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.

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).

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]

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.

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.

The authors’ practice is to routinely perform bronchoscopy in all patients after the successful induction of anesthesia. This allows the surgeon to verify that a sleeve resection is a viable option and to obtain visual confirmation of the patient’s specific anatomy. Once the bronchoscopy is completed, the patient is positioned and the procedure can commence.

All pulmonary sleeve resections can be broken down into a few general steps, as follows:

• Dissection and exposure
• Isolation of vascular and airway structures
• Resection
• Airway and vascular anastomosis
• Closure

Because right upper lobectomy is the prototypical sleeve resection, it will be described first and used as the general model for the other lobar sleeve resections, with any significant differences between the procedures outlined where necessary.[17]  Resections of lesions at various locations, along with the postresection anatomy, are illustrated in the images below.

Minimally invasive approaches to sleeve resection have been described and are the subject of increasing study; however, they are not described in detail in this article.[18, 19, 20, 21, 22]

Upon entry into the chest, a detailed and complete exploration of the chest, including the chest wall and the entire lung, is performed. This ensures that no evidence of metastatic disease exists elsewhere within the chest, which would preclude continuing with resection. Next, the hilum is addressed (see the image below), and the pulmonary artery is dissected out and isolated; a right-angle clamp should be easily placed behind the structure, and a vascular loop or cord tape is passed.

This and every other aspect of dissection in these cases must be deliberate and complete. Failure to make it so will only ensure that later steps are more difficult. If any concern exists regarding the ability to obtain good proximal control of the artery, the authors do not hesitate to open the pericardium at this point and obtain control lateral to the superior vena cava.

Attention is then directed toward the right mainstem and the right-upper-lobe (RUL) bronchus, which are similarly dissected free. At the bifurcation of the RUL bronchus and the bronchus intermedius (BI), a solitary lymph node is typically found in the “crotch” area. Running deep to this node is the superior segmental branch of the pulmonary artery. The BI should now be easily isolated, and an umbilical tape may be passed around it to isolate the structure. The RUL is now isolated, and resection can take place.

The RUL vein is ligated. The truncus branch of the pulmonary artery is ligated. The fissure is completed by firing a linear stapler along its natural course. The remaining pulmonary artery branches are ligated. The mainstem bronchus is then sharply divided just proximal to the takeoff of the RUL bronchus; in a similar fashion, the BI is then divided just distally to the RUL takeoff. Division of the bronchus must occur perpendicularly to the long axis of the airway. Failure to do so may result in a difficult bronchial anastomosis later.

Frozen-section margins are then analyzed. A positive margin at this point requires further resection, including a possible conversion to a pneumonectomy.

Reanastomosis of the bronchus (main bronchus to residual BI) is then performed. There should be no tension on the anastomosis (this is essential), and no torsion or kinking should exist. A size discrepancy is expected, and consequently, precise suture placement is crucial for  making up this difference. Sutures are placed in either an interrupted fashion or a continuous fashion depending on surgeon preference (see the image below). Travel on one side should be proportional to travel on the other; this ensures an air-tight seal with proper adjustment for size discrepancy.

The chest is then filled with saline, and the seal is checked under a Valsalva maneuver. If no leak is detected, the authors proceed with the operation. Reinforcement of the anastomosis with a flap is controversial, though some surgeons do it routinely. Note that this flap is not what produces an air-tight seal; it is placed only to help prevent anastomotic breakdown.

Next, the patient’s chest is closed. In some centers, postoperative bronchoscopy is routinely performed at this point. Most patients can then be extubated.

As noted, an RUL sleeve resection is the classically described procedure; a right-middle-lobe (RML) sleeve resection is fairly uncommon. An RML resection is similar to a RUL resection in general terms, with attention turned to the middle-lobe vasculature and airway structures. However, it should be noted that in all of the described resections, proximal control is essential; accordingly, isolation of the main pulmonary artery is performed in almost all cases.

The vascular supply to the RML is less accessible than the that to the RUL. The vein lies anterior to the bronchus, and the artery is immediately posterior. Division of the distal airway is a critical step because the superior segmental bronchus lies opposite the middle-lobe bronchus and thus is angled to preserve the takeoff of the superior segmental bronchus. Consequently, division of the proximal airway must also be slightly angled to ensure a well-matched anastomosis.

As with right-side resection, proximal control is obtained first (see the image below). Obtaining control may be more difficult because of the shorter pulmonary artery on the left side; it also is inherently more hazardous because of the early takeoff of the apical-posterior branch.

In a left-upper-lobe (LUL) resection, much as in an RUL resection, the posterior fissure is completed with a linear stapler after identification all pertinent structures. Care is taken to avoid injuring the arterial branch to the superior segment of the lower lobe, which runs in this area. The venous and arterial branches are then divided, including branches to the lingula.

Division of the bronchus occurs just proximal and distal to the takeoff of the LUL. Division of the distal aspect is potentially hazardous because the takeoff of the superior segmental bronchus occurs a short distance from the LUL takeoff, and care must be taken not to injure this structure. The anastomosis is performed as previously described.

Resection of the more proximal airway (carina and distal trachea) understandably requires a sleeve-type anastomosis in all cases. For resection of the more proximal trachea, including larynx, a different set of considerations, workup, and techniques is implemented that is outside of the scope of this article.

To begin resection of the distal trachea or carina, a bronchoscopy is performed as noted above.

Adequate exposure and dissection are, again, essential to a safe and successful operation. Here, this begins with mobilization of the left pulmonary artery and aortic arch, with careful identification and preservation of the recurrent laryngeal nerve, or with dissection of the carina and mobilization of the right pulmonary artery and bronchus. After adequate dissection and isolation of the appropriate structures, umbilical tape is again passed to help with isolation.

One must be careful not to mobilize too much of the airway, because the vascular supply is tenuous. Typically a 3- to 4-mm area is dissected away from the pretracheal space; this is where the division takes place.

Because division of the airway occurs proximal to the bifurcation, traditional single-lung ventilation is impossible. To facilitate continued ventilation, a sterile circuit is passed onto the field and prepared to ventilate a single lung directly, something that requires a high level of communication with the anesthesia team. After division of the main bronchus, direct intubated is performed and ventilation across the surgical field obtained, or the JET ventilator can be used.

The classic approach for this procedure is to anastomose the distal trachea to the left main bronchus in an end-to-end approach, in a fashion similar to that described above. After this anastomosis is completed, the orotracheal tube is carefully advanced across the anastomosis for single-lung ventilation. To include the right lung in the airway, an end-to-side anastomosis is performed, either to the distal trachea or to the left mainstem bronchus (depending on available length), in a tension-free manner. (See the image below.)

This anastomosis is completed in a similar interrupted fashion. Of note, the placement of the tracheotomy or bronchotomy should be within the cartilaginous rings so as to provide strength to the anastomosis. Both anastomoses are traditionally then wrapped with a pedicled flap before closure of the chest. Various tracheal release maneuvers can also be performed if underlying anastomotic tension is observed.