INTRODUCTION

Bronchial and vascular sleeve resections have come to replace pneumonectomy in the management of central disease of the airway and pulmonary artery (PA). Sleeve resection is performed in approximately 5% of patients undergoing resection for lung cancer.¹ Although this technique was initially reserved for patients with inadequate pulmonary reserve, it is now considered the optimal technique in all patients, regardless of pulmonary status.

Bronchial sleeve resection was introduced by Price Thomas in 1947 at the Brompton Hospital in London. In this case, sleeve lobectomy was carried out for a carcinoid tumor located in the right main bronchus.² Following this, bronchial sleeve resection became the standard procedure for benign lesions of the central airway. In lung cancer patients, much of the credit for popularizing bronchial sleeve resection as an alternative to pneumonectomy has to be given to Paulson and coworkers.^3,⁴ Initial reports of postoperative morbidity and mortality prohibited routine use of sleeve resection in patients with adequate pulmonary reserve. However, the increased morbidity in patients undergoing sleeve resection reflected the decreased pulmonary reserve, which required a sleeve resection in these early reports of sleeve lobectomy.⁵

Sleeve resection may be appropriate with any lobectomy but is most frequently performed in a right upper lobectomy (Fig. 66-1). Combined bronchovascular sleeve resections are most common on the left owing to the position of the PA (Fig. 66-2). Again, the most commonly performed sleeve resection on the left is the upper lobe.

Figure 66-1 Tumor involving the right upper lobe bronchus with lines of transection demonstrate an adequate resection margin on the proximal and distal bronchus with reanastomosis.

Figure 66-2 Bronchial and vascular sleeve lobectomy specimen demonstrates the proximity of the left upper lobe bronchus and left pulmonary artery.

Bronchial and bronchovascular sleeve resections are complex, technically demanding procedures. Operative mortality ranges from 0% to 6.2%,^6,⁷ with postoperative morbidity ranging from 10% to 50%.^8,⁹ Some data demonstrate that the perioperative risks of bronchial and bronchovascular sleeve resection are comparable with those of standard lobectomy.^1,¹⁰^–¹² Although concerns have been raised over the adequacy of oncologic clearance with this technique, the literature demonstrates equivalent local recurrence and long-term survival in patients undergoing sleeve resection compared with those receiving pneumonectomy.¹³^–¹⁵ The advantages of sleeve resection have been clearly demonstrated. As the preoperative management strategy of patients with advanced lung cancer has shifted over the past two decades, additional data demonstrate that bronchial and bronchovascular sleeve resection may be performed safely after neoadjuvant therapy.¹³

Factors affecting survival include the presence of nodal disease, the type of bronchoplastic procedure, impaired lung function, and the presence of cardiovascular risk.^16,¹⁷ An additional important consideration is the postoperative quality of life in patients who undergo pneumonectomy compared with sleeve lobectomy. Pneumonectomy, “a disease,” is associated with long-term sequelae of pulmonary hypertension and respiratory failure. Also, one must not forget that patients may go on to develop a second primary tumor.

INDICATIONS

• Tumors with involvement of lobar bronchus precluding lobectomy, but not infiltrating so far as to require pneumonectomy (Fig. 66-3)

• Patients with compromised pulmonary reserve who cannot tolerate pneumonectomy

• N1 Nodal disease with involvement of lobar bronchus and/or PA

• Metastatic malignancies with lobar extension to main bronchus

• Major bronchial disruption as result of penetrating or blunt chest trauma requiring débridement and reapproximation

• Benign bronchial stricture related to trauma or inflammatory disease

Figure 66-3 Computed tomography (CT) images of a left upper lobe tumor that would suggest a potential for sleeve lobectomy.

OPERATIVE STEPS

Step 1 Bronchoscopy to evaluate extent of disease within airway by operating surgeon (Fig. 66-4)

Step 2 General anesthesia with double-lumen tube placed in bronchus opposite planned side of resection

Step 3 Lateral decubitus position

Step 4 Thoracotomy (posterolateral and anterior approaches both adequate)

Step 5 Thoracic exploration (visual and manual)

Step 6 Assess resectability prior to irreversible maneuvers

Step 7 Mediastinal lymphadenectomy

Step 8 Obtain proximal and distal control of PA, ligate and divide vein to lobe being resected

Step 9 Venous control if unable to get distal control of PA

Step 10 Circumferential dissection of main stem and distal bronchus. Place umbilical tapes to facilitate division

Step 11 Complete fissures around disease when possible

Step 12 Stay sutures on proximal and distal airway to orient anastomosis

Step 13 Harvest pericardium for vascular repair when needed

Step 14 Notify anesthesiologist when preparing for resection and clamping PA

Step 15 Heparin 30 units/kg intravenously when planning on vascular sleeve resection prior to clamping main PA

Step 16 Divide proximal airway and artery once vessels have been controlled (stay sutures) (Fig. 66-5)

Step 17 Frozen section margins (Fig. 66-6)

Step 18 Bronchial anastomosis (Fig. 66-7)

Step 19 Vascular anastomosis or patch angioplasty

Step 20 Wrap bronchial anastomosis with viable flap

Step 21 Closure

Step 22 Fiberoptic bronchoscopy

Step 23 Extubate patient in operating room

Figure 66-4 Bronchoscopic image demonstrates a right upper lobe tumor extending into the right main stem orifice.

Figure 66-5 Intraoperative photograph of the tumor in Figure 66-4 with the proximal right main stem divided and stay sutures on the proximal and distal airway.