Lobectomy with sleeve resection in the treatment of tumors of the bronchus

Late Results after Sleeve or Wedge Lobectomies for Non-Small-Cell Lung Carcinoma

From January 1971 to June 1983, 35 lobectomies with bronchoplastic procedures for invasive non-small-cell lung carcinoma were performed. Sleeve lobectomy was carried out in 21 cases, wedge lobectomy in 11, and upper sleeve bilobectomy in 3. There were 23 stage I, 10 stage II, and 2 stage IIIa tumors. Completion pneumonectomy was required in 1 case for anastomotic fistula and in 2 for atelectasis of residual lung. One of these patients died later due to empyema. The 5-year probability of death with recurrence was 31.98%. The 5-year disease-free survival was 58.57%. Metastatic relapse was observed in 8 cases and locoregional recurrence in 5. A new primary lung tumor occurred in 2 patients.

Risk factors for the development of postoperative complications after bronchial sleeve resection for malignancy: a univariate and multivariate analysis

BACKGROUND

This study was designed to identify risk factors responsible for postoperative complications after bronchoplastic procedures.

METHODS

Excluding sleeve pneumonectomies between January 1994 and December 2001, 108 patients underwent bronchoplastic procedures for bronchial malignancy. Prospectively documented data were age, gender, side, type of bronchial reconstruction, extended resection, histology, TNM stage, diseased lobe, and bronchial tumour occlusion. Cardiovascular (CV) risk factors included heart disease, arterial hypertension, cerebro-occlusive disease, peripheral artery disease of the lower extremities, diabetes mellitus, and abdominal aortic aneurysm. Patients were grouped according to the presence/absence of any CV risk factor and the absolute number of CV risk factors present (zero to four). Non-CV risk factors included neoadjuvant chemotherapy, alcoholism, lung disease, sleep apnea, history of recent pneumococcal sepsis, and repeat thoracotomy. Groups were assembled according to the presence or absence of any non-CV risk factor, neoadjuvant chemotherapy, and alcoholism. Respiratory risk factors included lung function and blood gas analysis. Groups were assembled according to the absolute number of respiratory risk factors in each person (zero to three) and the combination of respiratory and CV risk factors. Complications were defined as septic (pneumonia, empyema, brochopleural fistula, colitis) and aseptic. For univariate statistical analysis, t test, cross-tabulation, and chi2 test were used. All factors with a significance of p < 0.1 were entered into a binary backwards-stepwise logistic regression model.

RESULTS

The combination of respiratory and CV risk factors (p = 0.012, OR = 0.165) was predictive for overall complications. Coronary artery disease (p = 0.02, OR = 0.062) and the combination of two respiratory risk factors (p = 0.008, OR = 0.062) were predictive for septic complications. Peripheral artery disease (p = 0.024, OR = 0.28), moderate (p = 0.01, OR = 0.13) and severe chronic obstructive pulmonary disease (p = 0.018, OR = 0.11), and extended resections (p = 0.003, OR = 0.017.) were predictive for aseptic complications.

CONCLUSIONS

Comorbidity significantly influences the postoperative complication rate and is therefore crucial for evaluation of patients for bronchoplastic procedures. Different risk factors are responsible for the occurrence of septic and aseptic complications after bronchoplastic procedures.

Low morbidity of bronchoplastic procedures after chemotherapy for lung cancer

OBJECTIVE

To evaluate if induction chemotherapy, with or without irradiation, represents an additional risk factor for early and late morbidity and perioperative mortality in bronchoplastic procedures for lung cancers.

METHODS

From January 1998 to January 2001, 27 patients underwent a bronchial sleeve resection after induction treatment at the European Institute of Oncology in Milan. They represent 7% of lung cancer resections (387) and 27% of those performed after neoadjuvant treatment (100 cases). Histology was: 17 epidermoid carcinoma, 8 adenocarcinoma and 2 SCLC. Twenty-four patients (89%) received a preoperative cisplatin based polichemotherapy, and three cases (11%) a chemo-radiation therapy. A right sleeve lobectomy or bilobectomy was undertaken in 21 patients (78%) and a left lobectomy in 6 (22%). A resection of tracheal carina was associated in three cases and a vascular resection in 10 (five vena cava and five pulmonary artery). Twelve patients (44%) received adjuvant mediastinal irradiation. Perioperative morbidity of the study group (group 1) was compared with that of patients submitted to sleeve resection without neoadjuvant treatment (group 2), or standard pneumonectomy after induction treatment (group 3).

RESULTS

There were no postoperative deaths. A major perioperative complication occurred in two patients (7%) of group 1, one patient of group 2 (3.5%), and four in group 3 (17%). Among patients of the study group, no anastomotic dehiscence or pleural empyema were observed. Only one late anastomotic stricture occurred after postoperative radiation treatment. No significant difference in early and late complication rate was found between the three groups of patients. High rate of complete resection was achieved (93%) in patients of the study group and extent of nodal dissection was similar between sleeve resections and pneumonectomy patients.

CONCLUSIONS

Preoperative chemotherapy or combination of chemo-radio therapy is not associated with an additional risk of anastomotic complications in bronco and angioplastic procedures. Parenchyma sparing resection is a valid option for selected patients with locally advanced lung cancer after induction treatment. A longer follow up is necessary to evaluate efficacy of the procedure in term of survival and local control.

Postoperative complications after bronchoplastic procedures in the treatment of bronchial malignancies

OBJECTIVE

The purpose of this study was to determine the frequency of postoperative complications after bronchoplastic procedures in the treatment of pulmonary malignant tumors and to analyze the factors influencing the complication rate.

METHODS

During a 5-year-period (1992-1996) 79 patients (68 male, 11 female, mean age 57 years) underwent reconstructive operations for bronchial malignancies. We performed 58 bronchoplastic procedures and 21 combined broncho- and angioplastic procedures. Among the bronchoplastic procedures the number of sleeve resections (n = 44) and wedge resections (n = 35) were comparable.

RESULTS

Fifty-nine patients (74,7%) showed a regular postoperative course; 12 patients (15,2%) had severe postoperative complications (death, re-operation). Concerning the primary operation the operative 30-day mortality was 5.1% (n = 4) and including the two deaths after re-operation it was 7.6% (n = 6). After subdividing the patients into three groups (severe, less severe and no complications) we tried to determine predictors for occurrence of postoperative complications. There was a higher rate of severe complications in the age group 61-70 years (6/25 = 24%) as compared with younger patients between 51 and 60 years (4/38 = 10,5%; P < 0,05). Concerning the location, the outcome was better after sleeve- or wedge lobectomies of the upper lobes (four complications/51 patients = 7.8%) compared with procedures of the lower lobes (3/14 = 21.4%). The data could not prove a lower frequency of severe postoperative complications or specific morbidity after pleural coverage following bronchial sleeve resection. The complication rate was higher when sleeve resection of the bronchus was performed (10/44 = 22.7%) as compared with wedge resections (2/35 = 5.7%; P = 0,011) and after resection of T3/T4 tumors (6/28 = 21,4%) compared with T1/T2 tumors (4/37 = 10.8%; P < 0,05).

CONCLUSIONS

Bronchoplastic procedures represent a fairly safe therapy opportunity in patients with centrally localized bronchial carcinoma and compromised or uncompromised pulmonary function. In this study the complication rate was higher after sleeve resection of the bronchus as compared with wedge resection. Pleural coverage of the anastomosis was not effective to prevent major complications due to dehiscence of the bronchial anastomosis. A pedicled muscle flap could be a valuable alternative.

Long-term survival after bronchial sleeve resection: univariate and multivariate analyses

BACKGROUND

Long-term results after bronchial sleeve resection remain controversial, especially in relation to nodal involvement. In a previous report, there were no 10-year survivors among patients with N1 or N2 disease.

METHODS

From 1960 to 1989, 145 patients underwent bronchial sleeve resection for a bronchogenic tumor. Follow-up was updated until the end of 1994, so the minimum follow-up was 5 years for surviving patients. A univariate analysis and a multivariate analysis were performed.

RESULTS

For the whole group, 5-year, 10-year, and 15-year survival rates were 46%, 33%, and 22%, respectively. The median survival time was 53 months. Five-year and 10-year survival rates for the 71 patients with no disease were 62% and 51%, respectively; for the 58 patients with N1 disease, 31% and 10%; and for the 16 patients with N2 disease, 5-year and 7-year survival rates were 31% and 13%. There was a highly significant difference in survival between patients with no and N1 or N2 disease but not between those with N1 and N2 disease. Multivariate analysis showed only nodal stage and patient age to be significant factors in relation to survival.

CONCLUSIONS

Long-term results after bronchial sleeve resection are influenced chiefly by nodal stage. A significantly lower survival is found in patients with N1 and N2 disease, and most of these patients die of distant metastases.

Bronchoplastic and angioplastic techniques in the treatment of bronchogenic carcinoma

From 1979 to 1991, 51 bronchoplasties, 18 angioplasties, and 4 combined broncho-angioplasties were performed for bronchogenic carcinoma. Sixteen patients underwent operation because of compromised pulmonary function; bronchoplasty, angioplasty, or the combined procedure was performed in the remaining 57 patients because of a suitable anatomic location of the neoplasm. Twenty-four patients had stage I disease, 32 stage II, and 17 stage IIIa. Three patients died postoperatively (3.65%). Major postoperative complications occurred in 20 patients (27.3%) (10 early, and 10 late). A completion pneumonectomy was required in 4 patients (5.4%), 2 for anastomotic stricture, 1 because of vascular thrombosis after angioplasty, and 1 for local recurrence after angioplasty. Three-year and 5-year survival rates for the entire group were 55.4% and 40.8%, respectively. One-year and 3-year survival rates after angioplasty were 78.6% and 31.4%. Of the 4 patients who underwent a combined bronchoangioplastic procedure, 1 died after 23 months and 3 are alive and well after 11, 15, and 20 months. Survival was more favorable in the combined N0-N1 group (62% and 43.1%) than in the N2 group (23.4%), but the difference was not significant (p < 0.2). Three-year survival after angioplasty was found to be lower than, although not significantly different from, the overall 3-year survival rate (31.4% versus 55.4%; p = not significant). No statistically significant differences were found among survival rates of patients with compromised and noncompromised pulmonary reserve. We conclude that bronchoplastic and angioplastic procedures are valid techniques as curative operations in carefully selected patients with bronchogenic carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment for higher stage non-small cell lung cancer

Locally advanced lung cancer (stage IIIa, IIIb) in which the primary tumor is proximal (T3) or has invaded adjacent structures (T3) or organs (T4) or in which mediastinal lymph nodes are involved (N2, N3) worsens the prognosis significantly. However, in stage IIIa (T3 or N2), when surgical treatment results in total removal of the primary tumor and involved lymph nodes, there still is a reasonable chance for ultimate cure. On the other hand, total excision can be very rarely performed in T4 or N3 tumors. Therefore, this group (stage IIIb) usually indicates unresectability. Disseminated lung cancer with distant metastasis (stage IV) is still considered to be incurable. Nevertheless, solitary metastatic sites (M1), especially brain, have been treated on occasion by resection of the primary tumor and removal of the solitary metastasis. This appears to improve median survival and does yield 5-year survival in selected patients. The results after surgical treatment in these patients with higher stage lung cancer reported over the last 10 years are reviewed.

Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy

The number of patients reported to have undergone bronchoplastic procedures has increased nearly fourfold in the past decade. These techniques represent excellent surgical therapy for patients with benign endobronchial lesions, traumatic airway disruptions, or tumors of low-grade malignant potential, and for select patients with surgically resectable lung cancer. Eighty-nine percent of bronchoplastic procedures are performed for malignancy. We reviewed 1,915 bronchoplastic procedures for carcinoma reported over the past 12 years to determine the incidence of complications and survival. Complications included local recurrence (10.3%), 30-day mortality (7.5%), pneumonia (6.7%), atelectasis (5.4%), benign stricture or stenosis (5.0%), bronchopleural fistulas (3.5%), empyema (2.8%), bronchovascular fistulas (2.6%), and pulmonary embolism (1.9%). Results were further stratified into sleeve lobectomy and sleeve pneumonectomy groups. Five-year survivals for stage I, II, and III carcinoma were 63%, 37%, and 21%, respectively. Sleeve lobectomy for carcinoma extends surgical therapy to select patients with complication rates comparable to pneumonectomy and long-term survival similar to that for conventional resections.

TNM staging and long-term follow-up after sleeve resection for bronchogenic tumors

From 1960 to 1989, 145 patients (132 men and 13 women) with a mean age of 60.3 years underwent sleeve lobectomy or sleeve resection of a main bronchus for a bronchogenic tumor. Squamous cell carcinoma was predominantly found (116 patients, 80.0%), followed by carcinoid tumor in 13 patients (9.0%). Postoperative staging was: stage I, 61 patients (42.1%); stage II, 47 (32.4%); stage IIIA, 33 (22.8%); and stage IIIB, 4 (2.7%). Thirty-day mortality was 4.8% (7 patients). Follow-up was complete except for 1 patient who was lost to follow-up 4 years after operation. For the whole group, 5-, 10-, and 15-year survival rates were 49%, 37%, and 18%, respectively. Better survival was noted in patients with carcinoid tumor and squamous cell carcinoma. Considering 112 patients with T2 and T3 squamous cell carcinoma, 5- and 10-year survival rates for N0 disease (52 patients) were 59% and 47%, for N1 disease (51 patients) 21% and 0%, and for N2 disease (9 patients) 44% and 0%. Differences between N1 and N2 disease were not statistically significant. Survival after sleeve resection is best for carcinoid tumors and squamous cell carcinoma with negative nodes. Presence of N1 or N2 disease significantly worsens prognosis, with no 10-year survivors and no difference between N1 and N2 status.

Results in 104 patients undergoing bronchoplastic procedures for bronchial lesions

Bronchoplastic procedures were used in 104 patients with various bronchial disorders. Ten had benign lesions and 94, malignant tumors. The principal operative procedures were sleeve lobectomy and sleeve pneumonectomy for bronchogenic carcinoma, but 11 limited bronchial resections were performed in patients with benign lesions, minute bronchogenic carcinomas, and low-grade malignant tumors. Of the 94 patients with malignant tumors, 79 underwent a bronchoplastic procedure without carinal resection (sleeve lobectomy in 75 and limited bronchial resection in 4), and there was one operative death (1.3%). The overall 5-year survival rate for the patients with bronchogenic carcinoma in this group was 45% and that for patients undergoing curative resection, 57% (survival of patients in stages I, II, and IIIA was 79%, 55%, and 30%, respectively). A bronchoplastic procedure with carinal resection was performed in 15 patients. Twelve in this group underwent sleeve pneumonectomy. There were two operative deaths, and 1 patient has survived for longer than 4 years. Two patients with low-grade malignant tumors underwent carinal resection without lung resection and are still alive. We believe that bronchoplasty is a safe and valuable procedure and that limited bronchial resection appears to be the procedure of choice for localized bronchial lesions.

Results of surgical treatment of stage III lung carcinoma with carinal proximity. The role of sleeve lobectomy versus pneumonectomy and the role of sleeve pneumonectomy

Sleeve lobectomy in specific situations can be an alternative to pneumonectomy. Sleeve pneumonectomy is an aggressive resection for carcinoma involving the tracheobronchial angle, carina, or lower trachea and lung. Sleeve lobectomy is questioned because of its technical difficulties and its postoperative complications. Sleeve pneumonectomy is controversial in that its postoperative mortality and long-term survival rates are similar, it is a technically difficult procedure, and its mortality rate is greater than that of standard pneumonectomy. The indications for the procedures and patient selection are discussed.

[Bronchoplastic and angioplastic operations in bronchial carcinoma]

The various forms of bronchoplastic and angioplastic procedures are the best means of avoiding pneumonectomy. Essential indications are limited respiratory reserve and central site of a malignancy. In a retrospective study 248 broncho- and angioplastic operations carried out in the years 1973 to 1983 were analyzed. Reference date for the analysis of survival was January 1986. In consequence the minimum period of follow-up was two years. For all patients (n = 248) the 5-year-survival was 22% with a 30-day-lethality of 13%. The 5-year-survival of all bronchial sleeve resections operated radically (stage I and II of the TNM-classification) (n = 44) was 42% with a 30-day-lethality of 7%. The 5-year-survival of all bronchoplastic operations of stage I and II (n = 88) was 38% with a 30-day-lethality of 14%. Improved suture material and surgical techniques caused a reduction of operative lethality from 23% to 8% during the described period. In the first thirty postoperative days the following complications caused death: Hemoptysis (n = 5), insufficiency of the anastomosis (n = 3), right heart failure (n = 5), pulmonary embolism (n = 4) and sepsis (n = 1).

Results of sleeve lobectomy for bronchogenic carcinoma in 101 patients

Sleeve lobectomy for bronchogenic carcinoma is an alternative to pneumonectomy. The extent and location of the tumor must be such that a sleeve procedure is feasible. The conservation of lung tissue benefits both compromised and uncompromised patients. From 1961 to 1982, 101 patients underwent sleeve lobectomy for bronchogenic carcinoma of the lung. There were 58 procedures on the right side and 43 on the left. Life-table analysis of 94 of the patients shows a 5-year survival of 30% and a 10-year survival of 22%. Preoperative irradiation was utilized in 51 patients with a 5- and 10-year survival of 25% and 16%, respectively. The sleeve lobectomy group that did not have radiation therapy demonstrated a 5-year survival of 36% and a 10-year survival of 28%. There were 2 operative deaths (2%). Completion pneumonectomy was required in 7 patients because of anastomotic dehiscence in the early postoperative period in 6 and tumor at the margin in 1. Other major complications included empyema and granulation tissue at the anastomosis that were successfully managed by bronchoscopic dilation and suture removal. Tumor recurred locally in the area of the anastomosis in 9 patients. Sleeve lobectomy is a safe procedure and when technically feasible can be considered the procedure of choice for bronchogenic carcinoma.

Bronchoplastic surgery for lung cancer and the results

Fifty-nine patients with lung cancer underwent bronchoplastic surgery in our institute from September, 1965 to May, 1982. The post surgical stages of disease were as follows: 7 cases of Stage I disease, 7 cases of Stage II, 41 cases of Stage III, 4 cases of Stage IV. The bronchoplastic surgery performed included sleeve resection combined with lobectomy in 35, wedge resection combined with lobectomy in 11, reconstruction of the lower area of the trachea in 5, bronchial sleeve resection combined with pulmonary artery resection in 6 and bronchial wedge resection combined with pulmonary artery resection in 2. There was no case of operative mortality within 30 days after the operation. To prevent postoperative complications, careful techniques are required in suturing and postoperative bronchoscopic suction of intrabronchial secretion is necessary. The use of Dexon or Dexon S, polyglycolic acid sutures, showed good results. Adjuvant therapies were performed on 42 cases, including preoperative infusion of Mitomycin C into the bronchial arteries or postoperative irradiation or both. Twenty-eight of 59 were alive and well from 7 months to 16 years after the operations. The relative 5 year survival rates were 40.5 per cent in total cases and 46.5 per cent in those with squamous cell carcinomas. The prognosis of patients undergoing bronchoplasty was compared with that of patients undergoing lobectomy and pneumonectomy. There was a statistical difference between bronchoplasty and pneumonectomy.

Sleeve resection of the bronchus and the pulmonary artery for pulmonary lesions

The tissue preserving resections for non-small-cell bronchial carcinoma can be grouped into three main categories: I. bronchoplastic procedures, II. angioplastic procedures, and III. concomitant broncho- and angioplastic procedures, and into the subgroups, standard and extended sleeve resection. The indication are; elderly patients, impaired respiratory reserve, limited tumour growth, and palliative surgery. The analysis of 229 cases yielded follow-up data in 192. The estimated 5 year survival rate was 34 per cent, 19 per cent and 14 per cent in categories I, II and III, respectively. The decrease in survival was due to a greater tumour burden. The operative mortality rate was 8.9 per cent in category I and 17 per cent in category III, such being comparable with standard or extended pneumonectomy, respectively. Surgical techniques and postoperative complications are discussed.