Preservation Of Lung Parenchyma Research Articles

Sleeve Pulmonary Artery Resection and Sleeve Lobectomy in the Treatment of Non-small Cell Lung Cancer: Report of Two Cases

Central-located non-small cell lung cancer may involve not only the bronchus but also the pulmonary artery. Sleeve lobectomy is a widely used surgical technique for preserving lung parenchyma. However, sleeve lobectomy combined with sleeve pulmonary artery resection to preserve the distal lung is not common. We report two patients who underwent sleeve lobectomy of the left upper lobe and sleeve resection of the pulmonary artery to treat non-small cell lung cancer of the upper lobe of the left lung. We used small atraumatic vascular clamps to control blood flow through the pulmonary and interlobar arteries. No heparin was used during or after operation. Both patients recovered well and were tumor-free 28-months and 6-months respectively after surgery.

Postoperative perforation in the bronchus intermedius: completion sleeve bilobectomy is an option

We read with great interest the case report of postoperative perforation in the bronchus intermedius membrane after a primary lung cancer resection reported by Hirami et al. [1]. In a similar situation we reported [2] a case with postoperative non-stump bronchopleural fistula due to necrosis of large area of the membranous part of the bronchus intermedius up to the opening of the right upper lobe. A completion lower sleeve bilobectomy was performed; we removed the middle lobe, all of the bronchus intermedius and part of the right main bronchus; followed by anastomosis of the upper lobe bronchus to the right main bronchus. The patient passed an uneventful postoperative course and is still doing well 10 months after surgery. We did the same technique in another patient but he died 1 month after the second operation due to sepsis and multi-organ failure. The residual lobe expanded and the anastomosis was intact up to the time of death. We agree with the authors that ischemia is the main predisposing factor for fistulization; the subcarinal area is traversed by feeding bronchial arteries and dissection in this area must be performed as carefully as possible to preserve some of these nutrient vessels [3]. Excessive use of cautery may exaggerate ischemia (rather than causing fistula by direct injury) with subsequent development of fistula. We prefer division of the vessel with scissors between liga clips whenever possible. Middle lobectomy with the creation of new bronchial stump at a more proximal healthy bronchus and coverage of the new stump with viable flap as reported by the authors in two patients should be the first option. On the contrary, completion pneumonectomy should be the last choice. In one report [4] the mortality rate of completion pneumonectomy, employed for an early complication of a primary operation, reported to be 37.5% and the mortality rate after right side procedure was significantly higher than the left side. Sleeve bilobectomy has the advantage of preserving lung parenchyma that can fill the pleural space and may be a source of retrograde blood supply to the new suture or anastomosis line. Needless to say that decortication of the residual lobe and debridement and cleaning of the pleural space are essential for the success of the procedure. Finally, we agree with the authors that early endoscopic diagnosis and surgical intervention before the development of empyema and systemic sepsis is crucial for good results. Also, we recommend that every effort should be made to avoid completion pneumonectomy; in difficult situations sleeve bilobectomycanbeaviableoptioninthemanagement of this complication.

Extending Indications for Radiofrequency Ablation of Lung Tumors Through an Intraoperative Approach

Radiofrequency ablation (RFA) is a means of local destruction of lung tumors. The role of this technique in regards to improved survival or quality of life has yet to be well defined. RFA can be performed through an intraoperative or percutaneous route. Percutaneous RFA can be performed without single-lung ventilation under local anesthesia with sedation and is often the preferred route of ablation. We detail instances of RFA in patients who were either not candidates for percutaneous RFA or in whom the tumor was found to be unresectable at operation. Ten patients with either primary or secondary lung tumors who underwent operation with consideration of intraoperative RFA were reviewed. Patients were followed up with chest computed tomography scans at least every 6 months. Preoperative characteristics, intraoperative techniques, complications, and tumor response were noted. The median patient age was 60 years (range, 40 to 85 years). Six patients had lung cancer, 4 had cancer metastatic to the lung, and 5 patients had hilar lesions. Combined lung resection and RFA was done in 4 patients; 6 underwent RFA only. The average size of the ablated lesion was 3.0 cm (range, 1.0 to 5.8 cm). No serious intraoperative or perioperative complications were noted. No immediate or delayed hemorrhage or hemoptysis has been noted. Of patients at least 6 months out from ablation, 4 had no growth of the ablated tumor at an average of 13.5 months (range, 8 to 23 months) after ablation, and 5 have had growth of the tumor first noted at an average of 12.8 months (range, 9 to 14) after ablation. Intraoperative RFA is useful (1) when the lesion is near vital structures such as the great vessels, hilum, or heart, (2) if resectability can only be determined at the time of operation, and (3) when used in patients with secondary tumors of the lung combined with limited resection to preserve lung parenchyma.

M07-02: Pneumonectomy Versus Sleeve Resection

The indication for a sleeve resection for lung cancer is well established: a tumor arising at the origin of a lobar bronchus but not infiltrating as far as to require pneumonectomy. In addition, a sleeve resection may be indicated when N1 nodes infiltrate the bronchus from the outside, as is often the case in the left upper lobe tumors requiring a combined reconstruction of the bronchus and the pulmonary artery. From a functional point of view, sleeve lobectomy is strictly indicated in patients who cannot withstand pneumonectomy, but recent experiences have shown that the advantages of sparing lung parenchyma are evident also in patients without cardio-pulmonary impairment. Oncologically, the primary goal is in every case the complete resection of the tumor with free resection margins. When analyzing survival data reported in literature in the last 15 years, most of the studies show similar or better results for parenchymal sparing resections if compared with pneumonectomy. Moreover, in the analysis of 5-year survival according to stage (Table-1) and nodal status, sleeve lobectomy results in higher survival rates for stages I, II and III, although the survival advantage in stage III appears to be limited. In a recent report (Ludwig’05), sleeve lobectomy results a statistically significant favourable prognostic factor for long-term survival with a survival advantage in patients with N0, N1 and N2 disease. However, this prognostic advantage for stage III-N2 patients is not always confirmed, and there are other studies reporting a more evident adverse effect on survival for patients with N2 involvement who have undergone sleeve lobectomy. Therefore the role of parenchymal sparing operations in patients with N2 disease still remains not completely defined (Fadel’02).Table 1Author (year)Stage I patientsStage II patientsStage III patientsStage I 5-yr survival (%)Stage II 5-yr survival (%)Stage III 5-yr survival (%)Sleeve LobectomyVan Schil (‘91)6157−5921−Gaissert (‘96)293112425343Icard (‘99)325716603027Tronc (‘00)83732663488Fadel (‘02)544736556221Mezzetti (‘02)34321761399Terzi (‘02)485250603222Deslauriers (‘04)837229665019Kim (‘05)14181588528Ludwig (‘05)314144574022PneumonectomyGaissert (‘96)92521−43−Mizushima (‘97)81584584213Deslauririers (‘04)164361471503422Kim (‘05)281110753638Ludwig (‘05)3152111454213 Open table in a new tab These results justify the increasing use of parenchymal sparing procedures for lung cancer also in patients with good cardio-pulmonary function, as observed in the last years. Postoperative morbidity and mortality data reveal overall better results for patients undergoing sleeve lobectomy with respect to pneumonectomy (Table-2). Looking at literature data, when morbidity is evaluated according to the type of complication, pneumonectomy patients appear to experience a higher rate of cardiac complications, while sleeve lobectomy patients show increased pulmonary and airway complications incidence.Table 2Author (year)Complications (%)Postoperative mortality (%)Local recurrence (%)Distant recurrence (%)Sleeve LobectomyGaissert (‘96)11414−Icard (‘99)442.81724Okada (‘00)138−Tronc (‘00)161.62211Fadel (‘02)162.91511Mezzetti (‘02)10.83.620−Terzi (‘02)14.512518Kim (‘05)74.96.12222Ludwig (‘05)384.3−−PneumonectomyGaissert (‘96)169−−Okada (‘99)22210−Deslauriers (‘04)−5.335−Kim (‘05)444.1620Ludwig (‘05)264.6−− Open table in a new tab The incidence of microscopic infiltration of the bronchial margins has strong significance when analyzing the anastomotic complication and local recurrence rate. Authors (Kim’05) who have observed a significantly higher incidence of anastomotic leak in their sleeve lobectomy series, report an increased rate of positive margins on frozen section. In our experience (since 1989) of 192 bronchial sleeve resections and 100 resections and reconstructions of the pulmonary artery no increased overall and pulmonary morbidity and mortality rate has been observed. The preservation of lung parenchyma has been indicated by some authors as the possible cause of a theoretical increased risk for loco-regional recurrence after sleeve lobectomy. However, although in some experiences (Fadel’02) a higher local recurrence rate is reported for sleeve resection with advancing nodal status (N2), the few studies (Fadel’02,Terzi’02,Kim’05) analyzing risk factors for recurrence, show that the tumor stage and the nodal status are the only negative predictive factors, rather than the type of operation performed. Postoperative quality of life has been advocated as one of the strongest indicators that should influence the decision to perform a sleeve lobectomy rather than a pneumonectomy. A number of studies indicate that lung parenchyma sparing improves postoperative quality of life determining a greater cardio-pulmonary reserve, less pulmonary edema and less right ventricular dysfunction due to a lower pulmonary vascular resistance (Terzi’02,Martin-Ucar’02). Special concern has been expressed by many thoracic surgeons when considering broncho-vascular reconstructive procedures after induction therapy, due to the significantly higher risk of perioperative complications and mortality. Although only a few authors (Rendina’97,Ohta’03,Stamatis’02) use sleeve resection routinely after neoadjuvant therapy, it has been proven in our experience (2,3), that also complex parenchymal sparing operations can be performed after oncological treatment without increased morbidity and mortality rates observing long-term results comparable to those of the standard procedures (5-year survival: 31%; local recurrence rate:15%).

Video-assisted resection of bilateral intralobar pulmonary sequestrations

Bronchopulmonary sequestrations (BPSs) are characterized by anomalous vascular and tracheobronchial connections and account for a small proportion of pulmonary malformations. Bilateral BPSs are extremely rare, and the traditional surgical approach has been sequential resections with staged thoracotomies. We report a single-stage, sequential, video-assisted thoracoscopic surgery (VATS) approach to bilateral intralobar pulmonary sequestrations (ILSs). An otherwise healthy 7-year-old girl was referred with low-grade fevers, productive cough, and a right lower lobe infiltrate on standard chest radiographs. She was given 2 courses of antibiotics, with only partial resolution of her right lung infiltrate. Subsequent high-resolution computed tomographic imaging demonstrated bilateral lower lobe BPS (Figure 1, A). Arterial supply to both sides was from the abdominal aorta (Figure 1, B). In the operating room, after achievement of general anesthesia with a single-lumen endotracheal tube and bronchial blocker, the patient was initially placed in the left lateral decubitus position. The lung was carefully inspected with a 5-mm, 30° thoracoscope through a 5-mm anterior ninth interspace thoracoport. A 5-cm access incision was made in the fifth interspace anteriorly, sparing the serratus anterior muscle. Visualization was improved by placing a figure-of-eight stitch in the tendinous portion of the diaphragm and drawing it down through the same ninth interspace thoracoport. A consolidated intralobar sequestration was noted in the posterior and lateral basilar segments of the right lower lobe, with the aberrant arterial supply located in the inferior pulmonary ligament. The arterial supply was dissected and divided with a vascular TA-30 stapler. A sequestrectomy was performed with multiple applications of an Endo GIA 3.5-mm linear stapler (Figure 2). A 20F chest tube was placed, the lung was inflated under direct vision, and the incisions were closed in layers. The patient was then turned to the right lateral decubitus position, access to the left pleural space was obtained through a 5-mm ninth interspace thoracoport, and a 5-cm access incision was made in the fifth interspace anteriorly. The lung was inspected, and a similar intralobar sequestration was observed in the posterior basilar segment of the left lower lobe. The aberrant arterial source in the inferior pulmonary ligament was isolated and divided, and sequestrectomy was performed in similar fashion. A single left chest tube was placed, and the patient was transferred to the pediatric intensive care unit. Both chest tubes were removed on the second postoperative day, and the patient was discharged to home on the fourth postoperative day. Final pathology showed bilateral intralobar sequestrations with severe inflammation. ILSs are characterized by nonfunctioning lung tissue that lacks normal communication with the tracheobronchial tree. The arterial supply to ILSs is most often from the abdominal aorta, and venous drainage is usually through normal routes to the left atrium. Although children with BPSs are at risk for associated abnormalities, they occur less with intralobar than with extralobar sequestrations. To date, there have been 12 reported cases of bilateral BPS in the literature, with only 5 intralobar cases.1Spinella P.C. Strieper M.J. Callahan C.W. Congestive heart failure in a neonate secondary to bilateral intralobar and extralobar pulmonary sequestrations.Pediatrics. 1998; 101: 120-124Crossref PubMed Scopus (10) Google Scholar All operative cases were approached with staged sequential thoracotomies.1Spinella P.C. Strieper M.J. Callahan C.W. Congestive heart failure in a neonate secondary to bilateral intralobar and extralobar pulmonary sequestrations.Pediatrics. 1998; 101: 120-124Crossref PubMed Scopus (10) Google Scholar More recently, surgical resection of BPSs has been accomplished with a VATS approach.2Wan I.Y. Lee T.W. Sihoe A.D. Ng C.S. Yim A.P. Video-assisted thoracic surgery lobectomy for pulmonary sequestration.Ann Thorac Surg. 2002; 73: 639-640Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 3Sakuma T. Sugita M. Sagawa M. Ishigaki M. Toga H. Video assisted thoracoscopic wedge resection for pulmonary sequestration.Ann Thorac Surg. 2004; 78: 1844-1845Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 4Klena J.W. Danek S.J. Bostwick T.K. Romero M. Johnson J.A. Video-assisted thoracoscopic resection for intralobar pulmonary sequestration single modality treatment with video-assisted thoracic surgery.J Thorac Cardiovasc Surg. 2003; 126: 857-859Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Lobectomy, sequestrectomy, and wedge resections have all been described, with excellent results and a small number of conversions to thoracotomy.5de Lagausie P. Bonnard A. Berrebi D. Petit P. Dorgeret S. Guys J.M. Video-assisted thoracoscopic surgery for pulmonary sequestration in children.Ann Thorac Surg. 2005; 80: 1266-1269Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Because disease in this patient was limited to the basilar segments of the lower lobes, it was possible to perform sequestrectomies and preserve lung parenchyma. This unique case of bilateral ILS demonstrates the feasibility of a single-setting, sequential VATS approach to minimize postoperative pain and limit multiple or prolonged hospitalizations.

Personal experience in lung cancer sleeve lobectomy and sleeve pneumonectomy

Background. Sleeve lobectomy (SL) and tracheal sleeve pneumonectomy (TSP) represent valuable alternative techniques to standard resections in the treatment of benign and malignant conditions of the airway and allow preservation of lung parenchyma. Methods. Eighty-three sleeve lobectomies and 27 tracheal sleeve pneumonectomies have been performed for nonsmall cell lung cancer in the thoracic department of the University of Milan from 1979 to 1999. There were 46 upper right lobectomies, 11 upper and middle lobectomies, 18 upper left lobectomies, 8 lower left lobectomies, and 27 right pneumonectomies. Results. Mortality rate was 3.6% in SL and 7.4% in TSP. Complications were 10.8% of all SLs and 15% of all TSPs. The overall 5-year survival rate was 43% for SL and 20% for TSP; the 10-year survival rate was 34% and 14%, respectively. There was a highly significant difference in survival between patients with N0 and N1-N2 disease. Conclusions. Sleeve lobectomy is an appropriate surgical procedure and an alternative to pneumonectomy in patients with limited respiratory reserve whenever the situation permits. Trachael sleeve pneumonectomy is associated with more complications and poor survival.

Surgical treatment of pulmonary hydatid cysts in children

Objective: Hydatid disease is a parasitosis and endemic in many sheepraising areas; it is still an important health problem in Turkey. We report our experience with childhood hydatid cyst and discuss the concepts of treatment. Methods: The clinical courses of 128 children with thoracic and liver hydatid cyst operated on from 1994 to 2000 were reviewed. The group consisted of 71 boys and 57 girls aged from 8 months to 16 years. Intact cysts were found in 144 patients and ruptured cysts in 68. Results: In the postoperative course we have encountered 20 perioperative complications in 16 patients. The most common complication was residual pleural space and delayed air leakage, which occurred in 9 patients. There was no early death. Conclusion: Surgery is the treatment of choice for most patients with pulmonary hydatid disease. The aim of surgery is evacuation of the cyst, removal of the endocyst, and management of the residual cavity. Conservative surgical methods that preserve lung parenchyma should be preferred. (J Thorac Cardiovasc Surg 2000;120:1097-101)

Identification of prognostic factors determining risk groups for lung resection

Background. Pulmonary resection belongs to a group of surgical procedures with significant morbidity and mortality. The aims of this study were to classify postoperative complications and to identify prognostic factors determining risk group. Methods. In a prospective study 500 patients undergoing lung resection (wedge resection, n = 141; lobectomies, n = 245; bilobectomies, n = 12; and pneumonectomies, n = 102) were included. In 178 patients (36%) pulmonary resections were extended to structures or thoracic organs. Sleeve resection of the bronchus to preserve lung parenchyma was performed in 22 patients. Results. Classification of postoperative complications fell into four categories: patients without postoperative complications; patients with moderate complications (n = 137); patients with severe complications (n = 38); and death (n = 33). Factors adversely affecting postoperative complications by multivariate analysis included pulmonary pathology, bronchoplastic technique, forced expiratory volume in 1 second (FEV 1), extended resection, type of lung resection, comorbidity indices, and preoperative chemotherapy. Four risk groups were determined. Risk group I (n = 60) with the best prognosis included patients with FEV 1 greater than or equal to 80% undergoing wedge resection for a benign lesion or metastasis. Risk group II (n = 161) included patients with FEV 1 greater than or equal to 80% undergoing major pulmonary resection for a benign lesion or metastasis or lung cancer, or patients with FEV 1 less than 80% undergoing wedge resection for benign lesion or metastasis. Risk group III (n = 233) with a fair prognosis included patients with comorbidity indices less than 4 and FEV 1 greater than or equal to 80% undergoing extended pulmonary resection for a benign lesion or metastasis or lung cancer, or patients with FEV 1 less than 80% and emphysema. Risk group IV (n = 46) with the worst prognosis included patients with FEV 1 less than 80% undergoing an extended lung resection or bronchoplastic procedures for a benign lesion or metastasis or lung cancer, or patients with comorbidity indices greater than or equal to 4 undergoing extended lung resection for lung cancer. Conclusions. In a prospective study, based on these prognostic factors, a practical, easy-to-use risk group system of lung resection is proposed as a tool to aid the decision to perform lung resection.

Surgical Management of Tracheal Tumors

Resection of tracheal tumors is particularly challenging when the neoplasm involves the carina or is located in close proximity. We reviewed our experience with 22 tracheal resections for tumor. In this retrospective review, adenoid cystic carcinoma was diagnosed in 13 patients, squamous cell carcinoma in 5, typical carcinoid in 2, and leiomyoma and benign fibrous histiocytoma, in 1 each. There were 19 segmental resections with direct anastomosis, and 3 complex resections in which the carina was involved. One patient with tumor in the trachea and left main bronchus underwent resection through simultaneous bilateral thoracotomy and died. During 2 to 17 years of follow-up, 2 patients died of unrelated disease, 2 died of metastases, and 1 is receiving radiotherapy for recurrence. Sixteen patients are well and free of tumor. Complete resection of all neoplastic tissue is mandatory, but benign and low-grade malignant tumors should be resected conservatively with preservation of lung parenchyma. Options for treatment of neoplasms involving trachea and left bronchus should include resection of the neoplasm in two stages, thus minimizing trauma of each operation.

Tracheobronchial sleeve resection in children and adolescents

Bronchoplastic techniques preserving lung parenchyma allow resection and reconstruction of the major bronchi and carina and are widely used in adults. The smaller and more delicate airways of children make such operations more demanding, but successful outcome can still be achieved with particular attention to technique. The authors treated 12 patients age 8 to 19 years (mean, 13.8 years) over a 12-year period. Ten patients had tumors of the airway: carcinoid (4), mucoepidermoid (2), malignant fibrous histiocytoma (1), adenocarcinoma (1), granular cell (1), and invasive fibrous tumor (1); and 2 had nonneoplastic strictures. Previous operative treatment included incomplete local excision in 2 and laser ablation in 1. Carinal resection and reconstruction was performed in 6 patients, main-stem bronchial resection in 3, and sleeve lobectomy in 3. There was one death after a complex airway reconstruction for extensive mediastinal fibrosis involving the airway. Postoperative morbidity consisted of prolonged atelectasis in 3 patients. Residual malacia in 1 patient with postpneumonectomy syndrome required further tracheobronchial resection. Follow-up is complete (mean, 64 months; range, 7 to 130). There has been no anastomotic stenosis or tumor recurrence. Preservation of lung function is expected in all patients. In 7 patients, bronchoscopy 4 months to 11 years postoperatively confirmed anastomotic patency and growth. The understanding of bronchoplastic techniques and precise attention to technical detail should allow these procedures to be successfully performed in pediatric patients.