Extended Sleeve Lobectomy Research Articles

Clinicoradiologic Predictors of Anastomotic Complications After Bronchoplasty for Lung Cancer

BackgroundWe investigated the predictive factors for anastomotic complications in sleeve lobectomy for lung cancer. MethodsBetween February 2008 and April 2023, 196 patients underwent sleeve lobectomy for lung cancer; 140 were included after exclusion of those who underwent extended sleeve lobectomy and salvage surgery after definitive chemoradiotherapy. Clinicopathologic and computed tomography (CT) findings were retrospectively investigated, and predictors of anastomotic complications were analyzed. The CT finding of azygos arch invasion was defined as a compression or stenosis of the azygos arch by the tumor. ResultsLobectomy types were right upper lobectomy in 71 patients, right lower lobectomy in 5, left upper lobectomy in 53, and left lower lobectomy in 11. CT finding of azygos arch invasion was detected in 21 cases. Anastomotic coverage was performed in 41. Bronchial anastomotic complications were observed in 11 patients (7.9%), including 9 with an anastomotic fistula and 2 with stenosis, all of which were on the right side. Only right upper sleeve lobectomy was a significant predictor of anastomotic complications (odds ratio, 5.29; 95% CI, 1.07-26.13). In 71 cases of right upper sleeve lobectomy, anastomotic complications were significantly more frequent (33.3% vs 4.0%; P < .01) and predictive of anastomotic complications when tumor invasion into the azygos arch was detected on CT (odds ratio, 12.00; 95% CI, 2.24-64.42). ConclusionsRight upper sleeve lobectomy is a predictor of anastomotic complications. Particular attention should be paid to anastomotic complications in right upper sleeve lobectomy with suspected tumor invasion of the azygos arch on CT.

Single-center clinical experience of extended sleeve lobectomy (ESL) versus standard sleeve lobectomy (SL).

Sleeve lobectomy (SL) and extended SL (ESL), which aim to preserve pulmonary function and enhance the quality of life of patients while ensuring oncological outcomes, are valuable surgical options for the treatment of centrally located non-small cell lung cancer (NSCLC). This study aimed to compare perioperative adverse events and long-term survival between SL and ESL in NSCLC patients, providing a comprehensive review of surgical outcomes, complications, and survival to assess the roles of SL and ESL in thoracic oncology. This single-center retrospective study assessed the outcomes of NSCLC patients who underwent SL or ESL from June 2014 to January 2022. The patients were selected based on specific inclusion criteria, and statistical analyses were conducted to examine the postoperative outcomes, overall survival (OS), and disease-free survival (DFS) of the patients. A total of 218 patients met the inclusion criteria. Among 218 patients, 33 underwent ESL and 185 underwent SL. Compared to SL, ESL was associated with longer operative times and higher R0 resection rates (93.9% vs. 78.8%, P=0.047). Despite the higher complexity of ESL compared to SL, there were no significant differences in the perioperative complications or mortality rates between the groups. Survival analysis was conducted on the propensity score matching (PSM) data, the results demonstrated superior OS and DFS in the ESL group compared to the SL group. Advanced age, more advanced nodal (N) status, and non-R0 resection were significant predictors of poorer prognosis. ESL is a feasible and effective alternative for treating centrally located NSCLC, with better R0 resection rates and comparable survival outcomes to SL, without increasing the risk of grade III-IV complications. Further studies with larger cohorts need to be conducted to validate these findings and refine the surgical techniques.

Extended-sleeve resection for endoluminal recurrence of B3 thymoma: does aerogenous spread really exist?

Thymomas are a variant of thymic epithelial tumours. They are considered malignant due to their tendency to local invasion and they showed lower metastatic behaviour. Distal metastasis is rare and an endobronchial mass is a rare presentation. First-line treatment for early-stage thymomas is surgery; for Masaoka-Koga stage III, neoadjuvant or adjuvant chemoradiation therapy should be considered in association with surgery after Multidisciplinary Tumour Board evaluation. We report a rare case of radical resection with type A extended-sleeve lobectomy in a 63-year-old woman who was affected by endobronchial recurrence of B3 thymoma, 31 months after complete and radical thymectomy.

V-shaped Incision of the Proximal Cartilage for High-Caliber Mismatch in Bronchoplasty

BackgroundThe problem of high-caliber mismatch in bronchoplasty is not uncommon. This report describes a technique using a V-shaped proximal cartilage incision to adjust high-caliber mismatch. MethodsAmong 255 patients who underwent tracheoplasty or bronchoplasty at a single institution (Juntendo University School of Medicine, Tokyo, Japan) between February 2008 and December 2022, 12 patients (4.7%) who underwent bronchoplasty with a proximal cartilage V-shaped incision for the adjustment of high-caliber mismatch were investigated. Bronchial anastomosis was performed using a continuous running monofilament suture at the bottom of the cartilage. Interrupted 3-0 or 4-0 monofilament sutures were used for the remaining cartilaginous tissue. Before completing the cartilaginous suture, a V-shaped incision was made in the proximal cartilage at the junction of the membranous portion. The cartilage and membranous portion of the incision were sutured using 3 interrupted sutures with 4-0 polydioxanone sutures. Finally, the membranous portion was sutured to complete the anastomosis. ResultsEleven patients were men, and the median age was 66 years. The histologic diagnoses were adenocarcinoma in 2 patients and squamous cell carcinoma in 10 patients. Three patients underwent operation after definitive chemoradiotherapy. Right sleeve pneumonectomy, right upper sleeve lobectomy, type A extended-sleeve lobectomy, and type C extended-sleeve lobectomy were performed in 7 patients, 3 patients, 1 patient, and 1 patient, respectively. No anastomotic complications were observed. The V-shaped incision group had a significantly higher frequency of right sleeve pneumonectomy than the group without the V-shaped incision (P < .01). ConclusionsCreation of a proximal cartilaginous V-shaped incision is a useful technique for adjusting high-caliber mismatch, especially in right sleeve pneumonectomy.

Surgical training in extended sleeve lobectomy with fresh-frozen human cadavers: a case report

BackgroundExtended sleeve lobectomy is a useful technique for avoiding pneumonectomy; however, it requires advanced surgical skills.Case presentationHerein, we report the case of a 67-year-old male, who presented with locally advanced lung adenocarcinoma in the left lower lobe and was scheduled to undergo extended sleeve lobectomy (left lower lobectomy + lingulectomy). In order to complete this operation safely, we practiced the procedure on fresh-frozen human cadavers 2 weeks before the surgery. The cadaveric tissue was soft, and the bronchi exhibited comparable fragility to those in the living body. During the actual surgery, the bronchoplasty procedure matched our experience with the cadaver model, and the patient’s postoperative course was uneventful.ConclusionsFresh-frozen human cadavers are useful for training surgeons in technically demanding procedures.

Long-Term Survival after Extended Sleeve Lobectomy (ESL) for Central Non-Small Cell Lung Cancer (NSCLC): A Meta-Analysis with Reconstructed Time-to-Event Data

We conducted a thorough literature search on patients with central non-small cell lung cancer (NSCLC) undergoing either extended sleeve lobectomy (ESL) or pneumonectomy (PN). We identified all original research studies that compared the long-term survival of ESL versus PN from 1990 to 2022. The primary endpoints were the median overall survival (OS) and disease-free survival (DFS). Complications, operative mortality, and the reoperation rate were the secondary endpoints. Regarding the primary endpoints, independent patient data were extracted from the included studies, and pooled Kaplan-Meier curves were constructed. A sensitivity analysis was performed using the leave-one-out method. Nine studies were included in the qualitative and seven in the quantitative synthesis, including 431 patients. Patients in the ESL group demonstrated a significantly higher OS compared with the PN group (HR, 0.63; 95% CI, 0.46-0.87; p = 0.005). In addition, patients undergoing ESL presented a significantly higher DFS compared to the PN group (HR, 0.57; 95% CI, 0.40-0.80; p = 0.004). These findings were further validated with a sensitivity analysis. The most common complications in the ESL group were bronchopleural fistula (4.6%), stricture (3.1%), prolonged air leakage (7.3%), sputum retention (4.6%), pneumonia (7.7%), and pulmonary vein thrombosis (1.5%). ESL was associated with a low reoperation rate (1.5%) and operative mortality (1.2%). The present meta-analysis indicates that ESL is associated with enhanced survival outcomes compared to PN for patients with central NSCLC. Further randomized controlled trials are necessary to validate our findings.

Are Sleeves the New Pneumonectomy?

Outcomes after sleeve resection are increasingly studied for patients with advanced non-small cell lung cancer.1 Sleeve lobectomies avoid pneumonectomy (PN) and preserve lung parenchyma. In this issue of The Annals of Thoracic Surgery, Hattori and colleagues2 evaluated 43 patients who underwent extended sleeve lobectomy (ESL) with complex reconstruction and resection of more than 1 lobe for centrally located non-small cell lung cancer. Of the 43 patients, long-term survival was relatively good. The 3-year overall survival was 62.8% with 3-year recurrence-free survival of 43.5%.

Surgical Outcome After Extended Sleeve Lobectomy in Centrally Located Non-small Cell Lung Cancer

BackgroundWe primarily aimed to evaluate the operative techniques, clinicopathologic characteristics, and surgical outcomes after extended sleeve lobectomy (ESL). Additionally, we evaluated the feasibility of ESL for centrally located non-small cell lung cancer (NSCLC) compared with pneumonectomy (PN). MethodsA retrospective review identified 119 patients who underwent pulmonary resections for centrally located NSCLC; of whom, 43 underwent ESLs and 76 underwent PNs. Perioperative morbidity and oncologic outcomes of ESL were analyzed. Postoperative morbidity was evaluated according to the Common Terminology Criteria for Adverse Events version 5.0. Overall survival was evaluated using a Cox proportional hazard model. ResultsAccording to the classifications of ESL, 10 patients comprised type A, 8 (19%) type B, 16 (37%) type C, and 9 (21%) type D. Pulmonary artery reconstructions were performed in 5 of type A, 8 of type B, 1 of type C, and 1 of type D, and pulmonary vein reconstructions occurred in 3 of type A and 2 of type C. After ESL, 30-day hospital mortality occurred in 1 patient (2.3%), and grade ≥3 morbidities occurred in 13 patients (30%). In particular, bronchial anastomosis/stump fistula was seen in 4 patients (9.3%) after ESL, and blood perfusion disorders due to the presence of thrombi were seen in 4 (9.3%). The 3-year overall survival was significantly better after ESL compared with that after PN (62.8% vs 45.2%, P = .047). ConclusionsESLs to preserve lung parenchyma will likely become a promising operative strategy in appropriately selected patients with centrally located NSCLC.

Extended Sleeve Lobectomy is an Alternative for Centrally Located Lung Cancer With Superior Short- and Long-term Outcomes

IntroductionExtended sleeve lobectomy (ESL) is a feasible alternative to pneumonectomy; however, the survival benefit is unclear, and preoperative selection of potential candidates for ESL remains a problem. Matierals and MethodsESL was performed on selected candidates with double sleeve lobectomy for more than 1 lobe (eg, left upper lobe and S6 segment resection). Three-dimensional (3-D) reconstruction was routinely validated. Patients were candidates for ESL if the predicted distal stump length was > 6 mm and the pulmonary vein of the remaining segments was not invaded. ResultsOf the 1809 patients with centrally located lung cancer for surgical resection, 86 patients with tumors invading more than 1 lobe were enrolled in the study. After evaluation by 3-D reconstruction, 22 (95.7%) of 23 selected candidates underwent ESL, and 63 patients were deemed unsuitable for ESL and underwent pneumonectomy (43 cases) or thoracic exploration (20 cases). Surgical outcomes between the ESL and pneumonectomy groups were similar in terms of complications, blood loss and surgical duration, but the 6-minute walking distance was significantly improved in the ESL group (371 ± 111 m vs. 191 ± 55 m, respectively; P < .001). The mean forced expiratory volume in 1 second was 1.6 ± 0.3 L at the 1-year follow up examination in the ESL group. In the survival analysis, no difference was observed between the ESL and pneumonectomy groups in terms of 3-year overall survival (85% vs. 89%, respectively; P = .626) and 3-year disease-free survival (75% vs. 76%, respectively; P = .625). ConclusionsESL is a feasible and superior surgical procedure in terms of its short-term and long-term outcomes, and we suggest 3-D reconstruction to identify candidates for ESL.

Extended sleeve-lobectomy for centrally located locally advanced non-small cell lung cancer is a feasible approach to avoid pneumonectomy.

BackgroundsThe aim of this study was to report our Institutional experience with extended sleeve lobectomy (ESL) in centrally located non-small cell lung cancer (NSCLC), focusing on technical details, post-operative results, recurrence and survival, to determine whether ESL can be accepted as a favorable alternative procedure to pneumonectomy (PN).MethodsTwenty-two consecutive patients undergoing ESL for centrally located tumors from January 2014 to June 2019 were prospectively enrolled.ResultsSix (27.3%) patients had been preoperatively considered unfit for PN. Neo-adjuvant chemotherapy was administered in 7 (31.8%) out of the 10 patients that showed a cN2 disease. According to Okada classification, 8 cases of type A ESL (resection of right upper plus middle lobe ± segment 6), one case of type B (resection of left upper lobe + segment 6) and 13 cases of type C (resection of left lower lobe + lingulectomy) ESL were performed. Concomitant pulmonary angioplasty was done in 7 (31.8%) patients. Complete resection was achieved in all patients. There was no postoperative mortality. Major postoperative complications developed in 2 (9.1%) patients (one small anastomotic dehiscence healed in few weeks, one pulmonary embolism). Complete long-term patency of the reconstructed airway was documented in all patients by fiber-optic bronchoscopy. At the median follow-up of 21 months (4–57 months), the recurrence rate was 54.5%, with 4 (18.2%) patients developing a loco-regional recurrence but no endobronchial or perianastomotic recurrence occurred. The overall 3-year survival rate was 45% with a median survival of 33 months.ConclusionsESL is a safe and effective procedure that should be considered a favorable alternative to PN whenever it may guarantee a complete resection.

Wine cup stoma anastomosis after extended sleeve lobectomy for central-type squamous cell lung cancer

BackgroundExtended sleeve lobectomy is rarely applied to pulmonary surgery for primary lung cancer to avoid a pneumonectomy. As there is a size discrepancy between main bronchus and peripheral bronchus, ingenuity to improve anastomosis is required in the bronchoplasty. We report herein a case in which successful reconstruction of extended sleeve lobectomy with bronchial wall flap.Case presentationWe report on a 64-year-old man suffering from hemoptysis, cough, mild fever and dyspnea. His computed tomography (CT) scan showed solid tumor of 40 mm in diameter in left lower bronchus, which obstructed the lower bronchus and caused obstructive pneumonia of left lower lobe and expanded to second carina and pulmonary artery. His bronchoscopy showed that tumor was exposed in the bronchial lumen and infiltrated to left main bronchus and upper bronchus even though the scope could pass through the exposed tumor of upper bronchus. Transbronchial lung biopsy showed squamous cell carcinoma. He had undergone left sleeve lingular segmentectomy and left lower lobectomy. Reconstruction was performed with bronchial wall flap. Pathological findings revealed pT3N0M0 stage IIB according to UICC 8th edition. Postoperative bronchoscopic findings showed no troubles at the anastomotic site. He has been well for eighteen months without recurrence after surgery.ConclusionsWe experienced a successful case who was reconstructed with bronchial wall flap (wine cup stoma) after extended sleeve lobectomy. This technique might be also useful for other types of extended sleeve lobectomy and lung transplantation to adjust caliber changes of bronchi.

Late-onset Bronchopleural Fistula at the Distal Side of the Bronchial Anastomosis After an Extended Sleeve Lobectomy

Late-onset Bronchopleural Fistula at the Distal Side of the Bronchial Anastomosis After an Extended Sleeve Lobectomy

Extended right upper sleeve lobectomy with double-barrel segmental bronchoplasty.

Extended sleeve lobectomy (ESL), which is defined as the atypical sleeve resection of more than one lobe, has been widely accepted to preserve the pulmonary function (1-3). Double-barrel anastomosis has been reported as a method of bronchial reconstruction after carinal resection; however, it is rarely applied in the reconstruction of segmental bronchi. We herein report a case in which ESL with double-barrel anastomosis of the middle lobar bronchus (MLB) and basilar bronchus (BB) was successfully applied in the treatment of a patient with centrally located lung adenocarcinoma.

Surgical procedure of extended right upper sleeve lobectomy with double-barrel anastomosis of the middle lobar bronchus and basilar bronchus

Surgical procedure of extended right upper sleeve lobectomy with double-barrel anastomosis of the middle lobar bronchus and basilar bronchus

Extended sleeve lobectomy for centrally located non-small-cell lung cancer: a 20-year single-centre experience.

Extended sleeve lobectomy (ESL), an atypical bronchoplasty with resection of more than 1 lobe, might be technically demanding but has certain theoretical advantages, including the avoidance of pneumonectomy. However, clinical outcomes after ESL are not well known. Between March 1995 and December 2015, 540 patients with centrally located non-small-cell lung cancer underwent sleeve resection. Among them, 63 patients underwent an ESL procedure. We retrospectively analysed those patients in terms of hospital mortality, postoperative complications and local recurrence and compared clinical outcomes with patients who underwent simple sleeve lobectomy in the same period. The 63 patients were classified into 4 groups: anastomosis between the right main and lower bronchi (n = 14), anastomosis between the right main and upper bronchi (n = 37), anastomosis between the left main and basal segmental bronchi (n = 4) and anastomosis between the left main and upper divisional bronchi (n = 8). No operative deaths occurred within 30 days, but there were 2 in-hospital deaths from postoperative acute lung injury. Ten (16%) patients had anastomosis-related complications including 3 strictures, 5 bronchopleural fistulas and 2 pulmonary vein thromboses. There were no significant differences in in-hospital mortality (3% vs 3%, P = 0.67), anastomosis-related complications (16% vs 9%, P = 0.07) and loco-regional recurrence rate (8% vs 10%, P = 0.63) between ESL and simple sleeve lobectomy. According to our findings, ESL is a safe and feasible procedure that does not compromise oncological principles. It can be considered an appropriate alternative to pneumonectomy and should be considered in patients with centrally located tumours.

Surgical treatment of air way disease.

Airway lesions are treated by resecting and subsequent reconstructive surgery. Tracheoplasty and bronchoplasty are applied to inflammatory stenosis, damage due to trauma, and primary tumors of the airways. The indications for lobar (bronchial) sleeve resection are commonly applied to lung cancers that develop at the proximal portion of the lobar bronchus. Recently, extended sleeve lobectomy (ESL) is widely indicated among the routine techniques used to avoid pneumonectomy because of its reliability and effectiveness. In some cases the cancer is limited to the segmental bronchi, segmental sleeve resection is sometimes performed. In the field of respiratory surgery, carinal resection-reconstruction is one of the most rare procedures and challenging issues, involving difficult surgical techniques, anesthetic techniques, and postoperative management. Tracheal surgery was generalized so that it could be applied to any type of tracheal disease that required resection, including tumors.

Extended sleeve lobectomy after induction chemoradiotherapy for non-small cell lung cancer.

Extended sleeve lobectomy is a challenging surgery. While induction chemoradiotherapy (ChRT) followed by surgery is one of the therapeutic strategies used for locally advanced non-small cell lung cancer (NSCLC), ChRT can impair the anastomotic healing potential. We herein present our experience with cases who underwent an extended sleeve lobectomy after induction ChRT. The medical records of patients who underwent a surgery for NSCLC after ChRT were reviewed. Between December 2007 and January 2013, nine patients underwent an extended sleeve lobectomy; the left lingular division and lower lobe in four patients, the right upper lobe and trachea in one patient, the carina and trachea in one patient, the right middle and lower lobes in one patient, the right upper and middle lobes and carina in one patient and the right upper lobe and superior segment of the lower lobe in one patient. While no postoperative 90-day deaths occurred, one case developed a bronchopleural fistula on postoperative day (POD) 25 and one case developed a bronchovascular fistula on POD 163. No cases of local recurrence developed. Our experience suggests that an extended sleeve lobectomy after induction ChRT is feasible, but careful patient selection and perioperative management are mandatory.

Extended Sleeve Lobectomy: One More Step Toward Avoiding Pneumonectomy in Centrally Located Lung Cancer

The purpose of this study was to evaluate surgical outcomes of extended sleeve lobectomy (ESL)incentrally located non-small-cell lung cancer (NSCLC),sparing lung tissue and aggressively avoiding pneumonectomy. Patients who underwent ESL between January 2006 and January 2013 were included prospectively. An atypical bronchial anastomosis was used for sleeve lobectomy involving additional lobes or segments. We included 27 patients, aged 62.7 ± 8.2 years (range, 49-83 years), with a forced expiratory volume in 1second (FEV1) of 2.27 ± 0.6 (range, 1.6-2.7). According to the Okada classification, 16 cases were type A (right upper lobe+ middle lobe ± segment 6), 7 cases were type B (left upper lobe+ segment 6), and 2 cases were type C (left lower lobe+ segments 4-5); we additionally classified 2 patients with right lower lobe tumors involving the right main bronchus as type D (right lower lobe+ middle lobe). Anastomosis was performed between the right superior and right main bronchial stumps. Eleven patients underwent combined pulmonary angioplasties. Complete resection was achieved in all cases. There were no operative deaths. Mean segment reimplantation was 4.5 ± 0.84 (range, 3-6), resulting in a mean FEV1 improvement of 0.620 ± 0.16 (right-sided ESL) and 0.393 ± 0.21 (left-sided ESL). The complication rate was 25% (no immediate anastomosis-related complications; 1 case of delayed bronchial stenosis). No local recurrence was reported. At 6 months, mean FEV1 was 1.5 ± 0.4 (right-sided ESL) and 1.4 ± 0.3 (left-sided ESL). Mean follow-up time was 28 ± 19 months (range, 7-72 months). Overall 5-year survival was 62%. In patients with centrally located NSCLC, lung-sparing ESL, whose safety and reliability rival that of pneumonectomy, should be considered. Functional effectiveness is higher with right-sided than with left-sided ESL.

Reply to Baisi et al

We thank Dr Baisi and colleagues for their interest and kind comments. The authors fully endorse all the assessments made by Dr Baisi and colleagues [1]. We consider the lung sparing techniques (regular or extended sleeve lobectomy) [2] as the only way to obtain an increase in survival after neoadjuvant therapy in central tumours owing to their ability to reduce complications and mortality. It is worthwhile, beyond doubt, to use any surgical technique that spares the parenchyma and avoids the complications related to peumonectomy. With regard to the preoperative radiotherapy doses, our protocol currently includes only concurrent chemoradiotherapy (60 Gy) for mediastinal sterilization. However, we do not prohibit the performance of this surgery in second opinion patients coming from other units, with lower radiation doses or even after the classical timing window (8 weeks) [3]. In clinical practice, we restage the mediastinium after chemoradiotherapy by noninvasive methods (chest CT scan or positron emission tomography–CT) and selectively using other invasive techniques (endobronchial ultrasound, endoscopic ultrasound-guided fine-needle aspiration or mediastinoscopy). We pay great attention to ruling out distant metastases after induction, expending as much time and resources as necessary, because, in our opinion, the induction therapy also ‘naturally’ selects patients who have an extremely poor prognosis (e.g. occult distant metastases or progression despite treatment). Among the reasons for this protocol, we have found that the oncologist requests surgical treatment if there is a tumour response in the absence of prohibitive risk (even with one positive station); a low surgical mortality rate is achieved in experienced institutions after chemoradiotherapy (<3%); and there is a reasonably good quality of life after surgery [4] following pulmonary resection rather than pneumonectomy.

Extended sleeve lobectomy for interlobar lymph node metastasis invading the bronchus from peripheral lung cancer

Although extended sleeve lobectomy has been used as an alternative to pneumonectomy for the treatment of centrally located lung cancer, the validity of this surgical procedure is unclear in patients with peripheral lung cancer with interlobar lymph node metastasis invading the bronchus. We herein report four patients with peripheral lung cancer in the left lower lobe who underwent extended sleeve lobectomy consequent to interlobar lymph node metastasis. The tumor and metastasized lymph node was extirpated en bloc with division of the main bronchus and upper division bronchus, and those bronchi were anastomosed using the telescope method. All patients were doing well without recurrence. Extended sleeve lobectomy may be applicable to patients with peripheral lung cancer with interlobar lymph node metastasis invading the bronchus to avoid pneumonectomy.