Sleeve Bilobectomy Research Articles

Evaluation of Risk Factors for Early Insufficiency after Bronchial Sleeve Resections.

Bronchoplastic resections are now widely used as a surgical treatment for resectable central lung cancer. However, bronchial dehiscence is one of the most life-threatening complications, making it important to identify its risk factors to separate patients who require more attention during the postoperative period. The data of 285 patients who underwent bronchoplasty from 2006 to 2021 were retrospectively reviewed. We collected demographic characteristics, history of neoadjuvant therapy, preoperative assessment, perioperative outcomes, and postoperative complications to investigate different variables as risk factors for bronchial dehiscence by univariate and multivariate analyses. Bronchial dehiscence was diagnosed in 12 patients (4.2%) with a mean presentation on postoperative day 10 (range: 1-24 days). By multivariate analysis, current smoking (odds ratio [OR]: 4.8, 95% confidence interval [CI]: 1.1-20.1, p = 0.032), chronic obstructive pulmonary disease (COPD; OR: 6.5, 95% CI: 1.2-33.8, p = 0.027), bronchoplastic right lower lobectomy (OR: 12.9, 95% CI: 2.4-69.7, p = 0.003), and upper sleeve bilobectomy with segmentectomy S6 by performing an anastomosis between right main bronchus (RMB) and bronchus of basal pyramid (BP) (OR: 30.4, 95% CI: 3.4-268.1, p = 0.002) were confirmed as relevant risk factors for developing bronchial dehiscence. Current smoking, COPD, bronchoplastic right lower lobe, and upper l with segmentectomy S6 by performing an anastomosis between RMB and bronchus of BP were identified with the occurrence of bronchial dehiscence after sleeve resection.

Uniportal VATS right sleeve bilobectomy and carinal reconstruction

Uniportal VATS right sleeve bilobectomy and carinal reconstruction

Uniportal VATS right upper sleeve bilobectomy with artery suspension

Uniportal VATS right upper sleeve bilobectomy with artery suspension

Uniportal VATS right lower sleeve bilobectomy for a 13-year-old boy

Uniportal VATS right lower sleeve bilobectomy for a 13-year-old boy

Robot-assisted right wedge-shaped sleeve lower bilobectomy with knotless suture anastomosis: a case report

BackgroundIn bronchoplasty of wedge resections, it is necessary to transect the bronchus at a sharp angle and depth. As a result, anastomoses after wedge resections have the disadvantages of poor visibility and operability. Here, we report a case of right wedge-shaped sleeve bilobectomy that was successfully performed with continuous knotless suturing using robotic assistance.Case presentationAn 81-year-old male patient was referred for the treatment of a tumor in the right lower lobe, which protruded into the bronchus intermedius. The tumor was diagnosed as squamous cell carcinoma by transbronchial biopsy, cT1cN1M0 stage IIB carcinoma for which surgery was indicated. Because the pulmonary middle lobe artery was involved and a resection margin from the tumor protruding into the bronchial mucosal epithelium was necessary, a right wedge-shaped sleeve bilobectomy was performed. The bronchial anastomosis was performed with robotic assistance. After dissection of pulmonary vessels and interlobes, the upper lobe bronchial bifurcation was transected in a wedged shape, and a lower bilobectomy was performed. The bronchi were sutured continuously with knotless sutures. A continuous suture was performed from the ventral to the caudal side. After suturing to the dorsal side, another continuous suturing was performed from the cranial side. Continuous sutures were made until each thread passed through the other. Pericardial fat was wrapped around the anastomosis.ConclusionsA better visual field could be obtained owing to robot-assisted surgery, and robotic arms enabled an accurate and safe operation. Furthermore, continuous suturing using a knotless suture made it easier for the sutures to be handled and enabled bronchial anastomosis without assistance.

Primary Endobronchial Conventional Chondrosarcoma Right Lung Upper Lobe: A Case Report and Literature Review

Primary endobronchial chondrosarcoma is extremely rare and hardly reported while reported chondrosarcomas of primary lung origin are rare with most literature coming from a series of case reports and small case series. These tumours can present as centrally located masses and therefore, require extensive workup to exclude alternative aetiology and to confirm diagnosis. Literature review revealed only four reports of primary endobronchial and 29 primary pulmonary chondrosarcoma cases, excluding the current report. We present a rare case of biopsy-proven non-metastatic primary endobronchial conventional chondrosarcoma of the right upper lobar bronchus extending into the right main bronchus managed with technically challenging sleeve bilobectomy of right upper and middle lobes and a viable anastomosis of lower lobe bronchus with the right main bronchus stump and thus, prevented a pneumonectomy. Final histopathology confirmed the diagnosis. Thus, these tumours are difficult to diagnose and challenging to manage and need more data in future to establish protocols.

Surgical Outcomes After Pulmonary Resection With Typical or Atypical Bronchoplasty in Patients With Primary Lung Cancer.

Atypical bronchoplasty is essential for complete tumor removal and preservation of peripheral lung tissue. This study compared surgical outcomes after atypical or typical bronchoplasty in patients who underwent pulmonary sleeve resection with bronchoplasty. Typical bronchoplasty was defined as that after one-lobe sleeve resection; atypical bronchoplasty was defined as that after sleeve bilobectomy or sleeve removal of one lobe plus segments. Double-barreled bronchoplasty was also included in the atypical group. Surgical outcomes were retrospectively investigated according to type of bronchoplasty. Fifty-one patients underwent typical bronchoplasty and 20 atypical bronchoplasty. Recurrence was seen in 17 out of 51 (33%) patients after typical bronchoplasty and 10 out of 20 patients (50%) after atypical bronchoplasty. The recurrence-free survival rate was significantly poorer in the atypical bronchoplasty group (p=0.038). However, patients in the atypical bronchoplasty group were able to receive anticancer treatment for tumor recurrence, and there was no significant difference in overall survival rates between the groups. Preservation of pulmonary function by atypical bronchoplasty might contribute to tolerability of anticancer treatment for tumor recurrence. Pulmonary resection with atypical bronchoplasty is reliably beneficial for overall survival.

Surgical management of post-transplant bronchial stenoses: a single-center experience

PurposeBronchial stenoses are challenging complications after lung transplantation and are associated with high rates of morbidity and mortality. We report a series of patients who underwent bronchoplasty or sleeve resection for bronchial stenoses that did not resolve with endoscopic treatment after lung transplantation.MethodsBetween 1995 and 2020, 497 patients underwent lung transplantation at our Institution. 35 patients (7.0%) experienced bronchial stenoses with a median time from transplantation of 3 months. Endoscopic management was effective in 28 cases (5.6%) while 1 patient required re-transplantation. Six patients (1.2%) underwent bronchoplasty or sleeve resection.ResultsThe procedures of the six patients who underwent bronchoplasty or sleeve resection were as follows: lower sleeve bilobectomy (n = 3), wedge bronchoplasty of the bronchus intermedius (n = 1), isolated sleeve resection of the bronchus intermedius (n = 1), and isolated sleeve resection of the bronchus intermedius (n = 1), associated with a middle lobectomy. All patients were discharged after a median time of 11 days. At a median of 12 months from surgery, two patients remain alive with a preserved pulmonary function. Four patients died after a median time of 56 months from bronchoplasty of causes that were not related to surgery.ConclusionsBronchial reconstructions are challenging procedures that can be performed in highly specialized centers. Despite this, they can be considered a good strategy to obtain a definitive resolution of stenosis after lung transplantation.

Preoperative chest computed tomography evaluation for predicting intraoperative lung resection strongly depends on interpreters experience

ObjectivesPreoperative planning of lung resection extent is decisive for preoperative functional work-up and selection for multimodal treatment. It is mainly based on preoperative chest CT. We aimed at evaluating chest CT adequacy to predict the extent of lung resection and hypothesized a relation with CT interpreters’ level of experience. Materials and MethodsA pseudonymized CT library was built from patients who had curative intent lung resection for centrally located NSCLC. CT library was interpreted by 20 thoracic surgery residents or attendings. Interpreters were blinded to intraoperative findings and scored one point when lung resection was adequately planned. Points were summed up in a score from 0 to 20. Interpreters’ experience was evaluated through nine variables: age, position (resident vs. attending), years of experience in evaluating chest CTs, number of anatomic resections and sleeve resections attended as first assistant or performed as surgeon in presence of a teaching assistant or as main surgeon/teaching assistant.Variables characterizing interpreters’ experience were divided into equal sized groups. Independent sample T-test and one-way ANOVA/Tukey post hoc tests were used to compare scores between groups. ResultsCT library included 20 patients. Lung resections were lobectomy (n = 7, 35 %), sleeve lobectomy (n = 10, 50 %), sleeve bilobectomy (n = 2, 10 %), pneumonectomy (n = 1, 5%). Twenty interpreters scored a median of 10 (4–14). Attending surgeons had significantly higher mean scores (11.2 ± 1.3) compared to residents (7.7 ± 2.3, p = 0.001). All scores were significantly different between groups related to interpreters’ levels of experience, except for interpreters’age. ConclusionPreoperative CT evaluation for predicting intraoperative lung resection for centrally located NSCLC strongly depends on interpreters’ experience.

Optimal timing of surgery for bronchial sleeve resection after neoadjuvant chemoradiotherapy.

Sleeve resection is an established oncological operative treatment for centrally located tumors with reduced complications compared to pneumonectomy. In cases of neoadjuvant chemoradiotherapy, the optimal timing of surgery for bronchial anastomotic healing has not been adequately explored. Between 2006 and 2017, 584 tracheobronchial sleeve resections were retrospectively analyzed. We selected all patients (n = 88) after sleeve lobectomy or sleeve bilobectomy for lung cancer with fully completed neoadjuvant chemoradiotherapy. Bronchial healing was assessed by bronchoscopy on the 7th postoperative day using our earlier published classification from grades 1 to 5. The median interval to surgery was 50 days (interquartile range 46-53, mean 50.03 ± 3.72). Mean anastomotic grade was 2.05 ± 1.03 and in 29.5% of the patients a critical anastomosis (grade ≥3) was documented. Anastomotic healing showed optimal results (bronchoscopic grade mean value: 1.5 ± 0.70) between the 6th and 8th postchemoradiotherapy week (P = .001). All patients operated before (bronchoscopic grade mean value: 2.3 ± 1.02) or after the above period (bronchoscopic grade mean value: 2.5 ± 1.15) had an increased ratio of anastomotic healing complications. It is safer to perform sleeve-resections for non-small cell lung cancer after neoadjuvant trimodal treatment between the 6th and 8th week of completion of chemoradiotherapy.

Intrapericardial upper sleeve bilobectomy with division of the azygos arch

Intrapericardial upper sleeve bilobectomy with division of the azygos arch

Right side sleeves

Right bronchial sleeve resection is a demanding surgical technique that is applied in case of lung tumors or lymph nodes invading the origin of the right lobar bronchus. Sometimes the tumor invades also the pulmonary artery (PA) and in this instance, a vascular resection and reconstruction of the artery may be required. On the right side, the most frequent bronchoplastic procedure is the upper lobe sleeve resection with the anastomosis of the mainstem bronchus with the bronchus intermedius. Exceptionally, a middle lobe sleeve resection or a sleeve bilobectomy may be required. In every case, the technique of the bronchoplasty includes the anastomosis between the two bronchial stumps with two running sutures with a non-absorbable monofilament obtaining a telescopic anastomosis. In case of PA involvement, an angioplasty may be associated. In this review we report our experience in treating lung cancer infiltrating the origin of the upper bronchus, the middle bronchus and the intermediate bronchus requiring resection and reconstruction describing the surgical anatomy of right bronchial and vascular tree, and illustrating in details our surgical technique of bronchoplasty.

Middle lobe preservation and fixation: right upper and lower sleeve bilobectomy. How to do it

We herein report the case of a 65-year-old female with primary lung cancer who underwent a right upper and lower sleeve bilobectomy. The radiological findings revealed that the tumor was located in the superior segment of the right lower lobe and had invaded the posterior segment of the upper lobe and the truncus intermedius. We performed a right upper and lower sleeve bilobectomy. A latissimus dorsi flap was utilized to separate the thoracic cavity into upper and lower portions, and the preserved middle lobe was fixed in the upper portion to prevent torsion. Postoperative radiography showed good expansion of the middle lobe.

Sleeve resections with unprotected bronchial anastomoses are safe even after neoadjuvant therapy

Sleeve resection is the operation of choice in patients with centrally located tumours, in order to avoid a pneumonectomy. Most surgeons protect the bronchial anastomoses with tissue to prevent insufficiencies. The purpose of this study is to report on outcome of unwrapped bronchial anastomoses, especially after neoadjuvant chemo- or chemoradiotherapy. Between 2000 and 2010, 103 patients [59 years (range 16-80), 40 females] underwent bronchial sleeve resections without coverage of the anastomosis with a tissue flap. We retrospectively reviewed the data for morbidity, mortality and survival, especially with regard to the type of resection, neoadjuvant therapy and stage. Sleeve lobectomy was performed in 88, sleeve bilobectomy in 8, sleeve pneumonectomy in 4 and sleeve resection of the main bronchus in 3 patients. Twenty-seven patients had a combined vascular sleeve resection. Neoadjuvant chemotherapy was performed in 20 and radiochemotherapy in 5 patients. Non-small cell lung cancer (NSCLC) was present in 76 patients (squamous cell carcinoma in 44, adenocarcinoma in 24, large cell carcinoma in 6and mixed cell in 2) and neuroendocrine tumour in 20 and other histological types in 7 patients. The pathologic tumour stage in NSCLC was stage I in 26, stage II in 26, stage IIIA in 16, stage IIIB in 7 and stage IV in 1 patient. There were no anastomotic complications, especially no fistulas. One patient developed narrowing of the intermediate bronchus without need for intervention. Twenty-four patients had early postoperative complications, including 11 surgery-related complications (air leakage, nerve injury, haemothorax or mediastinal emphysema). The 30-day mortality was 3% (one patient died due to heart failure and two with multiorgan failure). The 5-year survival rate was 63% in NSCLC patients and 86% in neuroendocrine tumour patients. Sleeve resection without wrapping the bronchial anastomoses with a tissue flap is safe even in patients who underwent neoadjuvant chemo- or chemoradiotherapy. Therefore, wrapping of the bronchial anastomoses is not routinely mandatory.

Sleeve resection for postlobectomy stump fistulas: a case report

In this article, we present three cases who had postresectional bronchial stump fistulas after resection for lung cancer. Two cases had right upper lobectomy and one case had a right upper double (bronchial and vascular) sleeve bilobectomy operation. Two cases underwent sleeve resections of the right main bronchus, while one patient underwent resection of the carina for the treatment of bronchopleural fistula. Sleeve resection may be an alternative treatment method for bronchopleural stump fistulas that develop after lung cancer resection.

A quarter of a century experience with sleeve lobectomy for non-small cell lung cancer☆

Sleeve lobectomy represents an effective and widely accepted surgical therapy for non-small cell lung carcinoma (NSCLC). We sought to review our experience in terms of mortality, early and late morbidity, and long-term survival evaluating the technical progresses overtime. From 1980 to 2005, 199 patients underwent sleeve lobectomy. Pathology revealed 167 (83.9%) squamous carcinomas, 23 (11.6%) adenocarcinomas, 7 (3.5%) large cell and 2 (1%) adenosquamous carcinomas. In 39 (19.6%) patients a vascular procedure was associated. Nineteen (9.5%) patients had preoperative radiotherapy, 14 (7%) preoperative chemotherapy and 10 (5%) chemoradiotherapy. Overall postoperative mortality was 4.5% (n=9) and morbidity was 17.9% (n=34). Preoperative radiotherapy was identified as a significant risk factor for perioperative mortality (OR: 5.34, 95% CI: 1.16-24.47; p=0.03) and early anastomotic complications (OR: 3.73, 95% CI: 1.01-13.68; p=0.04). Overall 5-year survival rate was 39.7% and stage-by-stage analysis did not reach a significant survival difference. With growing skills the number of procedures, associated angioplasty and difficult sleeves (such as sleeve bilobectomy) increased. Also in term of mortality, in the last 10 years we had 0.8% of mortality rate. Sleeve lobectomy is a safe and effective therapy for selected patients with NSCLC. Vascular procedures and the use of induction chemotherapy did not increase mortality and morbidity; otherwise, the use of preoperative radiotherapy is not recommended. Overtime trend showed a significant lower mortality in the last period. This emphasises the importance of a learning curve and encourages the performance of this procedure in experienced centres.

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.

Surgical Treatment of Posttransplant Bronchial Stenoses: Case Reports

Background Bronchial stenoses are still a frequent complication after lung transplantation. The stenosis usually involves the anastomotic site, but rarely a distal site. The first choice treatment is an endoscopic balloon dilatation, laser ablation, and stenting. Unrelenting strictures may require an open surgical approach. Materials and Methods Between 1995 and 2006, 154 patients underwent lung transplantation, including 134 who survived the perioperative period and were followed to evaluate the incidence of bronchial stenosis. Among 219 anastomoses at risk, 13 (5.9%) stenoses occurred in 11 patients. Conservative endoscopic management was effective for eight patients, but a surgical approach was necessary for three patients with segmental distal stenosis. Results One patient received a lower sleeve bilobectomy; one patient, wedge bronchoplasty of the bronchus intermedius; and another patient, an isolated sleeve resection of the bronchus intermedius. All patients had good outcomes with resolution of stenosis. Conclusions Although rare, the surgical approach for bronchial strictures after lung transplantation is a good option. Parenchyma-sparing techniques are feasible and effective.

Trachea-bronchoplasty in the surgical treatment of locally advanced non-small cell lung cancer

Some of the locally advanced non-small cell lung cancer (NSCLC) need different trachea-bronchoplasty operative styles in order to make the widest possible to resect the tumor and remain normal pulmonary function. The aim of this study is to explore the surgical problem during trachea-bronchoplasty operation. There were 2206 patients with NSCLC underwent surgical treatment from January 2003 to June 2005 in this hospital. Of the 2206 cases, 100 patients accepted the trachea-bronchoplasty, whose clinic data were analyzed. There were 42 cases of squamous cell carcinoma, 23 adenosquamous carcinoma, 11 adenocarcinoma, 5 mucoepidermoid carcinoma, 4 adeoid cystic carcinoma, 3 carcinoid and 12 undetermined. Thirty-four cases were in stage IB, 23 in stage IIB, 23 in stage IIIA and 20 in stage IIIB. There were 42 cases of right upper sleeve lobectomy, 1 right lower sleeve lobectomy, 24 left upper sleeve lobectomy, 4 left lower sleeve lobectomy, 8 sleeve bilobectomy, 17 carinal reconstruction, 4 sleeve lobectomy plus pulmonary artery angioplasty. Complete resection (R0) of the cancer was performed in 97 patients and uncomplete resection (margin positive, R1) was performed in 3 patients. Postoperative complication happened in 5 cases (the occurrence rate was 5%): Pneumonia in 2 cases, pleura cavity infection in 1 case, broncho-pleura fistula in 1 case, alveoli-pleura fistula in 1 case. One patient died of pulmonary infection, the operative mortality was 1%. The postoperative inpatient time was from 4 days to 27 days, with median of 11 days. Trachea-bronchoplasty is suitable for some patients of the locally advanced NSCLC and consistent to the tumor surgical treatment principle. A satisfactory cure effect can be obtained for undergoing such operative style. The key point of successful operation is the operating skill to manage trachea, bronchi and pulmonary vessels.

Double prosthetic replacement of pulmonary artery and superior vena cava and sleeve lobectomy for lung cancer

We present a case of double prosthetic replacement of the right pulmonary artery and superior vena cava combined with upper sleeve bi-lobectomy for a limited pT4N1 adenocarcinoma occurring in a patient with poor pulmonary reserve, which, to the best of our knowledge, has never been reported before.