Patient Education and Consent
As with any surgical procedure, a thorough and frank explanation of the risks and possible complications must occur before consent is obtained from a prospective patient. Risks for sleeve resection are similar to those of other large pulmonary resections, with an operative mortality of up to 5.5% [8, 12] and a morbidity of around 30%. [8, 13] The most common complications are postoperative pneumonia, bronchopleural fistula, anastomotic stenosis, and locoregional recurrence.
The expected postoperative course for these patients obviously varies greatly, depending on their preoperative status and on the extent of the planned resection. Given the variable nature of native lung health, baseline functional status, and tumor burden, the discussion with patients regarding expected recovery will naturally differ considerably from one case to another. All available information about the likely postoperative course should be presented to the patient in detail during the preoperative visit, with ample time devoted to answering any questions that may arise.
Patients should be informed that a chest tube will be left in place after the resection and that the tube will likely be removed in the first few postoperative days.
Providers should counsel patients that they will not be able to return to work during the early recovery phase and that they will likely require some degree of assistance at home for a few days (though not permanently).
Preprocedural Planning
As in all cardiothoracic operations, the operative approach, the ventilation needs, the planned procedure, and relevant patient-specific factors must be discussed with the anesthesia team in detail before the start of the case.
Workup of any mass within the pulmonary system, including the lung and airway, involves fine-cut computed tomography (CT) and positron emission tomography (PET) to evaluate the burden of disease and to help establish proper staging. The fine-cut contrast-enhanced CT scan has the added benefit of helping to establish resectability; following adequate staging, operative planning will begin here. Routine laboratory work is also sent, and if a sufficient cardiac history exists, a stress test may be required preoperatively.
In addition to routine laboratory testing, all patients undergoing any kind of lung resection require establishment of current lung function and reserve with pulmonary function tests (PFTs).
At the authors' center, if there is any concern about possible mediastinal involvement on PET/CT, endobronchial ultrasonography (EBUS) or mediastinoscopy is performed to aid in staging the patient. Many institutions routinely perform mediastinoscopy or ultrasound-guided fine-needle aspiration (FNA) before any pulmonary resection for a neoplastic process; the efficacy of this measure in the current era of PET has been a subject of debate. [14, 15]
Patient Preparation
Anesthesia
In these cases, lung isolation requires the placement of a double-lumen endotracheal tube (for lesions beyond the main carina; see the image below) or a single-lumen tube with a sterile circuit available (for lesions of the carina or trachea or those for which a sleeve pneumonectomy will be required).
Correct placement of the airway is confirmed by means of anesthesia using bronchoscopy. [16] This is a critical conversation to have with the anesthesia team. Because of the considerable length of the left mainstem, double-lumen tubes are routinely used on the left side. However, for a planned left-side sleeve resection, one should consider a right-side double-lumen tube.
Positioning
After bronchoscopy, the patient is positioned for a posterolateral, serratus-sparing posterolateral, or lateral incision, depending on the surgeon's preference. Occasionally, a tracheobronchial sleeve resection can also be done via a median sternotomy.
Monitoring & Follow-up
As with any major thoracic procedure, optimizing residual lung function with pulmonary toilet, adequate pain control, and appropriate fluid management is essential.
Pain after thoracotomy has historically been significant; however, the use of intraoperative nerve blocks, epidural analgesia, and muscle-sparing incisions has substantially reduced such pain. Improving pain control improves the patient’s ability to cough and take deep breaths, thereby reducing the risk of complications from pneumonia postoperatively. After the procedure, patients are transitioned to oral pain medication (typically acetaminophen-oxycodone or acetaminophen-hydrocodone) and are discharged with this and a stool softener.
A major barrier to removal of the chest tube is a persistent air leak. This occurs at variable rates and is typically uncommon; however, in cases where patients have poor wound healing because of malnutrition or previous radiation or chemotherapy, the risk for development of a persistent leak rises significantly. When a persistent leak is noted, the chest tube is kept in place for a longer period, and this often leads to resolution of the leak over time. In some cases, reoperation is required, but this is uncommon.
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Placement of double-lumen endotracheal tube.
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Hilar anatomy (right and left).
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Tracheobronchial sleeve resection. Bronchial anastomosis. Sutures are individually placed and evenly spaced.
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Tracheobronchial sleeve resection. Anatomic lesion locations and postresection anatomy.
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Tracheobronchial sleeve resection. Anatomic lesion locations and postresection anatomy.
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Tracheobronchial sleeve resection. Completion of carinal resection and anastomosis.
