Comparison of surgical results after pneumonectomy and sleeve lobectomy for non-small cell lung cancer: trends over time and 20-year institutional experience.

OBJECTIVE: Sleeve lobectomy is a lung-saving procedure for central tumors for which the alternative is pneumonectomy. The purpose of this study was to report the clinical characteristics, operative results, survival, and late outcomes over 20 years in patients who underwent sleeve lobectomy and pneumonectomy at our institution. METHODS: There were 62 patients who underwent sleeve lobectomy (SL group) and 110 who underwent pneumonectomy (PN group). Comparisons of the demographics, morbidity, and survivals between the groups were performed by unpaired t-test, chi(2)-test, and log-rank test. RESULTS: Patients who underwent a pneumonectomy showed a significantly advanced pathological stage, and a larger tumor size than those who received a sleeve lobectomy, whereas there were no significant differences in histology, ratio of combined resection and induction therapy, or total morbidity. There were three in-hospital deaths (4.8%) in the SL group and four (3.6%) in the PN group. Local relapse and distant recurrence incidence were similar between the two groups. The 5-year-survival rates of the SL and PN groups were 54% and 33%, respectively (p<0.0001). However, there were no differences in 5-year survivals in patients with pathological stage I/II (SL, 59% vs PN, 63%) and those who received induction therapy (SL, 22% vs PN, 52%) between the groups. CONCLUSIONS: Both pneumonectomy and sleeve lobectomy were performed with an acceptable risk of operative mortality and satisfactory 5-year survival rate. The indication of pneumonectomy is aimed to perform a curative resection for locally advanced lung cancer, particularly after induction therapy that is otherwise unresectable, and the selected patients will likely benefit from a complete resection.     

Results in 104 patients undergoing bronchoplastic procedures for bronchial lesions

Bronchoplastic procedures were used in 104 patients with various bronchial disorders. Ten had benign lesions and 94, malignant tumors. The principal operative procedures were sleeve lobectomy and sleeve pneumonectomy for bronchogenic carcinoma, but 11 limited bronchial resections were performed in patients with benign lesions, minute bronchogenic carcinomas, and low-grade malignant tumors. Of the 94 patients with malignant tumors, 79 underwent a bronchoplastic procedure without carinal resection (sleeve lobectomy in 75 and limited bronchial resection in 4), and there was one operative death (1.3%). The overall 5-year survival rate for the patients with bronchogenic carcinoma in this group was 45% and that for patients undergoing curative resection, 57% (survival of patients in stages I, II, and IIIA was 79%, 55%, and 30%, respectively). A bronchoplastic procedure with carinal resection was performed in 15 patients. Twelve in this group underwent sleeve pneumonectomy. There were two operative deaths, and 1 patient has survived for longer than 4 years. Two patients with low-grade malignant tumors underwent carinal resection without lung resection and are still alive. We believe that bronchoplasty is a safe and valuable procedure and that limited bronchial resection appears to be the procedure of choice for localized bronchial lesions.     

Chances in surgical treatment of bronchial carcinoma under palliative conditions

Palliative surgery aims at symptomatic relief in patients in whom curative therapy seems not feasible. When diagnostic imaging techniques describe advanced stage IIIa, IIIb or IV malignancy, despite of palliative intention curative resection may still be possible. Objective of the present study was to investigate lung cancer patients undergoing surgery with palliative intent and to compare their prognosis with patients whose tumor resection had been complete (R0) or incomplete (R1/R2). PATIENTS AND METHOD: Patients were assigned to one of the three groups on the basis of the following criteria: palliative intention with subsequent complete resection (group I, n = 11); curative intention with subsequent incomplete resection (group II, n = 38), palliative intention with incomplete resection (group III, n = 23). Additionally 3 patients were operated on by explorative thoracotomy. A total number of 75 patients was therefore investigated. Median follow-up period was 34.5 months. Survival rates were calculated using the Kaplan-Meier method. RESULTS: The following procedures involving resection of pulmonary tissue were performed: pneumonectomy (n = 10), extended pneumonectomy (n = 32), lobectomy (n = 5), extended lobectomy (n = 11), sleeve lobectomy (n = 7), bilobectomy (n = 3), extended bilobectomy (n = 4). The 30 days hospital mortality rate was 13%. Median survival times were 25.5 months in group I, 12.8 months in group II and 7.7 months in group III (statistical significance: group I vs. group II/III, p < 0.05). CONCLUSIONS: Results of the present study show that patients with bronchial carcinoma in advanced tumor stages III and IV may still benefit from pulmonary resection, particularly when reduction of their somatic complaints is considered. In 11 patients, R0 resection was feasible leading to a statistically significant prolongation of their survival rates.     

Local control of disease and survival following bronchoplastic lobectomy for non-small cell lung cancer.

BACKGROUND: This study was designed to determine whether bronchoplastic resection could be an alternative to pneumonectomy in patients with operable primary lung cancer. METHODS: From 1980 to 1996, 63 patients (59 males and four females; mean age 62 +/- 7 years) underwent a bronchoplastic lobectomy for non-small cell lung cancer, indicated because of a disabled respiratory function in 34 patients, and performed electively in 29 patients. There were 38 right upper lobectomies, four bilobectomies, one middle lobectomy combined with lower lobe apical segmentectomy, ten left upper and ten left lower lobectomies. The bronchoplasty was a full sleeve in 24 patients, and a bronchial wedge resection in 39. RESULTS: A single patient died post-operatively (1.6%). Specific procedure-related complications are summarized as follows: six anastomotic complications managed conservatively (9.5%), 15 space problems (23.8%), nine sputum retentions (14.2%). Pathologic staging classified 30 patients in stage I, 21 patients in stage II, and 12 in stage IIIA. Estimated 5-year survival was 69.7 +/- 9.8% in stage I, 37.1 +/- 12.1% in stage II, and 8.3 +/- 8.0% in stage IIIA. Fourteen patients (22.2%) developed locoregional recurrence. Three of them died with local recurrence alone, whereas 10 developed metastatic progression; a single patient is alive following completion pneumonectomy. According to stage, three recurrences occurred in stage I (10%), six in stage II (28%), and five in stage IIIA (38%). Actuarial freedom from local recurrence was significantly higher after elective procedures (P = 0.019); there was a trend towards improved outcome following right-sided procedures (P = 0.079) and following wedge bronchoplasty (P = 0.055). Five patients experienced a second primary cancer (7.9%), which was resected in four. CONCLUSION: Bronchoplastic resections achieve local control and long-term survival comparable to standard resections in patients with stage I or II disease, and may be considered as a valuable alternative to pneumonectomy.     

Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy.

The number of patients reported to have undergone bronchoplastic procedures has increased nearly fourfold in the past decade. These techniques represent excellent surgical therapy for patients with benign endobronchial lesions, traumatic airway disruptions, or tumors of low-grade malignant potential, and for select patients with surgically resectable lung cancer. Eighty-nine percent of bronchoplastic procedures are performed for malignancy. We reviewed 1,915 bronchoplastic procedures for carcinoma reported over the past 12 years to determine the incidence of complications and survival. Complications included local recurrence (10.3%), 30-day mortality (7.5%), pneumonia (6.7%), atelectasis (5.4%), benign stricture or stenosis (5.0%), bronchopleural fistulas (3.5%), empyema (2.8%), bronchovascular fistulas (2.6%), and pulmonary embolism (1.9%). Results were further stratified into sleeve lobectomy and sleeve pneumonectomy groups. Five-year survivals for stage I, II, and III carcinoma were 63%, 37%, and 21%, respectively. Sleeve lobectomy for carcinoma extends surgical therapy to select patients with complication rates comparable to pneumonectomy and long-term survival similar to that for conventional resections.     

Morbidity, mortality, and long-term survival after sleeve lobectomy for non-small cell lung cancer.

OBJECTIVE: Sleeve lobectomy is a widely accepted procedure for central tumors for which the alternative is pneumonectomy. The purpose of this study is to assess operative mortality, morbidity, and long-term results of sleeve lobectomies performed for non-small cell lung carcinoma (NSCLC). METHODS: A retrospective review of 218 patients who underwent sleeve lobectomy for NSCLC between 1981 and 2005 was undertaken. There were 186 (85%) men and 32 women with a mean age of 61.9 years (range, 19-82 years). Eighty patients (36.6%) had a preoperative contraindication to pneumonectomy. Right upper lobectomy was the most common operation (45.4%). Vascular sleeve resection was performed in 28 patients (12.8%) and was commonly associated with left upper lobectomy (n=20; 9.1%; p=0.0001). The histologic type was predominantly squamous cell carcinoma (n=164; 75%), followed by adenocarcinoma (n=46; 21%). Resection was incomplete in nine (4.1%) patients. RESULTS: There were nine operative deaths; the operative mortality and the morbidity rates were 4.1% and 22.9%, respectively. A total of 14 (6.4%) patients presented with bronchial anastomotic complications: two were fatal postoperatively, seven patients required reoperation, three required a stent insertion, and two were managed conservatively. Multivariate analysis showed that compromised patients (p=0.001), current smoking (p=0.01), right sided resections (p=0.003), bilobectomy (p=0.03), squamous cell carcinoma (p=0.03), and presence of N1 or N2 disease (p=0.01) were risk factors for mortality and morbidity. Follow-up was complete in 208 patients (95.4%). Overall 5-year and 10-year survival rates were 53% and 28.6%, respectively. After complete resection, recurrence was local in 10 patients, mediastinal in 20, and distant in 25. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0-N1 vs N2; p=0.01) and the stage of the lung cancer (stage I-II vs III, p=0.02). CONCLUSIONS: For patients with NSCLC, sleeve lobectomy achieves local tumor control, even in patients with preoperative contraindication to pneumonectomy and is associated with low mortality and bronchial anastomotic complication rates. Postoperative complications are higher in compromised patients, smokers, N disease, right sided resections, bilobectomies, and squamous cell cancers. The presence of N2 disease and stage III significantly worsen the prognosis.     

Does pneumonectomy for lung cancer adversely influence long-term survival?

OBJECTIVE: The increased operative mortality associated with pneumonectomy has stimulated the use of lung-sparing operations such as sleeve lobectomy. Whether pneumonectomy adversely affects long-term outcome after lung resection is unknown. METHODS: We reviewed the cases of patients who underwent lobectomy/bilobectomy or pneumonectomy because of non-small cell lung cancer between January 1980 and June 1998. Survival curves were compared by the log-rank test. Covariates were determined for operative mortality and survival using logistic regression analysis and Cox proportional hazards estimation, respectively. RESULTS: There were 259 men and 183 women who underwent lobectomy/bilobectomy (340) or pneumonectomy (102). Operative mortality was 36 (8.1%) patients overall, 24 (7.0%) for lobectomy/bilobectomy and 12 (12%) for pneumonectomy. Mean follow-up was 41 months (range 0-222 months). Median survival was worse for pneumonectomy (stage II: 17.9 vs 36.3 months, log-rank P =. 05; stage III: 11.7 vs 21.3 months, log-rank P =.07). However, important covariates for survival were age, primary tumor status, regional nodal status, and forced expiratory volume in 1 second. After adjusting for these covariates, survival did not differ significantly between the types of operations (hazard ratio for pneumonectomy 1.21; 95% CI 0.88-1.68). CONCLUSIONS: We did not detect a significant long-term adverse influence of pneumonectomy on survival after adjusting for other prognostic factors, but randomized clinical trials would be needed to definitively address this issue.     

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.     

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.     

Sleeve lobectomy for carcinoma of the lung.

Sleeve lobectomy for non-oat cell carcinoma involving a major bronchus preserves functioning lung tissue and, in carefully selected patients, provides long-term survival comparable to pneumonectomy. Seventy patients underwent sleeve lobectomy between 1967 and 1978. Twenty-seven patients were considered compromised (Group I) because they had severe respiratory impairment which contraindicated pneumonectomy. Forty-three patients were considered uncompromised (Group 2) and underwent elective sleeve lobectomy. Seventy patients with a similar non-oat cell carcinoma involving the proximal bronchi underwent pneumonectomy (Group 3) during this period. Perioperative complications occurred more frequently in Group 1 (59%) than in Group 2 (21%) or Group 3 (23%). Both periopeative mortality rate and the incidence of bronchial disruption (bronchovascular and bronchopleural fistulas) were higher in Group I (19% and 22%) than in Group 2 (9% and 5%) or Group 3 (3% and 7%). Survival depended primarily on the surgeon's ability to perform a complete resection of the tumor. An incomplete resection resulted when tumor was found in the highest lymph node or in the last bronchial resection margin when paraffin sections were reviewed. The 5 year survival rate was 18% for compromised patients (Group 1) who underwent complete resection, and there were no survivors among patients undergoing incomplete resections. Uncompromised patients ( Group 2) had a 5 year survival rate of36% with complete and 12% with incomplete resections. Pneumonectomy patients (Group 3) had a 64% 5 year survival rate with a complete resection and 16% with an incomplete resection. The stage of the disease at the time of operation had a profound effect on the survivail. There was no difference inthe 5 and 8 year survival rates between uncompromised patients undergoing sleeve resection ( Group 2) and patients undergoing peneumonectomy (Group 3) for comparable stage of their disease. A careful pre- and postoperative functional assessment revealed that pulmonary performance was improved in 44% of Group 1, 63% of Group 2, and only 14% of Group 3 patients. Patients wiht impaired pulmonary reserve underwent sleeve lobectomy with an adequate disease-free interval when complete tumor excision was possible. Uncompromised patients whose extensive disease required incomplete resection had palliation by sleeve lobectomy equivalent to that by pneumonectomy. When complete t-mor resection was possible, patients with uncompromised pulmonary reserve had a perioperative complication rate and long-term survival equivalent to that of pneumonectomy while preserving pulmonary parenchyma, which permitted an improvement in postoperative pulmonary performance.     

Management of traumatic lung injury: a Western Trauma Association Multicenter review.

BACKGROUND: Improved outcomes following lung injury have been reported using "lung sparing" techniques. METHODS: A retrospective multicenter 4-year review of patients who underwent lung resection following injury was performed. Resections were categorized as "minor" (suture, wedge resection, tractotomy) or "major" (lobectomy or pneumonectomy). Injury severity, Abbreviated Injury Scale (AIS) score, and outcome were recorded. RESULTS: One hundred forty-three patients (28 blunt, 115 penetrating) underwent lung resection after sustaining an injury. Minor resections were used in 75% of cases, in patients with less severe thoracic injury (chest AIS scores "minor" 3.8 +/- 0.9 vs. "major" 4.3 +/- 0.7, p = 0.02). Mortality increased with each step of increasing complexity of the surgical technique (RR, 1.8; CI, 1.4-2.2): suture alone, 9% mortality; tractotomy, 13%; wedge resection, 30%; lobectomy, 43%; and pneumonectomy, 50%. Regression analysis demonstrated that blunt mechanism, lower blood pressure at thoracotomy, and increasing amount of the lung resection were each independently associated with mortality. CONCLUSION: Blunt traumatic lung injury has higher mortality primarily due to associated extrathoracic injuries. Major resections are required more commonly than previously reported. While "minor" resections, if feasible, are associated with improved outcome, trauma surgeons should be facile in a wide range of technical procedures for the management of lung injuries.     

肺动脉切除重建术在肺癌外科治疗中的应用

目的 总结肺动脉切除重建术在肺癌外科治疗中应用的经验。方法 对36例中心型肺癌侵犯肺动脉的病人行肺动脉切除重建术。重建术采用自体心包移植补片5例、奇静脉移植补片3例、心包管间位移植2例,肺动脉袖式切除9例,侧壁切除17例;同时支气管袖式切除30例,肺叶切除6例。术后辅助放疗14例,化疗12例。结果 术后1例支气管吻合口瘘者死亡,余者肺通气及灌注良好。术后1、3和5年生存率分别为82．9％、48．1％和35．3％。结论 应用自体心包、奇静脉移植及直接肺动脉重建术治疗中心型肺癌是一种安全、有效、可靠的术式,能扩大手术适应证,彻底切除肿瘤,保存肺功能,疗效满意。     

Long-term Doppler echocardiographic evaluation of the right heart after major lung resections.

OBJECTIVE: The effects of major lung resections on cardiac function in the medium and long term have not been thoroughly evaluated. We have studied right heart function with serial Doppler echocardiography in patients undergoing lobectomy and pneumonectomy during 4 years of follow-up after surgery. METHODS: Thirty-six patients undergoing lobectomy and 15 receiving pneumonectomy were evaluated with one- and two-dimensional Doppler standard transthoracic echocardiography before surgery and 1 week, 3 months, 6 months, 1 year, and 4 years postoperatively. We have studied the right midventricular diastolic diameter (RVDD), the right ventricle free wall thickness, the tricuspid valve insufficiency (TVI) and regurgitation jet (TRJ), and the pulmonary artery systolic pressure (PASP). RESULTS: None of the patients died within the first postoperative year. After lobectomy there were no significant modifications of any variable at any time. RVDD progressively increased after pneumonectomy (26.5+/-2.2mm preoperatively vs 34.3+/-7.6 at 4 years; p<0.001). Four years after surgery all patients undergoing pneumonectomy had moderate TVI while only 55% of patients receiving lobectomy showed it (low grade in 50% and moderate in 5%). In this group of patients PASP increased from 26.1+/-2.6 mmHg preoperatively to 34.3+/-7.6 mmHg at 4 years (p<0.00001). CONCLUSIONS: Right ventricle modifications are clearly evident after pneumonectomy and even if they do not show a clear clinical impact they should not be neglected.     

Modern thirty-day operative mortality for surgical resections in lung cancer

Modern postoperative mortality rates for resectional operations for lung cancer are not readily available. In recent publications estimating the risk factors for surgical resection, mortality rates of 10% to 15% for pneumonectomy and 5% to 7% for lobectomy are frequently quoted. In order to determine modern operative mortality rates (up to 30 days postoperatively), the Lung Cancer Study Group (LCSG) analyzed the surgical mortality rates of the various participating centers during the years 1979 to 1981. A total of 2,200 resections for lung cancer were available for analysis. Of the 2,220 resections performed, 1,058 were lobectomies, 569 were pneumonectomies, and 143 were lesser resections (segmental or wedge). Eighty-one postoperative deaths occurred from among the 2,220 resections (3.7%). The mortality rate for pneumonectomy was 6.2% and for lobectomy, 2.9%. Lesser resections carried a 1.4% mortality rate, not statistically different from lobectomy. In patients under the age of 60 years, the mortality rate was 1.3%, 60 to 69 years, 4.1%, and over 70 years, 7.1%, all significantly different (p less than 0.01). The postoperative mortality rate for patients 70 years or older was 7.1% (pneumonectomy 5.9% and lobectomy 7.3%). It is obvious that greater care was taken in selection among the older pneumonectomy patients. The striking similarity of postoperative mortality rates for resectional operations for lung cancer among the various centers of the LCSG and among the various institutions within these centers suggest that these data are a reasonably accurate analysis of modern surgical mortality rates in the treatment of lung cancer.     

Sleeve lobectomy for bronchogenic cancers: factors affecting survival

BACKGROUND: Sleeve lobectomy is a parenchyma-sparing procedure that is particularly valuable in patients with cardiac or pulmonary contraindications to pneumonectomy. The purpose of this study is to report our experience with sleeve lobectomy for bronchogenic cancer and to investigate factors associated with long-term survival. METHODS: Between January 1981 and June 2001, 169 patients underwent sleeve lobectomy for non-small-cell lung cancer (n = 139) or carcinoid tumor (n = 30), including 61 with a preoperative contraindication to pneumonectomy. Mean age was 59 +/- 14 years (range, 19 to 82 years). Vascular sleeve resection was performed in 11 patients. The remaining bronchial stump contained microscopic disease in 7 patients. RESULTS: Major bronchial anastomotic complications occurred in 6 (3.6%) patients: one was fatal postoperatively, three required reoperation, and two were managed conservatively. In the non-small-cell lung cancer group, operative mortality was 2.9% (4 of 139), and overall 5-year and 10-year survival rates were 52% and 28%, respectively. Six patients experienced local recurrence after complete resection. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0 or N1 versus N2; p = 0.01) and microscopic invasion of the bronchial stump (p = 0.02). In the carcinoid tumor group, there were no operative deaths, and overall 5-year and 10-year survival rates were 100% and 92%, respectively. CONCLUSIONS: Sleeve lobectomy achieves local tumor control and is associated with low mortality and bronchial anastomotic complication rates. Long-term survival is excellent for carcinoid tumors. For patients with non-small-cell lung cancer, N2 disease or incomplete resection is associated with a worse prognosis; outcome is not affected by presence of a preoperative contraindication to 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 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 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.     

Sleeve lobectomy for non-small cell lung cancer and carcinoids: results in 160 cases.

OBJECTIVE: To assess operative mortality (OM), morbidity and long-term results of sleeve lobectomies performed for non-small cell lung cancer (NSCLC) and carcinoids during a 35-year period. METHODS: A retrospective review of patients who underwent a sleeve lobectomy for NSCLC and carcinoids was undertaken, univariate and multivariate analyses of factors influencing early mortality in NSCLC were performed and for this purpose the series was split into an early and a contemporary phase, the Kaplan-Meier method was used to calculate the cumulative survival rate, and statistical significance was calculated with the log-rank test. Causes of death were evaluated in relation to the stage of the disease. RESULTS: OM for NSCLC was 14.6% in the early phase and 6% in the contemporary one; late stenosis occurred in 7.7% of NSCLC patients in the early phase and in 2% in the contemporary one. No OM or late stenosis occurred in carcinoid patients. Three, 5 and 10-year survival rates excluding carcinoids were 77, 62 and 31% for stage I(A-B), 45, 34 and 27% for stage II(A-B), 33, 22 and 0% for stage III(A-B). The 10-year survival rate for carcinoids was 100%. There was no significant difference in long-term survival between stages II and III, while the difference between stage I and stages II and III was significant (P<0.001). When survival was analyzed in relation to nodal status, 3, 5 and 10-year survival rates were 71, 57 and 33% for N0 disease, 42, 33 and 22% for N1 disease, and 34 and 19% with the last observation at 82 months of 19% for N2 disease; there was no significant difference in survival between N1 and N2 disease. A second primary lung cancer occurred in six patients (3.7%) who underwent resection. Late mortality was not related to cancer in most stage I patients while in stages II and III patients it was related to local and distant recurrences. CONCLUSIONS: Sleeve lobectomy is a valid alternative to pneumonectomy: careful patient selection and surgical technique make it possible to achieve a mortality rate comparable to or lower than that for pneumonectomy along with a better quality of life. In addition, it allows further lung resection, if necessary.     

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.     

Bronchoplastic surgery for lung cancer and the results

Fifty-nine patients with lung cancer underwent bronchoplastic surgery in our institute from September, 1965 to May, 1982. The post surgical stages of disease were as follows: 7 cases of Stage I disease, 7 cases of Stage II, 41 cases of Stage III, 4 cases of Stage IV. The bronchoplastic surgery performed included sleeve resection combined with lobectomy in 35, wedge resection combined with lobectomy in 11, reconstruction of the lower area of the trachea in 5, bronchial sleeve resection combined with pulmonary artery resection in 6 and bronchial wedge resection combined with pulmonary artery resection in 2. There was no case of operative mortality within 30 days after the operation. To prevent postoperative complications, careful techniques are required in suturing and postoperative bronchoscopic suction of intrabronchial secretion is necessary. The use of Dexon or Dexon S, polyglycolic acid sutures, showed good results. Adjuvant therapies were performed on 42 cases, including preoperative infusion of Mitomycin C into the bronchial arteries or postoperative irradiation or both. Twenty-eight of 59 were alive and well from 7 months to 16 years after the operations. The relative 5 year survival rates were 40.5 per cent in total cases and 46.5 per cent in those with squamous cell carcinomas. The prognosis of patients undergoing bronchoplasty was compared with that of patients undergoing lobectomy and pneumonectomy. There was a statistical difference between bronchoplasty and pneumonectomy.