, which confirmed previous reports that sleeve resections may be performed safely without bronchial wrapping.

Bronchial Sleeve Resection with Complete Pulmonary Preservation: A Single-Center Experience

Purpose

Bronchial sleeve resection with complete pulmonary preservation (BSRCPP) is a classic surgical method for the treatment of benign or low-grade bronchial tumors. For elderly patients and patients with poor cardiopulmonary function, BSRCPP is particularly advantageous because some of these patients may not tolerate lobectomy or pneumonectomy. We retrospectively reviewed the clinical data of 20 patients who underwent BSRCPP during the past 7 years. This report presents the experience with BSRCPP in our department.

Patients and Methods

We collected the data of 20 patients who underwent BSRCPP. Of these 20 patients, 17 underwent thoracotomy and 3 underwent video-assisted thoracoscopic surgery (VATS). The study cohort comprised 7 male and 13 female patients with an average age of 44 years (range, 4–71 years). All patients underwent a systematic preoperative examination to confirm the surgical indications and methods. Regular follow-up was conducted after the operation.

Results

All patients survived and remained clinically well. Two of the 20 patients (10%) were re-admitted to the hospital because of pulmonary air leakage, which was resolved after thoracic drainage. No patients developed tumor recurrence.

Conclusion

BSRCPP may be an effective treatment for selected patients with bronchial tumors. Notably, however, many technical key points require improvement, especially in VATS. Therefore, thoracoscopic minimally invasive treatment requires more practice and exploration.

Extended sleeve-lobectomy for centrally located locally advanced non-small cell lung cancer is a feasible approach to avoid pneumonectomy

Backgrounds

The aim of this study was to report our Institutional experience with extended sleeve lobectomy (ESL) in centrally located non-small cell lung cancer (NSCLC), focusing on technical details, post-operative results, recurrence and survival, to determine whether ESL can be accepted as a favorable alternative procedure to pneumonectomy (PN).

Methods

Twenty-two consecutive patients undergoing ESL for centrally located tumors from January 2014 to June 2019 were prospectively enrolled.

Results

Six (27.3%) patients had been preoperatively considered unfit for PN. Neo-adjuvant chemotherapy was administered in 7 (31.8%) out of the 10 patients that showed a cN2 disease. According to Okada classification, 8 cases of type A ESL (resection of right upper plus middle lobe ± segment 6), one case of type B (resection of left upper lobe + segment 6) and 13 cases of type C (resection of left lower lobe + lingulectomy) ESL were performed. Concomitant pulmonary angioplasty was done in 7 (31.8%) patients. Complete resection was achieved in all patients. There was no postoperative mortality. Major postoperative complications developed in 2 (9.1%) patients (one small anastomotic dehiscence healed in few weeks, one pulmonary embolism). Complete long-term patency of the reconstructed airway was documented in all patients by fiber-optic bronchoscopy. At the median follow-up of 21 months (4–57 months), the recurrence rate was 54.5%, with 4 (18.2%) patients developing a loco-regional recurrence but no endobronchial or perianastomotic recurrence occurred. The overall 3-year survival rate was 45% with a median survival of 33 months.

Conclusions

ESL is a safe and effective procedure that should be considered a favorable alternative to PN whenever it may guarantee a complete resection.

[Clinical Effect of Pedicled Pericardial Fat Flap in Prevention of Bronchial Pleural Fistula in Bronchial Sleeve Lobectomy]

背景与目的

支气管袖式肺叶切除是中心型肺癌重要的手术方式，它是最能体现“最大程度切除肿瘤，同时最大程度保留肺功能”的肺癌手术原则。支气管胸膜瘘是支气管袖式肺叶切除最严重的手术并发症，严重威胁患者的生命安全。本文将总结带蒂心包脂肪垫包裹支气管吻合口在预防支气管袖式肺叶切除术后支气管吻合口瘘的临床效果。

方法

回顾性分析四川大学华西医院肺癌中心2016年1月-2019年5月期间行支气管袖式肺叶切除术，并用带蒂心包脂肪垫包裹支气管吻合口的39例中心型肺癌患者临床资料，观察该组患者术后并发症，尤其是支气管吻合口相关并发症发生情况。

结果

该组患者手术后恢复良好，均于术后6 d-14 d内出院；30 d内无支气管胸膜瘘发生，无因胸腔内出血再次行手术病例，无严重心律失常，无严重肺部感染及呼吸衰竭发生；术后继续随访期间，术后6个月发生重度吻合口狭窄导致术侧残余肺不张1例。

结论

支气管袖式肺叶切除的肺癌患者，术中用带蒂心包脂肪垫包裹支气管吻合口，可有效预防术后吻合口瘘相关并发症的发生，从而提高手术安全性。

The technique of VATS right pneumonectomy

Pneumonectomy has higher morbidity and mortality rate than any other anatomic lung resection. It is infrequently performed by VATS and mostly in high volume centers. The handling of central vessels with long instruments across very small incisions instead of palpation is the main cause of surgeon's discomfort and resistance to perform this radical type of resection. Published data on VATS pneumonectomy is still limited and based on case series. Nevertheless, the available series suggest that VATS pneumonectomy is at least equivalent to open pneumonectomy. Through a case presentation illustrated with surgical videos, we aim to describe the main technical features of a uniportal VATS right pneumonectomy for lung cancer. The clinical indications, contraindications, patient's preoperative evaluation and postoperative care will also be discussed.

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.

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.

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.

The Surgical Management of Lung Cancer

Since the introduction of the pneumonectomy as a technically feasible strategy for the treatment of lung cancer, surgical resection has played a pivotal role in the management of early stage non-small cell lung carcinoma (NSCLC). In the last two decades, surgical, medical, and radiation oncologists have produced a growing body of evidence to support the combination of neoadjuvant or adjuvant treatments with standard surgical resection, to improve disease-free and overall survival for specific patient subgroups. Furthermore, alternatives to aggressive surgical management have evolved for patients who are medically inoperable due to compromised pulmonary function or other comorbidities. In this review, surgical options and multimodal treatment strategies are discussed, as well as completed and ongoing clinical trials addressing the surgical management of NSCLC.

Bronchoplasty at the Level of the Segmental Bronchus

The efficacy of anastomosis including the segmental bronchus performed in Hyogo Medical Center was reviewed. There were 18 patients with anastomosis of segmental bronchi (group 1), 14 patients with anastomosis between the upper, lingular, or basal segmental bronchus and main bronchus, avoiding pneumonectomy (group 2), and a miscellaneous group (group 3). Patients in group 1 had early-stage lung cancer or low-grade malignant tumors, whereas those in group 2 had advanced hilar tumors. Though technical requirements for these operations are higher than for typical bronchoplasty, they provide better quality of life postoperatively and reasonably good outcomes without increasing morbidity. The specialist in general thoracic surgery must make every effort to avoid excessively large resection of lung tissue such as lobectomy or pneumonectomy.

Le traitement chirurgical du cancer bronchique non à petites cellules

INTRODUCTION

Surgery remains the best option for curative treatment of early stages Non-small cell lung cancer (NSCLC). In this article we review the current status and future perspectives of surgical treatment of NSCLC.

STATE OF ART

An important part of the surgical procedure is the final determination of the staging with evaluation of the resectability of the tumor and its nodal status. This requires a systematic hilar and mediastinal nodal dissection and a complete resection that remains a major prognostic factor.

PERSPECTIVES

In order to preserve pulmonary function, lobectomies with the use of broncho- or arterioplasty have been developed with reduction in the number of pneumonectomies. For peripheral T1N0 NSCLC, video-assisted (VATS) lobectomy has become technically feasible with survival, in non-randomised studies, at least as good as the survival after open resection. While VATS has a clear role in staging of lung cancer, its role in the treatment of lung cancer however remains debatable. In case of involved mediastinal nodes (N2 disease) induction therapy is given in many centers and patients with mediastinal downstaging have a significantly better survival than non-responders. Restaging of the mediastinum is at the moment far from accurate. In case of locally advanced tumour (cT4), new surgical techniques and approaches make resection of carina, vena cava superior, vertebrae feasible with acceptable morbidity and mortality but additional studies are required.

CONCLUSIONS

Surgery remains the treatment of choice for curative treatment of NSCLC. The evolution of surgical techniques and the use of multimodality treatment further improve the results of surgical management. Rigorous patient selection, meticulous surgical technique and adequate peri- and postoperative management can keep operative morbidity and morbidity acceptable.

Sleeve resection after induction therapy

Preoperative chemoradiotherapy seems to improve the overall survival in locally advanced lung cancer but may also expose patients to an increased risk of postoperative complications. In particular, extended procedures, such as pneumonectomy, and especially right pneumonectomy, are associated with increased morbidity and mortality. Therefore, the extent of the procedure should be carefully weighed against the oncologic completeness of the resection. Among the potential sources of complications, special concern is given to bronchial healing, because of the impairment in bronchial blood flow caused by chemotherapy and radiation therapy. Accordingly, bronchial sleeve lobectomy after induction therapy was not widely accepted as an alternative to pneumonectomy, until the current authors showed that even complex bronchial and vascular procedures can be done safely and effectively in this setting. Many controversial issues still exist, and this article provides an updated summary of the different views and experiences.

Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites or recurrences

BACKGROUND

Sleeve lobectomy (SL) in a lung-saving procedure indicated for central tumors for which the alternative is pneumonectomy (PN). Although it has been suggested that it may provide as good if not better survival results than pneumonectomy in the treatment of lung cancer, there are very few reports of clinical series comparing operative mortality, survival, and sites of recurrences between these procedures.

METHODS

Survival and sites of recurrences were analyzed and compared in 1,230 consecutive patients who underwent PN (n = 1,046) or SL (n = 184) in a single institution. Sleeve lobectomy was always done when technically possible. Thus PN was reserved for lesions that could not be removed by a bronchoplastic procedure. Pathologic staging was accomplished by nodal sampling except for N2 and selected N1 patients who underwent mediastinal lymphadenectomy. Ultimately, all patients were staged according to the 1997 TNM nomenclature.

RESULTS

There were 3 operative deaths of the 184 SL patients (operative mortality of 1.6%) and 55 operative deaths of the 1,046 PN patients (operative mortality of 5.3%, p = 0.036). Follow-up was complete for all 1,230 patients. For the entire group, survival at 5 years was 52% after SL and 31% after PN (p < 0.0001). These rates for patients with complete resection were 58% for SL and 33% for PN (p = 0.021). There was also a significant difference in survival favoring SL for patients with pathologic stage I (p = 0.018) and stage II (p = 0.005) disease. When recurrences occurred (n = 577), the site of first recurrence was local in 22% of patients with SL and in 35% of patients with PN.

CONCLUSIONS

Sleeve lobectomy can be done with a much lower risk of operative mortality than PN. Although it is recognized that stage for stage, PN patients likely have more advanced disease, long-term survival and local control are significantly better when complete resection can be achieved by SL.