Bronchusmanschettenresektion

Sleeve lobectomy is an established surgical procedure in patients with lung cancer. Usually the only surgical alternative would be a pneumonectomy. This article describes the perioperative risks and functional results in patients after sleeve lobectomy compared to pneumonectomy and typical lobectomy. There were only minor differences with respect to postoperative morbidity comparing the different procedures but the mortality rate was higher following pneumonectomy. Bronchopleural fistula rates were also similar comparing lobectomy and sleeve lobectomy but elevated following pneumonectomy. Bronchovascular fistulas after sleeve lobectomy are potentially life-threatening. Postoperative pulmonary function tests showed similar values for lobectomy and sleeve lobectomy patients and were considerably better than following pneumonectomy. Whenever possible sleeve lobectomy should take preference over pneumonectomy.     

Sleeve resections for the treatment of non-small cell lung cancer

Parenchyma-sparing sleeve lobectomies were originally developed as a surgical strategy for patients not fit for a pneumonectomy, because of impaired pulmonary function. As promising short- and long-term results were demonstrated, sleeve lobectomy was accepted as an alternative surgical procedure to pneumonectomy. Nowadays, sleeve resections are associated with prolonged long-term survival and better quality of life, compared to pneumonectomy. Therefore, sleeve resections should be performed for centrally located non-small cell lung cancer (NSCLC) whenever technically, anatomically and oncologically possible. In this review, we discuss the current status of sleeve resections in the management of NSCLC.     

Pneumonektomie

Lung cancer is localized in the upper lobes in more than half of the cases. The risk of tumor infiltration of centrally located structures, such as bronchi and vessels are enhanced due to the anatomic topography. Pneumonectomy competes with sleeve resection for the surgical resection of centrally located tumors. The present review deals with the question if pneumonectomy should be considered as an alternative to sleeve resection for the treatment of lung cancer. Primary pneumonectomy does not provide any advantage even in advanced nodal disease. Extended lymph node dissection is not a contraindication for sleeve resections. Local recurrence rate is lower after sleeve resections despite the same radicality for both surgical treatment options. Mortality and morbidity rates are significantly lower for sleeve resections. Sleeve resections are associated with prolonged survival and better quality of life even in elderly patients.     

Sleeve lobectomy for non-small cell lung cancer

Sleeve lobectomy is a procedure in which the involved lobe with part of the main stembronchus is removed. The remaining lobe (s) is reimplanted on the main stembronchus. This procedure is indicated for central tumors of the lung as an alternative to pneumonectomy. It is the aim of this study to describe the technique of sleeve lobectomy and to analyse the early postoperative results and late results (survival-recurrence) after sleeve lobectomy for non-small-cell lung cancer. MATERIAL AND METHODS: Between 1985 and 1999, 77 sleeve lobectomies for bronchogenic carcinoma were performed at the University hospitals Leuven. The most common performed sleeve lobectomy is the right upper lobe sleeve lobectomy (67.5%). In 6 patients a combined sleeve resection of the pulmonary artery was performed. The operative mortality was 3.9%. Two patients developed a broncho-pleural fistula. The five-year survival rate was 45.6%. In 5 patients, an anastomotic suture developed which required a completion pneumonectomy in 2. Thirteen patients developed local tumor recurrence. CONCLUSION: We conclude that sleeve lobectomy can be performed with an acceptable mortality and morbidity. Long term survival rate and recurrence rate are as good as after pneumonectomy. The operative mortality is lower when compared to pneumonectomy, exercise tolerance and quality of life are much better after sleeve lobectomy compared to pneumonectomy. For central tumours we believe that sleeve resection is the procedure of choice.     

Sleeve lobectomy in lung cancer

Sleeve lobectomy for lung cancer is now commonly performed around the world for central lung cancers that are anatomically suitable regardless of lung function. The morbidity and mortality are low, especially when compared with pneumonectomy. Bronchial complications are quite low. Local control seems to be at least as good as that obtained with pneumonectomy. Survival in most series is better with sleeve lobectomy than with pneumonectomy. Although there is still controversy with the use of sleeve lobectomy in patients with N1 disease, several recent series suggest better survival compared with pneumonectomy. Sleeve lobectomy can be safely performed after induction therapy. Quality of life is better with sleeve lobectomy compared with pneumonectomy.     

Sleeve Lobectomy for Non-Small Cell Lung Cancer

Sleeve lobectomy is a procedure in which the involved lobe with part of the main stembronchus is removed. The remaining lobe (s) is reimplanted on the main stembronchus. This procedure is indicated for central tumors of the lung as an altemative to pneumonectomy. It is the aim of this study to describe the technique of sleeve lobectomy and to analyse the early postoperative results and late results (survival-recurrence) after sleeve lobectomy for non-small-cell lung cancer.

Material and methods: Between 1985 and 1999, 77 sleeve lobectomies for bronchogenic carcinoma were performed at the University hospitals Leuven. The most common performed sleeve lobectomy is the right upper lobe sleeve lobectomy (67,5%). In 6 patients a combined sleeve resection of the pulmonary artery was performed. The operative mortality was 3,9%. Two patients developed a broncho-pleural fistula. The five-year survival rate was 45,6%. In 5 patients, an anastomotic suture developed which required a completion pneumonectomy in 2. Thirteen patients developed local tumor recurrence.

Conclusion: We conclude that sleeve lobectomy can be performed with an acceptable mortality and morbidity. Long term survival rate and recurrence rate are as good as after pneumonectomy. The operative mortality is lower when compared to pneumonectomy, exercise tolerance and quality of life are much better after sleeve lobectomy compared to pneumonectomy. For central tumours we believe that sleeve resection is the procedure of choice.     

Nohl-Oser type tracheobronchoplastic procedure in the treatment of advanced carcinoma of the right upper lobe

Two male patients were admitted with right upper lobe tumor. In both cases, standard upper lobectomy or sleeve lobectomy was not applicable because of the invasion of lateral wall of the lower trachea. The standard surgical option was tracheal sleeve pneumonectomy. Avoidance of pneumonectomy could be achieved by Nohl-Oser tracheobronchoplasty. Both patients had smooth postoperative course. We present these cases because of rarity and to emphasize the alternative techniques. The surgeon should be aware of the possibility of an alternative technique.     

Survival after bronchoplastic lobectomy for non small cell lung cancer compared with pneumonectomy according to nodal status.

BACKGROUND: In this retrospective study we have compared the results after sleeve lobectomy and pneumonectomy performed for non small cell lung cancer in the period January 1990-December 1995 at the Thoracic Surgery Unit, University Hospital of Siena. Follow-up was updated until December 2000. METHODS: In that period, 38 patients underwent sleeve lobectomy and 127 underwent pneumonectomy. The bronchoplasty was a full sleeve in 30 patients and a bronchial wedge resection in eight. Systemic nodal dissection was undertaken routinely. RESULTS: The 30-day postoperative mortality was 5.2% (2/38) in the sleeve lobectomy group and 3.9% (5/127) in the pneumonectomy group. Postoperative complications occurred in 23.6% of patients in the sleeve lobectomy group and in 23.2% of those in the pneumonectomy group. Local recurrences occurred in 5.2% of patients in the sleeve lobectomy group and in 4.8% of those in the pneumonectomy group. The overall 5-year survival for the sleeve lobectomy group was 38% whereas that for the pneumonectomy group was 25% (p=0.03). Regarding lymph-node involvement, in the sleeve lobectomy group, the 5-year survival for N0, N1 and N2 was 62.5, 17.5 and 12.5%, respectively. CONCLUSIONS: Our data confirm that sleeve lobectomy, when performed in selected patients with non small cell lung cancer, provides at least similar overall long term survival to that seen after pneumonectomy. Long term result are chiefly related to nodal stage with a significantly lower survival for patients with nodal involvement. As most patients with nodal involvement die from distant metastases, adjuvant treatment, instead of type of resection, would play a major role in prolonging survival.     

Evaluation of tracheobronchoplasty for lung cancer

Tracheobronchoplasty has become one of the standard procedures for lung cancer. In this study, we examined the incidence of complications and survival of tracheobronchoplasty and compared with these of pneumonectomy. In 119 patients underwent tracheobronchoplasty, bronchopleural fistula occurred in 6 (5.0%) and anastomotic stenosis occurred in 5 (4.2%). Five-year survival rate of 119 patients underwent tracheobronchoplasty was 47.3%, and the median survival time was 49.3 months. We compared the sleeve or wedge lobectomy and pneumonectomy, the incidence of complications and 30-days death were similar, but the rate of in-hospital death and the prognosis of the sleeve or wedge lobectomy were better than these of pneumonectomy. So to preserve a respiratory function, we should use a bronchoplastic procedures to avoid pneumonectomy.     

Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies

Background. Sleeve lobectomy and bronchoplasty are established alternatives to pneumonectomy for bronchial malignancies involving a main bronchus. However, potential bronchial anastomotic complications have deterred the general application of these types of resection. Some reports have contained a mixture of non-small cell lung cancer (NSCLC) and tumors of low-grade malignancy, making it difficult to assess the long-term results of these procedures as an alternative to pneumonectomy for lung cancer.

Methods. We retrospectively reviewed our experience with sleeve lobectomy and bronchoplasty for bronchial malignancies from January 1988 to September 1998 separating NSCLC (n = 58) from tumors of low-grade malignancy (n = 19). We compared the overall results between sleeve lobectomy and pneumonectomy (n = 142) performed for NSCLC over the same time interval.

Results. For NSCLC, after sleeve lobectomy, the operative mortality was 5.2% (3 of 58 patients) and the overall 5-year actuarial survival was 37.5%. After pneumonectomy, the operative mortality was 4.9% (7 of 142 patients) and the overall 5-year actuarial survival was 35.8%. For tumors with low-grade malignancy, there was no operative mortality after sleeve lobectomy or bronchoplasty and the 5-year actuarial survival was 100%. Major bronchial anastomotic complications occurred in 3 patients among the 77 patients who underwent sleeve resection.

Conclusions. Sleeve resection can be performed with a low risk of bronchial anastomotic complication. The long-term survival after sleeve resection for NSCLC is similar to pneumonectomy. Excellent results are obtained after sleeve resection for low-grade malignancies.     

Mortality, complications and loss of pulmonary function after pneumonectomy vs. sleeve lobectomy in patients younger and older than 70 years

Retrospective single institution analysis of all patients undergoing sleeve lobectomy or pneumonectomy between 2000 and 2005. Seventy-eight patients underwent pneumonectomy (65 patients <70 years, 13 patients >70 years) and 69 sleeve lobectomy (50 patients <70 years, 19 patients >70 years). Pre-existing co-morbidity, surgical indication and induction therapy was similarly distributed between treatment by age-groups. In patients <70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 3% vs. 0 and an overall complication rate of 26% vs. 44%, respectively. In patients >70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 15% vs. 0 and an overall complication rate of 23% vs. 32%. In both age groups, pneumonectomy was associated with more airway complications (NS) and a significantly higher postoperative loss of FEV(1) than sleeve lobectomy (P<0.0001, P<0.03). Age per se did not influence the loss of FEV(1) and DLCO for a given type of resection. Sleeve lobectomy may have a therapeutic advantage over pneumonectomy in the postoperative course of elderly patients.     

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.     

Sleeve lobectomy or pneumonectomy: optimal management strategy using decision analysis techniques

BACKGROUND: The choice between sleeve lobectomy and pneumonectomy is controversial for patients with early-stage lung cancer and who have acceptable lung function. METHODS: We performed a meta-analysis of results of sleeve lobectomy and pneumonectomy published in English from 1990 to 2003. A decision model was developed with 5-year survival, quality-adjusted life years (QALY), and cost effectiveness as the outcomes, and sensitivity analyses were performed. RESULTS: The model favored sleeve lobectomy (3.5 percentage point survival advantage) when the reward was 5-year survival; the results were influenced primarily by the 5-year survival rates for patients who did not develop recurrent cancer. Sleeve lobectomy was strongly favored when the reward was QALY (1.53 QALY advantage). Sleeve lobectomy was more cost effective than pneumonectomy, and had an incremental cost effectiveness ratio of $1,300/QALY. CONCLUSIONS: In patients with anatomically appropriate early-stage lung cancer, sleeve lobectomy offers better long-term survival and quality of life than does pneumonectomy and is more cost effective.     

Reconstruction and its prognosis in patients undergoing resection of tracheal bifurcation

Seventeen resections of tracheal bifurcation were performed: 12 for bronchogenic carcinoma, 2 for primary neoplasm of the trachea, one each for pulmonary sarcoma, inflammatory lesion and metastatic thyroid carcinoma. We performed carinal reconstruction in eight patients, sleeve pneumonectomy in eight patients and wedge pneumonectomy in one. In patients undergoing carinal reconstruction, there were 2 operative deaths and six patients survived over five years after the operation. However, in patients undergoing sleeve (wedge) pneumonectomy, there were 3 operative deaths, four patients died from 3 months to 7 months, and only two patients survived 5 years after the operation. Carinal resection with pneumonectomy had poorer prognosis than carinal reconstruction.     

Right pneumonectomy or sleeve lobectomy in the treatment of bronchogenic carcinoma

Although surgical resection is the only satisfactory treatment for lung cancer, its contribution to the total salvage of patients is small. Palliation of the majority of patients seems much more important than cure of a small minority. Therefore, the most economical procedure possible should be used. The high mortality and functional sacrifice of right pneumonectomy make this attitude mandatory for right-sided hilar carcinoma. Even a “forced” sleeve resection in the presence of proved lymphoglandular invasion of the right hilum may produce worthwhile palliation.The results of 21 sleeve lobectomies and 30 right pneumonectomies are compared. Operative mortality was distinctly lower and the mean survival time longer in the sleeve resection group. The quality of survival was better by far after sleeve lobectomy.     

Completion pneumonectomy after bronchial sleeve resection: incidence, indications, and results.

During the years 1960 through 1989, 145 patients underwent sleeve lobectomy or sleeve resection of a main bronchus. Completion pneumonectomy was performed in 19 patients (13.1%). Indications were bronchostenosis without malignancy in 10 patients, positive resection margins in 3, recurrent tumor in 5, and anastomotic dehiscence in 1. Mean age at sleeve operation was 59.3 years. In 18 patients the histology was squamous cell carcinoma and in 1 patient, carcinoid tumor. The mean interval between sleeve resection and completion pneumonectomy was 5.7 months (range, 3 to 16 months) for the patients with stenosis and 6.6 months (range, 1 to 17 months) for the others. There were 3 operative deaths (15.8%). The mean follow-up was 53.2 months. Five-year and 10-year survival rates after completion pneumonectomy for the patients with stenosis were 54% and 41%, respectively, and for the others, 52% and 52%.     

Surgical outcome of tracheobronchial reconstruction for lung cancer

We retrospectively evaluated the surgical outcome after sleeve lobectomy and pneumonectomy with tracheobronchial reconstruction for lung cancer. From 1993 to 2008, 46 patients with primary lung cancer underwent these surgical procedures. Seventeen patients (37%) received induction therapy, 15 received chemotherapy, while chemoradiotherapy or radiotherapy alone were received by one patient each. Sleeve lobectomy without carinal resection was performed in 41 patients. Carinal resection with 2 sleeve pneumonectomies was performed in 5 patients. There were no operative deaths. Bronchopleural fistula occurred in one patient, who required completion pneumonectomy. One patient presented local mucosal necrosis in the anastomotic site and was managed conservatively. Two patients had bronchial strictures as late complications and successfully dilated by a balloon using bronchoscopy. Overall 5-year and 10-year survival rates were 54% and 48%, respectively. No recurrence developed at any anastomotic site. The results showed that sleeve lobectomy and pneumonectomy with tracheobronchial reconstruction can be performed with low mortality and bronchial anastomotic complication rates. As well, local control of the tumor was satisfactory.     

Prognostic evaluation of tracheobronchial reconstruction for bronchogenic carcinoma

Fifty-two patients have undergone tracheobronchial reconstruction for bronchogenic carcinomas over a 20 year period and have been evaluated from the view point of prognosis. Five-year survival rates of the patients undergoing reconstructive operations were as follows: 35% for the total group, 50% for those with squamous cell carcinoma, and 64% for those with Stage I and II disease. No patients with adenocarcinoma or Stage III disease have survived more than 5 years. However, the number of patients with early adenocarcinoma was too small for us to conclude that the histologic type per se affected survival. Six of eight patients with sleeve lobectomy and pulmonary artery reconstruction died within 2 years, 7 months postoperatively. Five of seven patients died within 1 year after carinal reconstruction. However, two are alive at 4 months and 2 years, 9 months after left or right sleeve pneumonectomy. In summary, any types of lobectomy or pneumonectomy with reconstruction of the tracheobronchial tree can be conducted in patients with Stage I and II lung cancer. Sleeve lobectomy with pulmonary artery reconstruction can be an alternative to pneumonectomy when pneumonectomy is contraindicated because of low cardiopulmonary reserve. In patients undergoing reconstruction of the carina, prophylactic radiation therapy may be necessary during the postoperative course.     

Clinicopathological study of surgically treated cases of tracheobronchial adenoid cystic carcinoma

Between 1980 and 2007, five patients were pathologically diagnosed as tracheobronchial adenoid cystic carcinoma (ACC). All five patients were women aged 37–67 years. Four tumors were located in the larger airways, and one tumor was located in the peripheral lung. The following operations were done: bronchoplastic procedures in three (carinal resection with doublebarreled carinoplasty in one, sleeve right pneumonectomy in one, sleeve middle lobectomy in one), left pneumonectomy in one, and left upper lobectomy in one. Three of the five patients have survived for 172, 144, and 10 months after surgery, respectively. The best local treatment for ACC of the major airway is considered to be sleeve resection of the trachea or bronchus in an area where airway reconstruction may not be disturbed and to add postoperative irradiation when there is residual carcinoma at the stump. However, it seems controversial to recommend adjuvant radiotherapy in all patients undergoing resection.     

Risks of neoadjuvant chemotherapy and radiation therapy

Pulmonary resection for locally advanced NSCLC after induction chemotherapy or chemoradiotherapy can generally be performed with acceptable morbidity and mortality. Data from several phase II and a few randomized trials showed that patients should be carefully selected for surgery especially with respect to their age, performance status, and pulmonary and cardiovascular function tests. The presence of cardiovascular disease should be actively investigated and preexisting arrhythmias appropriately managed. Similarly, respiratory status should be evaluated and any reversible condition, such bronchial obstruction, infection, pulmonary embolism, and smoking, should be addressed. Surgical resection is technically more demanding; intraoperative blood loss should be minimized. Several studies demonstrated that pneumonectomy especially on the right side is associated with a significantly increased risk of postoperative morbidity and mortality especially in patients after induction chemoradiotherapy. Therefore, pneumonectomy should be performed very selectively and only when alternative procedures such as bronchial or vascular sleeve resection or both are technically not possible. Long-term follow-up reports of bimodality protocols without surgery versus bimodality followed by surgical resection are awaited. These results will heln to define standards of care and the role of surgery for patients with NSCLC stage III disease. Future decision-making will have to take into account treatment morbidity and mortality and parameters of organ-sparing surgery following induction. probably best represented by rates of pneumonectomy or rates of lobectomy in different patient groups.