Bronchovascular Sleeve Resection Technique

Updated: Mar 20, 2014
  • Author: Setu K Patolia, MD, MPH; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Technique

Approach

Posterolateral thoracotomy is the standard incision, but lateral or vertical axillary thoracotomy can also be performed. Before inserting the rib retractor, the intercostal flap is prepared to avoid injury to neurovascular bundle. Intercostal pedicle flaps are used to wrap around bronchial anastomosis.

The incision is made on the periosteum of the fifth rib; take care to avoid injury to the insertion of the intercostal muscles. The periosteum, along with intercostal muscle, is separated from the rib while avoiding injury to the neurovascular bundle. The intercostal muscles are incised near the sixth rib and near their anterior insertion. After checking blood flow in the intercostal arteries, the anterior end of the pedicle is ligated. The rib retractor can be introduced now. Alternatively, the pleural or pericardial flap can be used to wrap around bronchial anastomosis.

Bronchovascular sleeve resection is a special case of lung cancer resection surgery. It is typically performed when the tumor is invading the pulmonary artery, like a tumor involving the left upper lobe. Otherwise, only bronchoplastic operation with bronchial reconstruction is performed.

After careful exploration of the thoracic cavity to rule out metastatic disease, the superior pulmonary vein is divided for better access to the pulmonary artery (PA). After dissecting the PA intracardially or extrapericardially to achieve good stump for anastomosis, the PA is clamped at the site of origin with a Satinsky clamp.

Alternatively, small clamps like bulldog or vascular right-angle clamps can be used for clamping the pulmonary artery in fissures. To clamp the left PA at its origin, transecting the ligamentum arteriosum may be necessary. The PA is not clamped distally, but, to avoid back flow, the inferior pulmonary vein is clamped. After careful dissection, the pulmonary artery is transected proximally and distally to the tumor to achieve a tumor-free margin.

After PA transection, bronchial dissection is performed with care to preserve bronchial blood supply. After selecting a tumor-free margin, straight transection of the bronchus is performed with the knife. The specimen is removed en bloc and examined under the microscope. Both proximal and distal margin of bronchus and pulmonary artery must be tumor free.

After removing the tumor, bronchial and pulmonary artery reconstruction is performed. Usually bronchial anastomosis is performed before the arterial anastomosis. Performing bronchial reconstruction first avoids trauma to the PA anastomosis and allows better visualization of bronchial stumps. Some surgeons perform arterial reconstruction first if the pericardial patch is required for reconstruction to reduce arterial clamping time.

Bronchial reconstruction

Transection of the inferior pulmonary ligament or semicircular transection of the pericardium can be performed to reduce the tension on the bronchial anastomosis. Bronchial anastomosis can be performed by either interrupted or continuous suturing, using absorbable 4-0 monofilament sutures. Most surgeons prefer interrupted sutures. However, a study by Bayram et al on dogs showed that healing of the bronchial anastomosis was not affected by the technique of suturing. [4] Similar findings were reported by Kutlu et al in 100 cases of tracheobronchial sleeve resections.

Sutures are placed extramucosally on cartilaginous portion to avoid bulging in tracheal lumen. However, some authors prefer to put through-and-through sutures. Take care to avoid injury to bronchial vessels. First, 2 sutures are placed on the mediastinal side of the cartilage and tied outside. Because posterior sutures are difficult to place, they can be tied intraluminally without creating obstruction. All other sutures are placed at equal distance and tied extraluminally.

The distal lumen can be stretched to avoid discrepancy in luminal sizes of the 2 stumps. After bronchial reconstruction, the anastomosis is submerged in saline, and the lung is inflated with air-way pressure of 25-30 cm of H 2 O to check for air leak. If any air leak occurs, more sutures should be placed to reduce the leak. After ensuring that no air is leaking, the anastomosis is covered with either intercostal muscle, pleural, or pericardial flap.

Pulmonary artery reconstruction

Before PA sleeve resection, 3,000-5,000 units of heparin are given intravenously. Depending on time of procedure, a heparin IV bolus is repeated hourly. Heparinization is not reversed during the resection.

After reconstruction of the bronchus, PA anastomosis is performed. It can be achieved by simple end-to-end anastomosis if feasible or by pericardial/allograft conduit. To create the pericardial conduit, a pericardial leaflet larger than arterial defect is cut in front of the phrenic nerve. The pericardium shrinks after cutting. The pericardium is wrapped around 28-30 º F chest tube and trimmed to match the size of the defect. The pericardial conduit is sutured to the vessels with epicardial surface in the lumen. A 5-0 to 6-0 nonabsorbable monofilament suture is used for continuous suture technique. The arterial clamp is removed, and the anastomosis is checked for any oozing or leaks. Because PA pressure is low, take care to recognize minimal oozing or leaks that should be repaired.

The thoracotomy incision is closed by standard technique. Bronchoscopy should be performed through the endotracheal tube to check for the patency of the bronchial anastomosis.

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Postoperative Care

Patients are extubated postoperatively. Patients are monitored in ICU for 24-48 hours, and anticoagulation with subcutaneous heparin is continued. Patients are given aggressive chest physiotherapy. Adequate analgesia including epidural is required for pain control.

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Complications

Early complications

See the list below:

  • Atelectasis and pneumonia are the most common postoperative complications and occur in 5-10% of cases. [5, 6] These complications can be avoided by adequate postoperative analgesia and chest physiotherapy. The incidence is increased with prolonged postoperative mechanical ventilation because it increases the incidence of aspiration. Treatment involves bronchoscopy, chest physiotherapy, and antibiotics.
  • Persistent air leak and anastomotic dehiscence occur in 1-7% of cases. [7, 8] These complications result from ischemia of the anastomosis. Risk factors include bronchial vascular injury as a result of extensive lymph node dissection or excessive tension of the anastomosis as a result of extensive resection of the bronchus. It can be avoided by buttressing the anastomosis with vascular pedicle from muscle, pericardium, or omentum. This complication can lead to bronchopleural fistula. On CT scan, it is seen as a defect in the bronchial wall and/or extraluminal air around the anastomosis.
  • Bronchopleural fistula occurs in 1-7% of cases. [5, 7, 9] It carries a high mortality in the range of 14-70%. [10, 11] Risk factors for development of bronchopleural fistula include residual cancer tissue at the stump, preoperative radiotherapy, diabetes, long bronchial stump, prolonged mechanical ventilation, and pneumonia. [10, 11] Radiographic findings include either increasing air fluid level or increasing the size of the pneumothorax. CT scanning may reveal direct communication between the bronchus and the pleura in 50% of cases. Bronchoscopy should be performed to evaluate the size of fistula. If it is small, conservative management with antibiotics and complete drainage can be attempted. If the fistula fails to close after 3 months or is large enough, repair of the fistula can be tried. But if repair is impossible, then complete pneumonectomy is required.
  • Hemothorax most commonly results from inadequate hemostasis of systemic vessels than pulmonary vessels. It manifests as enlarging pleural effusion on radiograph. The PA may not bleed intraoperatively. However, postoperatively with the inflation of the lung and stretching of the pericardium, the suture line may separate and the patient may bleed from the suture site. This complication is seen in 1-2 days postoperatively.
  • Empyema can occur immediately in the postoperative period but can develop after months to years. It requires treatment with drainage and antibiotics.
  • Bronchovascular fistula results from anastomotic breakdown. The incidence is 0.9-7%. [12, 13, 14, 15] Usually, patients have herald bleed. Bronchoscopy should be performed to investigate any hemoptysis after surgery. If bronchovascular fistula is found, then completion pneumectomy should be performed.
  • Vascular thrombosis and ischemic necrosis can occur at the site of reconstruction. They can be avoided by adequate heparinization intraoperatively and anticoagulation postoperatively.
  • Pulmonary edema is less common as compared to pneumonectomy. It can be caused by excessive fluid administration during surgery. But it can also be due to intraoperative myocardial infarction, sepsis, or transfusion-related lung injury. It manifests as rapidly developing pulmonary infiltrates, shortness of breath, and hypoxemia.
  • Wound infection requires antibiotic and proper wound care.

Late complications

See the list below:

  • Bronchial stenosis results from ischemia of bronchial anastomosis and granulation tissue. The incidence rate varies from 2.5-18%. [16, 17, 18] The patient may be asymptomatic or may present with recurrent infection, shortness of breath, or atelectasis. This complication can be avoided by careful maintainence of bronchial blood supply and reabsorbable suture material. Treatment involves balloon and bougie dilatation of the anastomosis. Stenting of the bronchial anastomosis is difficult because of the difficulty in placing the stent and the shorter remaining segment of the bronchus. However, Tsang et al described success with the use of stenting in 2 patients. [19] If balloon dilation fails, then re-do surgery can be attempted after 3 months when the inflammation has subsided. However, a completion pneumonectomy is required if re-do surgery is impossible.
  • Recurrent malignancy is a late complication. Local recurrence rate has been reported between 9-24%. Local recurrence rate is higher with advanced nodal stage and incomplete resection.
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Mortality

Operative mortality has been described in up to 6% of patients. Vogt Moykopf et al reported a 30-day mortality of 5% in bronchovascular sleeve resection. [20] Lausberg et al compared bronchial sleeve resection with bronchovascular sleeve resection. Sixty-seven (67) patients had bronchovascular sleeve resection, as compared to 104 patients with bronchial sleeve resection and 63 patients with pneumonectomy. Groups were not different for their tumor staging. The 5-year survival was 42.9% for bronchovascular sleeve resection group as compared to 30.4% for the pneumonectomy group (P value = 0.16). Freedom from local recurrence of disease at 5 years was 84.2% in bronchovascular sleeve resection group as compared to 88.7% in the pneumonectomy group (P value = 0.56). [21]

Yin et al reported perioperative mortality of 2.9% in 34 patients who had lobectomy with PA reconstruction. Overall 5-year survival was 37%. The 5-year survival was 80% in stage I disease as compared to 11% in stage III disease. Also, patients with N0 disease had 5-year survival rates of 71% as compared to 9% in N2-3 disease. [22]

Takeda et al compared the operative mortality of sleeve resection with pneumenectomy. Sleeve lobectomy (SL) had a mortality of 4.8%, and pneumonectomy had mortality of 3.6%. The 5-year survival in stage I and II was similar in both groups. However, for patients who had received induction chemotherapy for their cancer, 5-year survival was lower in SL group as compared to the pneumonectomy group. This difference did not reach statistical significance. [6] However, Rendina et al described 39% 4-year survival rate in SL patients after induction chemotherapy as compared to 36% in the pneumonectomy group after induction chemotherapy.

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Five-Year Survival Rate

The 5-year survival rate after sleeve resection is reported between 36-63% for stage I disease, 13-62% for stage II disease, 0-48% for stage IIIA disease, and 0-25% for stage IV disease.

For N0 disease, the 5-year survival rate is 45-71% as compared to 30-46% for N1 disease and 0-43% for N2 disease.

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N2-Stage Disease

The role of bronchovascular sleeve resection remains controversial in the N2-stage disease. The 5-year survival rate is reported between 0-43%. Schirren et al reported a higher rate of distant metastasis in advance nodal stage as compared to limited nodal stage after sleeve resections.

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Safety in the Elderly

Bronchovascular sleeve resection can be carried out safely in the elderly. Bolukbas et al reviewed 31 patients older than 70 years who underwent sleeve resection. The 5-year survival rate was 56%. Nodal status did not affect the survival. However, dynamic airway collapse was associated with higher mortality. [23]

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