Tracheobronchial Sleeve Resection

Masses located in the proximal airway remain a challenge for the thoracic surgeon. Because of the proximal location, the tenets of preservation of lung function and oncologic resection would seem to be at odds, and in many cases, traditional resection (often meaning pneumonectomy) is not a feasible option for patients who have poor pulmonary reserve at baseline. Additionally, masses located at the level of the carina would be unresectable without a tracheoplastic procedure to restore airway patency.

The presence of such complicated problems resulted in the creation of specialized surgical procedures, pioneered first by Price-Thomas in 1947 ^[1] to meet the need of a right main bronchus carcinoid mass, and further advanced and popularized by Mathey ^[2]  and then by Paulson and Shaw. ^[3] The current derivation of these techniques is surgical resection that allows both adherence to oncologic principles and preservation of airway anatomy and lung parenchyma, which has been shown to be a valid option in most cases. ^[4]

Tracheobronchial sleeve resection has made great strides as a viable surgical option for patients requiring extensive pulmonary resections. The benefits make it a desirable surgical approach for many individuals in whom a larger resection either would not be feasible or would cause significant residual morbidity. As with any pulmonary resection, successful management of these patients requires utilization of a team composed of experienced surgeons, oncologists, clinic staff, and hospital nurses.

The primary indication for bronchial or carinal sleeve resection is lung cancer, with a full preoperative workup indicating both (1) that the patient is a suitable surgical candidate from a medical standpoint and (2) that surgical resection is indicated (ie, no indication of distant disease). If these requirements are not met but the patient has an obstructing or near-obstructing lesion that must be addressed, palliation with stenting or other options may be considered, including nononcologic palliative operations; however, discussion of these approaches is beyond the scope of this article.

When surgical resection for neoplastic processes within the lung is indicated, the traditional teaching has been that lobectomy or pneumonectomy is the standard of care. In many patients with baseline lung disease, however, pneumonectomy or bilobectomy may impose too large a burden on an already taxed pulmonary system. Traditional resection would not be an option for these patients, and sleeve resection provides an avenue for surgical excision.

Additionally, pneumonectomy has been shown to have a higher mortality than sleeve resection in all patients, ^[5]  though sleeve resection has been shown to have a slightly higher mortality than routine lobectomy. Pneumonectomy patients also appear to have a worse quality of life than lobectomy patients do, and they appear to have a higher risk of death from cardiopulmonary factors. ^[6]

Moreover, evidence exists that sleeve lobectomy is ultimately more cost-effective than pneumonectomy. ^[5] Because of the possibility of preserving increased amounts of native lung function, the authors typically attempt to offer sleeve resection to all patients who are candidates, as supported by others. ^{[6, 7, 8, 9]}

Contraindications for bronchial or carinal sleeve resection include the following:

• Advanced pulmonary disease
• Unresectable disease
• Distant metastases
• Significant cardiac disease

With operations that are both physiologically (for the patient) and technically (for the surgeon) difficult, the need for careful patient selection is all the greater, and any concerns raised during preoperative evaluation should prompt further workup.

Patients can expect a recovery at home that lasts several weeks, with a gradual return to normal function.

With appropriate management through all stages of their care, including the preoperative and postoperative setting, these individuals stand to have good outcomes with potential for curative resections or meaningful extension of healthy years.

Pagès et al used a decade of data from a French national database to compare outcomes following sleeve lobectomy (n = 941) and pneumonectomy (n = 5318) for non-small cell lung cancer (NSCLC). ^[10] ​ Although early differences in perioperative pulmonary outcomes favored pneumonectomy, early overall and disease-free survival differences favored sleeve lobectomy in the matched analysis (though not in the weighted analysis). The authors suggested that sleeve lobectomy, when technically feasible, should be the preferred technique.

In a retrospective study, Wang et al compared the outcomes of left sleeve lobectomy (n = 87) and left pneumonectomy (n = 48) in 135 patients with NSCLC. ^[11] There were no significant differences in general clinicopathologic features between the two groups. Operating time was longer and the extent of bleeding greater for sleeve lobectomy; however, overall survival was significantly longer with sleeve lobectomy. The outcomes of left sleeve lobectomy were associated only with pathologic stage. The authors suggested that left sleeve lobectomy, if anatomically feasible, may be a preferred alternative to left pneumonectomy for NSCLC patients.