Bronchovascular Sleeve Resection Technique

Updated: Oct 31, 2019
  • Author: Setu K Patolia, MD, MPH; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
  • Print
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 the 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. [8] It is typically performed when the tumor is invading the pulmonary artery, such as 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 a good stump for anastomosis, the PA is clamped at the site of origin with a Satinsky clamp.

Alternatively, small clamps such as 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 taken to preserve the 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 tumor excision, 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. [9] Similar findings were reported by Kutlu et al in 100 cases of tracheobronchial sleeve resections. [10]

Sutures are placed extramucosally on the cartilaginous portion to avoid bulging in the 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 airway pressure of 25-30 cm H2O 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 an intercostal muscle, pleural, or pericardial flap.

Higuchi et al report a case report in which successful reconstruction of extended sleeve lobectomy was accomplished with a bronchial wall flap (wine cup stoma). [11]

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 a 28-30F 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.

Next:

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.

Previous
Next:

Complications

Early complications

Atelectasis and pneumonia are the most common postoperative complications, occurring in 5-10% of cases. [12, 13] These complications can be avoided by adequate postoperative analgesia and chest physiotherapy. The incidence is increased with prolonged postoperative mechanical ventilation because that increases the incidence of aspiration. Treatment involves bronchoscopy, chest physiotherapy, and antibiotics.

Persistent air leak and anastomotic dehiscence occur in 1-7% of cases. [14, 15] 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. [12, 14, 16] It carries a high mortality, in the range of 14-70%. [17, 18] 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. [17, 18] Radiographic findings include either increasing air fluid level or increasing 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 the fistula. If the fistula is small, conservative management with antibiotics and complete drainage can be attempted. If the fistula fails to close after 3 months or is large, repair can be tried. If repair is impossible, however, complete pneumonectomy is required.

Hemothorax most commonly results from inadequate hemostasis of systemic vessels, rather than pulmonary vessels. It manifests as an enlarging pleural effusion on radiograph. The PA may not bleed intraoperatively, but postoperatively, with the inflation of the lung and stretching of the pericardium, the suture line may separate and bleeding from the suture site may occur. This complication is seen in 1-2 days postoperatively.

Empyema can occur immediately in the postoperative period but can also develop months to years later. It requires treatment with drainage and antibiotics.

Bronchovascular fistula results from anastomotic breakdown. The incidence is 0.9-7%. [19, 20, 21, 22] Usually, patients have a 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. Those can be avoided by adequate heparinization intraoperatively and anticoagulation postoperatively.

Pulmonary edema is less common than pneumonectomy. It can be caused by excessive fluid administration during surgery, but may 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

Bronchial stenosis results from ischemia of the bronchial anastomosis and granulation tissue. The incidence rate varies from 2.5-18%. [23, 24, 25] The patient may be asymptomatic or may present with recurrent infection, shortness of breath, or atelectasis. This complication can be avoided by careful maintenance of bronchial blood supply and use of resorbable suture material. Treatment involves balloon and bougie dilatation of the anastomosis. Stenting of the bronchial anastomosis is challenging 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. [26] 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 rates have been reported as 9-24%. The local recurrence rate is higher with advanced nodal stage and incomplete resection.

Previous
Next:

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. [27] 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 versus 30.4% for the pneumonectomy group (P = 0.16). Freedom from local recurrence of disease at 5 years was 84.2% in the bronchovascular sleeve resection group and 88.7% in the pneumonectomy group (P = 0.56). [28]

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 and 11% in stage III disease. In addition, patients with N0 disease had 5-year survival rates of 71% as compared with 9% in N2-3 disease. [29]

Takeda et al reported a mortality rate of 4.8% with sleeve lobectomy, versus 3.6% with pneumonectomy. [30] 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 the sleeve lobectomy group than in the pneumonectomy group. This difference did not reach statistical significance. [13] However, a study by Rendina et al of patients who underwent surgery after induction chemotherapy found a 4-year survival rate of 39% in sleeve lobectomy patients and 36% in pneumonectomy patients. [31]

Previous
Next:

Five-Year Survival Rate

The 5-year survival rates after sleeve resection, by disease stage, are reported as follows:

  • Stage I: 36-63%
  • Stage II: 13-62%
  • Stage IIIA: 0-48%
  • Stage IV: 0-25%

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

Previous
Next:

N2-Stage Disease

The role of bronchovascular sleeve resection in patients with N2-stage disease remains controversial. Reported 5-year survival rates range from 0-43%. Schirren et al reported a higher rate of distant metastasis in advanced nodal stage as compared with limited nodal stage after sleeve resections.

Previous
Next:

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. [32]

Previous