Bronchoplasty

Bronchoplasty is a reconstruction or repair of the bronchus to restore the integrity of the lumen. Bronchoplasty, or vascular reconstruction, is a technique in which 2 separate pieces of bronchus or vessels are reanastomosed. The most common indication for bronchospasm is lung neoplasm. ^[1]  Various novel techniques have been used to treat a wide range of pathologic conditions. Bronchoplastic procedures for benign and low-grade malignant tumors of the airway and benign stenosis allow preservation of maximum amount of pulmonary parenchyma (see the image below). ^{[2, 3]} Benign and low-grade malignancies require only minimally clear margins for cure and are ideally suited to bronchoplastic resections. In typical lung resection procedures, any airway involved with tumor is resected with its associated lung parenchyma. This results in extensive resections in the setting of central tumors involving the proximal airways. With bronchoplastic techniques, the involved airway may be resected to negative margins and the remaining ends anastomosed, thus preserving the distal lung parenchyma. ^[4]

Bronchoplastic techniques can also be used to repair traumatic airway injuries and benign strictures.

Types of bronchoplasty

Surgical bronchoplasty

Surgical bronchoplasty involves reconstruction or anastomosis of bronchus after lung procedures such as lobectomy, sleeve resection, wedge resection, and pulmonary artery angioplasty. In its most common form, this procedure involves resection of a portion of the airway without resection of the associated lung parenchyma and reconstruction of the airway with bronchial anastomosis (sleeve resection).

The typical scenario is a centrally located upper lobe lung cancer involving the origin of the right upper lobe bronchus and the origin of the bronchus intermedius. Without use of bronchoplastic techniques, a pneumonectomy would be required, but a right upper lobectomy may be performed with the resection extending to involve the proximal bronchus intermedius and reanastomosis of the right mainstem bronchus to the bronchus intermedius, thus preserving the right lower lobe. Tumors involving the main branches of the pulmonary artery can similarly be resected with pulmonary artery sleeve resection and reanastomosis.

Balloon bronchoplasty

Balloon bronchoplasty involves the use of balloons for symptomatic airway stenosis. Balloon bronchoplasty is a procedure essential to practice of interventional bronchoscopy. It is performed with both flexible and rigid bronchoscopy. This technique is generally used in conjunction with other techniques (eg, electrocautery, stent deployment).

Thermal bronchoplasty or bronchial thermoplasty (BT)

Severe asthmatics have increased airway smooth muscle (ASM) responsible for bronchoconstriction and increased resistance of airway. BT is a novel treatment modality that uses radiofrequency energy to reduce ASM mass and resistance of airway. It is safe, improves quality of life, and decreases severity and frequency of asthma exacerbations. ^[5]

Bronchoplasty is indicated for various benign and malignant pulmonary lesions. Surgical bronchoplasties are commonly performed in conjunction with lobectomy, wedge resection, and sleeve resection.

Open

Open bronchoplasty is performed via open thoracotomy or thoracoscopic video-assisted thoracoscopic surgery (VATS). VATS provides adequate visualization despite limited access to the thorax, allowing the procedure to be performed in patients in a state of debilitation and in patients who have marginal pulmonary reserve. ^{[6, 7]}

The criteria for VATS lobectomy with bronchoplasty are as follows ^[6] :

• Tumor size less than 5 cm

• No evidence of vessel invasion

• No direct invasion to the surrounding organs requiring reconstruction

• Patient and family agree to procedure

Closed

Closed bronchoplasties are performed via bronchoscope (rigid or flexible) mainly in central airway obstructions. The distribution of pathology for bronchoplastic surgeries are listed below. ^{[2, 3]}

Low-grade malignancy(most cases)

• Carcinoid (typical/atypical; most common)

• Non–small cell carcinoma (NSCLC)

• Adenoid cystic carcinoma

• Granular cell tumor

Benign masses

• Neuroendocrine tumors

• Inflammatory pseudotumor

• Mucous gland cystadenoma

• Hamartoma

• Lipoma

Stenosis

• Postinfectious stenosis due to histoplasmosis and bronchial tuberculosis

• Inflammatory

• Idiopathic

• Posttraumatic

• Postoperative

Balloon bronchoplasty

Balloon bronchoplasty is indicated in central airway obstructive lesions resulting in endoluminal stenosis due to endobronchial carcinoids, sarcoidosis, hamartoma, bronchogenic carcinoma, infections, Wegener granulomatosis, postintubation stenosis, idiopathic or posttraumatic stenosis, granulation tissue, and bronchial strictures after lung transplantation.

Bronchial thermoplasty

Bronchial thermoplasty is used for treatment of patients with symptomatic severe, persistent asthma who are 18 years and older.

Thoracic surgery

Thoracic surgery is contraindicated in the following cases:

• Markedly unstable or shocked patient

• Poor cardiopulmonary reserve

• Coagulopathy

• High-dose steroids

• Poor functional status

Video-assisted thoracoscopic surgery (VATS)

VATS is contraindicated for the following:

• Extensive adhesions obliterating the pleural space (ie, prior talc pleurodesis, reoperation)

• Extensive pleural diseases

Balloon bronchoplasty

Balloon bronchoplasty is contraindicated for the following:

• Refractory hypoxemia

• Life-threatening arrhythmias

• Recent myocardial infarction or angina

• Coagulopathy

• Uncooperative patient

Thermal bronchoplasty

Thermal bronchoplasty is contraindicated for the following:

• Patients with a pacemaker, internal defibrillator, or other implantable electronic device

• Patient with allergies to lidocaine, atropine, or benzodiazepines

• Active respiratory infection

• Coagulopathy

• Asthma exacerbations

• Recent changes in corticosteroid regimen (< 2 weeks)

Surgical bronchoplastic procedures represent a fairly safe therapy in patients with centrally localized bronchial carcinoma and compromised pulmonary function. Complication rates are higher after sleeve resection of the bronchus than after wedge resection. ^[8]

Pulmonary complications, early

Early pulmonary complications include the following:

• Excessive bronchial secretions

• Atelectasis

• Persistent air leak

• Erosion and bleeding of vessels

• Hemothorax

• Pneumonia

• Transient vocal cord paralysis

• Pulmonary embolism

Pulmonary complications, late

Late pulmonary complications include the following:

• Bronchial strictures

• Bronchopleural fistulas ^[9]

• Bronchovascular fistulas

• Dehiscence of bronchial anastomosis

• Empyema

• Bronchiectasis

• Recurrent stenosis ^[10]

• Recurrence of malignancy

Cardiac complications

Cardiac complications include the following:

• Arrhythmias

• Angina

• Myocardial infarction

Miscellaneous

Other complications include the following:

• Anesthesia complications

• Postoperative pain

• Wound infections

Bronchopleural fistula (BPF) is a rare but severe complication that may occur following bronchoplasty. Although the complication rate of BPF after bronchoplasty is low, associated mortality is high. Peng and associates identified the following risk factors for BPF: higher Charlson Comorbidity Index (CCI), history of right middle and/or lower lobectomy, and presence of residual tumor in the bronchial margin. ^[9]

Balloon bronchoplasty

Balloon bronchoplasty is generally safe, but complications such as chest pain, bronchospasm, airway rupture, pneumothorax, hemothorax, and mediastinitis are possible.

Late complications include recurrent stenosis and stent displacement.

Thermal bronchoplasty

Complications associated with thermal bronchoplasty include a transient and self-limited increase and worsening of respiratory symptoms, atelectasis, hemoptysis, anxiety, headaches, and nausea.

Surgical bronchoplasty

Multivariable analysis demonstrated the following 4 risk factors for poor survival:

• High tumor stage

• Type of bronchoplastic procedure

• Impaired lung function

• Presence of cardiovascular risk ^[11]

For patients with non–small cell lung cancer, 5-year actual survival rates were 60% in stage IB, 30% in stage IIB, and 27% in stage IIIA. ^{[12, 13, 14]}  Published reports document a 30-day operative mortality of 0-5%. Most major reports document a 5-year survival of 40-50% and functional results that are significantly better than those obtained following pneumonectomy. ^[15]

Balloon bronchoplasty

Outcomes and survival are excellent. ^[16]

Bronchial thermoplasty

In a double-blind, randomized, sham-controlled clinical study of bronchial thermoplasty, patients with severe asthma that were treated with bronchial thermoplasty showed improvement on an asthma-related quality-of-life questionnaire (ARQLQ), as compared to control patients, and experienced the following significant benefits that were maintained for at least 2 years:

• 84% reduction in emergency room visits for respiratory symptoms

• 73% reduction in hospitalizations for respiratory symptoms

• 66% reduction in days lost from work or school due to asthma symptoms

• 32% reduction in asthma attacks