Bronchoplasty 

Bronchoplasty is a reconstruction or repair of the bronchus to restore the integrity of the lumen. Bronchoplasties have a remarkable role in management of benign and malignant pulmonary lesions. The first bronchoplasty was performed by Bigger in 1932. 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).[1, 2] 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.[3]

Tracheal stenosis.

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.[4]

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.[5, 6]

The criteria for VATS lobectomy with bronchoplasty are as follows[5] :

• 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.[1, 2]

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 as compared with wedge resection.[7]

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

• Bronchovascular fistulas

• Dehiscence of bronchial anastomosis

• Empyema

• Bronchiectasis

• Recurrent stenosis

• Recurrence of malignancy

Cardiac complications

Cardiac complicatins include the following:

• Arrhythmias

• Angina

• Myocardial infarction

Miscellaneous

Other complications include the following:

• Anesthesia complications

• Postoperative pain

• Wound infections

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[8]

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.[9, 10, 11]  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.[12]

Balloon bronchoplasty

Outcomes and survival are excellent.[13]

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

Comorbidities have significant influence on survival; therefore, patients chosen to undergo bronchoplastic operations should be selected with caution.[14]

Factors that increase postoperative risk for any thoracic surgery include the following:

• Advanced age

• Coronary artery disease

• Chronic obstructive pulmonary disease or asthma

• Extensive lung resection[15]

• Immunocompromised status

• Morbid obesity

• Prolonged surgery

• Smoking history

• American Society of Anesthesiologists Physical Status class 2 or higher

Preoperative workup for thoracic surgeries should include the following:

• Complete history and physical

• Routine blood test

• Type and matched blood

• Pulmonary function test (lung volumes, FEV1 is the most important, and gas transfer DLCO)

• Arterial blood gas

• Cardiopulmonary exercise test

Cardiac workup

Patients who are completely asymptomatic and have no risk factors for coronary artery disease regardless of age do not need testing. Patients with symptomatic heart disease or evidence of a cardiac dysfunction need further assessments such as a stress test.

Imaging

Depending on the type of pathology and procedure performed, metastatic workup should include CT of the chest, brain, and upper abdomen; positron emission tomography (PET) scanning; and a brain MRI.

In malignant lung conditions, accurate TNM staging is a prerequisite; this may require bronchoscopy, mediastinoscopy, or PET scanning.

Patient education and consent

An informed consent should be obtained from all patients.

Personal protective equipment

Personal safety equipment includes the following:

• Sterile gown

• Sterile gloves

• Mask

• Sterile drapes

Equipment for thoracotomy

The instruments required for this procedure include the following:

• Scalpel

• Mayo scissors and Metzenbaum scissors

• Rib spreaders

• DeBakey forceps

• Retractors

• Electrocautery

• Lung grasper (Duval lung clamp)

• Satinsky vascular clamps (large and small)

• Long and short needle holder

• Sutures (silk, Vicryl)

• Kelly and tonsil clamp

• Endoscopic stapler

• Mixter dissecting forceps

• Skin stapler

• High-volume suction device

• Laparotomy packs

• Chest tube, 28-32F

• Water seal drainage system

Equipment for VATS

Instruments needed for VATS include the following:

• Thoracotomy tray (above)

• Video thoracoscope 5-10 mm

• Carbon dioxide insufflation

• Trocar cannulas

• Endoshears

• Endoscopic hook

• Mixter dissecting forceps

• Forester lung clamp

• Endoscopic stapler

• Endoscopic biopsy forceps

• EndoCatch bag

Equipment for balloon bronchoplasty

The instruments needed for balloon bronchoplasty include the following:

• Flexible fiberoptic bronchoscope (outer diameter 6.3-7 mm, working channel 2.8-3.2 mm)

• Bronchial balloons for bronchoplasty (balloons have variable expandable diameters of 6-7-8 mm, 8-9-10 mm, 10-11-12 mm, 12-13.5-15 mm, 15-16.5-18 mm)

• SEMS (self-expanding metal stent)

• Bronchial biopsy forceps for positioning of SEMS

• Silicon lubricant

Equipment for bronchial thermoplasty

Instruments for bronchial thermoplasty include the following:

• Flexible fiberoptic bronchoscope

• Alair catheter

• Alair controller system

Anesthesia

For bronchoplastic procedures, general anesthesia is maintained with a double-lumen tube. Double-lumen endotracheal tubes also protect the opposite lung from contamination by purulent secretions. Single-lung ventilation is started before bronchotomy and switched back to normal ventilation after bronchial continuity is restored. For carinal procedures, direct surgical intubation of distal trachea using new sterile tube may be required.

Flexible bronchoscopy is performed under local anesthesia and conscious sedation. Rigid bronchoscopy requires intravenous or inhalation general anesthesia.

Positioning

The patient is placed in the lateral decubitus position with the nonoperative lung in the dependent position and the operated side of lung unventilated. The operating table is flexed to expand intercostal space.

Monitoring

Close intraoperative monitoring should be performed with continuous pulse oximetry; capnography; and placement of an arterial line for measurement of mean arterial pressure, oxygen, and carbon dioxide content.

Follow-up

Postsurgery early extubation is the goal. However, based on duration and extent of surgery, some may require prolonged ventilatory support. Patients are monitored postoperatively in the surgical ICU for 24-48 hours or until stabilization of any postoperative complications.

Epidural analgesia and opioids are generally used for pain management in the postoperative period. Chest tubes are left in place until the air leak is resolved and the lung is fully expanded. Chest radiographs are performed daily to evaluate for pneumothorax, effusion, or parenchymal disease. The median time for removal of the chest tube is 2 days.[1, 2]

Median time to discharge is 7 days. Bronchoscopy is used liberally for pulmonary toilet and to ensure an intact anastomosis. Repeat bronchoscopy is required at time of discharge to confirm no dehiscence, stenosis, or strictures. After discharge, annual chest radiography and bronchoscopy are required to monitor for stenosis or recurrence of malignancy.

Balloon and thermal bronchoplasty

Monitoring pulse oximetry, heart rate, and blood pressure is essential during the procedure.

Chest radiography is performed after the procedure to ensure that there is no pneumothorax. Most patients are discharged the same day, after being monitored for a few hours.

Rigid and flexible bronchoscopies are performed to delineate the anatomy and degree of bronchial involvement. Operative strategies are based on frozen section results from biopsies.

The type of bronchoplastic procedure in individual cases is selected according to the location and extent of the pathologic lesion; modifications are performed according to the operative findings. The most commonly performed bronchoplastic procedure is a sleeve lobectomy. The principal aim of the procedure is to conserve as much of the healthy lung tissue as possible, while providing satisfactory cancer clearance.

A standard posterolateral thoracotomy is used for all bronchoplasties. Standard surgical technique is used for lobectomy until the bronchus is encountered.[1, 2, 16]

The area of involved bronchus is carefully dissected to preserve peribronchial blood supply. Proximal and distal points of transection are determined, and the bronchus is precisely divided. Additional segments of proximal and distal margin are removed for frozen section evaluation to confirm absence of tumor involvement.

Full-thickness traction sutures of 2-0 Vicryl are placed proximally and distally in the midlateral position of the bronchus and are left in place at the completion of the procedure. The anastomosis is performed in open fashion to allow precise placement of sutures commencing posteriorly. Anastomotic sutures of 4-0 Vicryl are placed so that the knots are outside the lumen. They are placed 3 mm deep and spaced accordingly to accommodate any size discrepancy that exists between the bronchi.

With the traction sutures pulled together and tied, each individual anastomotic suture is tied in the reverse order of placement. Once the anastomosis is completed, saline solution is placed in the pleural cavity, the lung is re-expanded, and the anastomosis is checked for air leaks. The anastomosis is wrapped with either pericardial fat or pleural flap or intercostal muscle flap for additional buttressing.

Flexible bronchoscopy is required at this time to confirm the alignment, patency, and adequacy of the anastomosis. Chest tubes are placed and connected to a water-seal device with suction.

Video-assisted thoracoscopic surgery (VATS) is an option for most patients with thoracic pathology. This technique has been shown to have better outcomes, less pain, and shorter recovery than the open approach.[17, 18, 19] VATS is a better alternative to thoracotomy and is performed under general anesthesia using a camera and 2 trocar ports. The VATS technique is very similar to the open technique, except endoscopic instruments are used to retract and dissect and visualization is via an image obtained with the thoracoscope projected on a screen.[20, 21]

A standard thoracoscopy is performed with 2-3 10-mm incisions: a camera port is placed in the anterior axillary line in the seventh or eighth intercostal space; an anterior port is placed between the latissimus dorsi and pectoralis major muscles in the fourth or fifth intercostal space; and a posterior port is placed adjacent to the scapula in the fifth or sixth intercostal space.

Through working thoracoscopy ports, an exploratory thoracoscopy is performed. Subsequently, the anterior thoracoscopy incision is extended to create a 3- to 5-cm muscle-sparing access incision to proceed with VATS lobectomy or wedge bronchoplasty or sleeve resection and allow for removal of the specimen. As in open lobectomy, the pulmonary vein branches from the targeted lobe are identified and dissected before their division using an endoscopic stapling device. Pulmonary artery branches and the bronchus are identified, dissected, stapled, and divided in a similar manner.

The specimen is removed from the pleural space using a plastic bag to avoid port-site contamination. After the lobectomy or sleeve resection is completed, a hilar and mediastinal lymphadenectomy or lymph node sampling is performed. Ends of bronchial stump are sent for frozen section to ensure tumor-free margin. Bronchial stump anastomosis is challenging, especially in VATS, because of limited access. Continuos sutures should be tied. A sliding knot technique combining with hitch and bend knots as described by Nakanishi is helpful.[5] The incisions are closed after a chest tube is placed in the inferior thoracoscopy port. The chest tube is connected to the water seal device.

Bronchoscopic balloon dilation is a simple, nontraumatic, minimally invasive, safe, rapid method to dilate a stenosis and restore adequate airflow. It may be used with fluoroscopic guidance over a guide wire or under direct vision. It does not require general anesthesia.

Balloon bronchoplasty is most commonly used with high long-term success for nonmalignant causes of airway stenosis, but it is also used in malignant diseases.

The balloon should be silicone based and able to provide radial force. The inflation syringe must have a pressure gauge, and knowledge of burst pressure must be observed. The balloon is usually filled with saline until full deployment is reached with the help of a pressure-measuring syringe, to a prespecified pressure unit ranging from 6-12 atm in adults. Inflation diameter ranges from 4-20 mm, with a length of 4-8 cm. The final desired diameter is usually the normal diameter immediately proximal or distal to the stenosis. Each dilation can be maintained for 15-60 seconds and repeated 2-3 times, with sequentially larger-diameter balloons (see the image below). If the cartilage has been compromised, a stent is needed to support the airway.[22]

Post balloon dilation.

Balloon dilation and stent placement are safe and effective for bronchial strictures and bronchomalacia after lung transplantation, resulting in significant improvement in pulmonary function testing (PFT) results.[23, 24]

Thermal bronchoplasty requires 3 separate outpatient bronchoscopic procedures 3 weeks apart; one for each lower lobe of the lung and another for both upper lobes.

Using a flexible bronchoscope, an Alair catheter is deployed into the airways, and controlled radiofrequency energy is delivered to a wire basket attached to the top of the catheter using the Alair controller system, in which thermal energy warms the lining of targeted airways to reduce airway smooth muscle (ASM) mass. Bronchial thermoplasty is intended to reduce, debulk, or partially eliminate smooth muscle tissue (see the images below).[25, 26]

Alair controller and catheter.

Alair catheter deployed in the subsegmental bronchus.