Bronchial and Pulmonary Arterial Sleeve Resection

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$i!ure 1 %om&uted tomo!ra&hy e#ore 'to&( and a#ter 'ottom( induction

chemothera&y) *es&ite mar+ed shrin+a!e, the tumor still in#iltrates the ori!in o# the
ri!ht u&&er loe and &ossily the su&erior vena cava) -ediastinosco&y .as &er#ormed to
rule out /2 nodal involvement)
The indication #or a sleeve resection #or lun! cancer is .ell estalished: a tumor arisin!
at the ori!in o# a loar ronchus &recludin! sim&le loectomy, ut not in#iltratin! as #ar
as to re0uire &neumonectomy) Bronchial sleeve loectomy is re&orted to e ade0uate #or
51 to 21 o# &atients .ith resectale lun! cancer ut rates as hi!h as 131 have een
re&orted recently) 3t is im&ortant to &oint out that this increased rate o# sleeve loectomy
is achieved at the e4&ense o# a decreased incidence o# &neumonectomy and not o#
loectomy, .hile the oncolo!ic results remain unchan!ed)
$rom a #unctional &oint o# vie., sleeve loectomy is strictly indicated in &atients .ho
cannot .ithstand &neumonectomy, ut recent e4&eriences have sho.n that the
advanta!es o# s&arin! one lun! loe are evident also in &atients .ithout cardio"
&ulmonary im&airment)
5ncolo!ically, the &rimary !oal o# sur!ery is com&lete resection o# lun! cancer .ith
ade0uate resection mar!ins #ree o# tumor) This is all the more true #or carcinoid tumors
or eni!n lesions) 6vidence has een otained that there is little i# any !ain in e4tendin!
the resection as #ar as &neumonectomy) These considerations a&&ly also to &atients .ith
nodal involvement limited to hilar lym&h nodes '/1()
Reconstructive sur!ery o# the &ulmonary artery has e4actly the same indications,
althou!h this o&eration has een less #re0uently &er#ormed to date)
5&erative Ste&s
7oar sleeve resection
The #irst case illustrates a ri!ht u&&er loe sleeve resection) The &atient has already had
&atch reconstruction o# the S8% '$i!ure 2() The a9y!os vein arch has een resected and
the ends are li!ated .ith sil+) The ri!ht u&&er loe has een resected, and a clear distal
mar!in on the ronchus intermedius and &ro4imal mar!in on the trachea have een
otained) 3t is im&ortant that the suture line is tension"#ree) This can e achieved y
dividin! the &ulmonary li!ament and, more o#ten on the ri!ht side, y incisin! the
&ericardium around the in#erior &ulmonary vein)

$i!ure 2: The ri!ht u&&er loectomy has een com&leted, as has &atch
reconstruction o# the S8%) The a9y!os vein arch has een resected) The mar!ins o# the
trachea and ronchus intermedius are lyin! in close &ro4imity, indicatin! the asence o#
tension that .ill e &resent once the anastomosis)
$i!ure 3: The initial ronchial cartila!inous sutures have een &laced and
tied, and the memranous &ortion sutures have een &laced and tied, rin!in! the ed!es
o# the cartila!inous &ortions into closer a&&ro4imation)

$i!ure 4: The remainder o# the cartila!inous sutures have een &laced)

They .ill suse0uently e tied e!innin! at either end and .or+in! to.ards the center)
The ronchial anastomosis is &er#ormed .ith interru&ted mono#ilament asorale 4:;
sutures &laced e4tramucosally on the cartila!inous &ortion) 5n the memranous &ortion,
&lacin! the sutures sumucosally is not necessary ecause the sutures do not ul!e in the
ronchial lumen i# they are &ro&erly tied) 3nitially, t.o sutures are &laced on the #ar
'mediastinal( end o# the cartila!inous &ortion and are tied e4traluminally) The sur!eon
ties the suture on his side .hile the assistant a&&ro4imates his to relieve tension)
Suse0uently, the assistant ties his suture .ithout tension than+s to the &reviously tied
suture) The memranous &ortion sutures are then &laced and tied '$i!ure 3()
The remainin! sutures are then &laced on the rest o# the ronchial circum#erence and are
le#t untied '$i!ure 4() The sutures are then tied, startin! #rom the either end o# the
cartila!inous &ortion and .or+in! to.ards the middle) Placin! and tyin! the sutures in
this order allo.s com&ensation #or even lar!e calier discre&ancies) This techni0ue
&revents torsion o# the ronchial a4is and !ently stretches and dilates the circum#erence
o# the distal ronchus) The lar!er ronchial stum& .or+s as a stent, increasin! the
calier o# the anastomosis and minimi9in! secretion retention in the early &osto&erative
course .hen edema at the site o# the anastomosis is more li+ely to occur) The
anastomosis is .ra&&ed .ith a vasculari9ed &edicle o# autolo!ous tissue, usually an
intercostal muscle #la&)

7e
#t
Ri!ht
$i!ure 5: The ri!ht u&&er loe ronchus has een &reserved #or reim&lantation) 3ts short
len!th e#ore 'le#t( and a#ter 'ri!ht( division is evident)
<Y<resection .ith loar reim&lantation
3n case o# u&&er loe reim&lantation a#ter =Y> sleeve resection, a #e. technical &oints
should e considered) The u&&er loe ronchus is o#ten so short that it is reduced to a
dis+ o# ronchial tissue .here the o&enin!s o# the se!mental ronchi can e seen) This is
more #re0uent on the ri!ht side '$i!ure 5() Also, the &ulmonary artery and the lun! are
very close to the suture line and the e4&osure is &oor, es&ecially on the mediastinal side
o# the anastomosis '$i!ure 6() The anastomosis is &er#ormed in the same #ashion as
descried aove '$i!ure ?()

$i!ure 6: The ri!ht u&&er loe ronchus 'ri!ht( and ri!ht mainstem ronchial
stum& 'le#t( are rou!ht into close a&&ro4imation) /ote the &ro4imity o# the a9y!os
vein, &ulmonary artery, and lun! &arenchyma)
$i!ure ?: The anastomosis et.een the ri!ht u&&er loe ronchus and the ri!ht
mainstem ronchus is &er#ormed)

$i!ure 2: %om&uted tomo!ra&hic evidence o# in#iltration o# the le#t

&ulmonary artery)
Patch reconstruction o# &ulmonary artery
This techni0ue is very versatile and can e used in a variety o# circumstances) These
ran!e #rom limited in#iltration involvin! the ori!in o# se!mental arteries to lar!e de#ects
e4tended lon!itudinally on the PA '$i!ures 2, @() The only necessary condition is that
the o&&osite side o# the circum#erence o# the PA is #ree #rom tumor)

7e#t Ri!ht
$i!ure @: 7ine dra.in! 'le#t( and intrao&erative ima!e 'ri!ht( sho.in! the usual &attern
o# in#iltration o# the interloar &ortion o# the &ulmonary artery &osterior to the le#t u&&er
loe ronchus)A

$i!ure 1;: 5val de#ect in the interloar &ortion o# the le#t &ulmonary artery a#ter
le#t u&&er loectomy)
*urin! resection control o# the main &ulmonary artery and the in#erior &ulmonary vein
is otained) The su&erior &ulmonary vein is divided in a standard #ashion) Pulmonary
arterial tissue is resected en loc .ith the s&ecimen) A#ter the resection, an oval de#ect
oriented alon! the PA a4is remains, even i# the resected &ortion .as circular in sha&e
'$i!ure 1;() This is due to the tension a&&lied on the vessel y the lo.er loe) The &atch
should e tailored accordin! to the si9e and sha&e o# the resected &ortion rather than
accordin! to the PA de#ect '$i!ure 11() A#ter the &atch is secured to the artery y 5:; or
6:; mono#ilament runnin! suture, the PA is declam&ed '$i!ure 12() The suture line must
e chec+ed care#ully #or oo9in!, .hich mi!ht not e evident due to the lo. PA &ressure)
Also it is im&ortant to chec+ the &osition o# the artery a#ter ree4&ansion o# the lo.er
loe, #or +in+in! mi!ht occur)

$i!ure 11: A suitale &ortion o# the &ericardium is harvested #or use in &atch
reconstruction o# a &ulmonary artery de#ect)
$i!ure 12: The &ulmonary artery de#ect has een success#ully &atched .ith
autolo!ous &ericardium)

$i!ure 13: 3ntrao&erative ima!e o# a lun! cancer o# the &osterior se!ment o# the
ri!ht u&&er loe in#iltratin! the &ulmonary artery) The u&&er loe is retracted u&.ard
and ac+.ard) The u&&er loe vein has een divided and the artery to the middle loe is
visile in the lo.er &ortion o# the ima!e)
$i!ure 14: A#ter ri!ht u&&er sleeve loectomy en loc .ith &artial resection o#
the PA, the stum& o# the main ronchus and the PA de#ect are visile o&en in the #ield)
3n#iltration o# the PA on the ri!ht side re0uirin! arterial reconstruction is less #re0uent)
Partial resection o# the PA o#ten is &er#ormed in conBunction .ith ri!ht u&&er loe sleeve
resection '$i!ure 13() A#ter ri!ht u&&er sleeve loectomy en loc .ith &artial resection
o# the PA, the stum& o# the main ronchus and the PA de#ect are le#t o&en in the #ield
'$i!ure 14() Carvestin! o# the &ericardium is &er#ormed as aove, ased on the si9e o#
the &ortion o# the resected &ulmonary artery) Patch reconstruction o# the PA is com&leted
as aove e#ore reim&lantation o# the ronchus to reduce the arterial clam&in! time
'$i!ure 15()

$i!ure 15: Patch reconstruction o# the &ulmonary artery is com&leted e#ore the
ronchial anastomosis is &er#ormed)
$i!ure 16: A#ter a sleeve resection o# the le#t u&&er loe .ith en loc resection o#
the entire circum#erence o# the &ulmonary artery, the de#ects are visile)
Ri!ht
$i!ure 1?: %onstruction o# a &ulmonary artery re&lacement conduit usin! a &iece o# autolo!ous &ericardium) The &iece is si9ed to match the de#ect, and is .ra&&ed around a 32 $r
chest tue 'le#t() The #ree ed!es are a&&ro4imated .ith 6:; or ?:; mono#ilament suture 'ri!ht()

$i!ure 12: The ronchial anastomosis

is com&leted #irst)
5n occasion a sleeve resection o# the u&&er loe and the &ulmonary artery is necessary
'$i!ure 16() Pulmonary artery and in#erior &ulmonary vein control are otained as
descried aove) The vascular conduit is constructed #rom a se!ment o# autolo!ous
&ericardium '$i!ure 1?() Dhen si9in! the conduit, t.o &oints must e considered: the
PA stum&s can e a&&ro4imated closer than it seems, and the conduit .ill stretch more
than &redicted) 3t is advisale to tailor the len!th o# the conduit on the asis o# the
resected arterial se!ment, ecause the elasticity o# the t.o tissues is com&arale) The
ronchial anastomosis is &er#ormed #irst to avoid traumati9in! the PA '$i!ure 12() The
PA is reconstructed y end"to"end anastomosis .ith runnin! 5:; or 6:; mono#ilament
suture '$i!ure 1@()

7e
#t
Ri!ht
$i!ure 1@: The arterial conduit is inter&osed 'le#t( and the &ro4imal and distal
anastomoses have een com&leted 'ri!ht()
A$i!ure @ Re&rinted .ith &ermission o# Rendina 6A and 8enuta $ <Reconstruction o#
the Pulmonary Artery,< %ha&ter 36 in PearsonEs Thoracic Sur!ery, Philadel&hia, D)B)
Saunders, 2;;2)
Pre#erence %ard
2)5 ma!ni#ication lou&es
Ceadli!ht
7on! '24cm( heavy titanium %astro"8ieBo needle holder '#or PA sutures(
7on! '24cm( #ine tooth #orce&s '#or mani&ulatin! the ronchus(
Ti&s F Pit#alls
3t is im&ortant that in candidates #or a sleeve resection &reo&erative ronchosco&y
is &er#ormed y one o# the o&eratin! sur!eons) This is advanta!eous at the time o# the
o&eration, .hen the ronchi are incised and divided) 3t is also use#ul to have &recise
+no.led!e o# the &reo&erative and intrao&erative a&&earance o# the air.ay i# any
ronchial com&lication should occur and laser recanali9ation or stentin! should
ecome necessary) Bronchosco&y is &er#ormed under local anesthesia to oserve
ronchial motion durin! voluntary reathin! and cou!hin!, and multi&le io&sies are
ta+en) %are#ul evaluation o# ronchial motion is im&ortant to in#er the state o# tissues
outside the ronchus, #or sti##ness o# the ronchial .all may indicate &erironchial
tumor in#iltration) This is &articularly im&ortant in areas .here the ronchus is +no.n
to e adBacent to the PA, .hich mi!ht conse0uently e involved)
Sometimes the distal ronchial incision #alls close to the ta+eo## o# the su&erior
se!mental ronchus or middle loe ronchus) This is not a contraindication to the
o&eration, ut care must e ta+en to avoid stricture o# the tiny se!mental ronchi
#allin! close to the suture line)
The use o# steroids in the &erio&erative &eriod in &atients under!oin!
tracheoronchial resection is controversial) De elieve that the antiedema e##ect o#
steroids is ene#icial ecause it reduces secretion retention and atelectasis, it
#acilitates &arenchymal ree4&ansion, and it minimi9es the ris+ o# dehiscence and
!ranuloma #ormation) Aerosoli9ed steroids 'methyl&rednisolone 5m! t.ice a day( are
also &art o# our &reo&erative treatment .hen sleeve loectomy can e &redicted
e#ore hand) 3t is our e4&erience that &atients treated .ith steroids do not need
ronchosco&y or close oservation in the &osto&erative &eriod) They recover #aster
and leave the hos&ital earlier)
Dhen the sleeve resection is &lanned &reo&eratively, .e &re&are an intercostal
&edicle #la& e#ore o&enin! the chest to avoid crushin! the intercostal vascular
undle) The intercostal muscle #la& is &recious #or &rotectin! the anastomosis, and .e
use it routinely in all our ronchial reconstructions) The #la& a##ords additional
&rotection a!ainst anastomotic #ailure and &reserves the continuity o# the air.ay in
case o# small dehiscence, thus avoidin! roncho&leural #istulas) The ris+ o# erosion o#
the adBacent PA is also minimi9ed) 3n addition, the revasculari9ation o# the distal
ronchus avoids &rolems related to ischemia)
The &osto&erative course o# ronchial sleeve resection de&ends to some e4tent on
&atient com&liance and Budicious clinical mana!ement) The short"term results o# PA
reconstruction de&end mostly on o&erative Bud!ment and techni0ue) 3# the o&eration
has een correctly &er#ormed, s&eci#ic com&lications may e e4&ected in no more
than 51 o# the &atients)
Because the PA is a lo. &ressure vessel, lea+a!e #rom the suture line may !o
unnoticed intrao&eratively) Also, the leedin! may start in the #irst or second
&osto&erative day a#ter a &atch reconstruction) A lood loss o# u& to 2;;ml to 1;;;ml
daily may occur a#ter 1 or 2 days o# no draina!e) This may last #or 1 or 2 days and
then sto& s&ontaneously inde&endent o# anticoa!ulant usa!e) A &ossile e4&lanation is
that the autolo!ous &ericardium shrin+s and curls mar+edly a#ter harvestin!, and it is
di##icult to &lace the suture ites at the a&&ro&riate distance) A#ter declam&in! and
distention, ites too .ide a&art may result) These .ould not cause leedin!
immediately ecause the PA is stretched do.n.ard y the atelectatic lo.er loe, and
sim&le a&&osition o# the tissue ed!es is enou!h to overcome the lo. PA &ressure)
Co.ever, in the &osto&erative &eriod, .hen the ree4&ansion o# the lo.er loe
elevates the hilum, the rotation and +in+in! o# the PA may distort the suture line and
o&en a leedin! site) 3t is there#ore very im&ortant, es&ecially .hen usin! autolo!ous
&ericardial &atches, to care#ully chec+ the suture line and test the PA &osition a#ter
ree4&ansion o# the residual loe) The latter maneuver is also im&ortant to &revent
thromosis) A#ter a &atch reconstruction o# the PA associated .ith a ronchial sleeve,
the ronchial a4is is shortened, and the len!th remains stationary) Some o# the
discre&ancy is com&ensated y the elasticity o# the vessel, ut the PA may tend to
+in+ and #old over itsel#) The a#orementioned re&ositionin! o# the PA due to the
ree4&ansion o# the lo.er loe #urther increases the ris+) 3m&airment o# lood #lo.
may ensue, and thromosis may e #acilitated) Gnder these circumstances, it is etter
to cut the distorted se!ment a.ay and &roceed to an end"to"end anastomosis)
Sometimes sleeve resection and end"to"end anastomosis are anatomically
im&ossile, such as in cases o# le#t u&&er loe tumors in#iltratin! the concave sur#ace
o# the PA #rom its ori!in do.n to the anteroasal artery) 5n the ri!ht side, the same
&rolem may arise .hen the &osterolateral as&ect o# the PA is in#iltrated #rom the
u&&er division artery to the artery #or the su&erior se!ment o# the lo.er loe)
Sleeve resection is sometime e4cessive i# the artery is only &artially in#iltrated)
An end"to"end anastomosis can e technically di##icult, o.in! to une4&ected
traction et.een the stum&s and calier discre&ancy) Tears on the arterial .all .hile
suturin! are di##icult to re&air, and #ailure to do so may &roduce disastrous results)
The main &it#alls o# the use o# a conduit are its si9in! and len!th) A&&lication o#
the &reviously mentioned technical insi!hts .ill &revent this &rolem)
Results
The recent literature contains a numer o# re&orts on the #avorale results o# sleeve
resection) %om&ared to &neumonectomy, com&lications and mortality are lo.er,
cardio&ulmonary #unction is more satis#actory, and lon!"term survival rates are
com&arale) 3n addition, a numer o# &a&ers dealin! more s&eci#ically .ith resection o#
the &ulmonary artery have een &ulished durin! the last #ie. years) A summary o# the
most recently &ulished data is &resented in Tales 3 to 38) All the 0uoted &a&ers a&&ear
in the 6n!lish literature and can easily een #ound in -edline)
TAB76 3 H Bronchial sleeve resection
Author Year Patients
%om&lications
'1(
Technical
%om&lications
'1(
-ortality
'1(
Survival
'5 yrI 1(
Ja.ahar
a
1@@4 112 ns 15)6 ns ns
8an
Schil
1@@6 145 12)6 ns 4)2 46
Kaissert 1@@6 ?2 11 1)3 4 42
Rea 1@@? 21? 12)5 ns 6)2 4@
3card 1@@@ 11; 5; 4)5 2)?5 3@
Jutlu 1@@@ 1;; 12 2 2 4@A
-assard 1@@@ 63 22)5 @)5 1)6 43
Suen 1@@@ ?? 41)3 3)2 5)2 3?)5
Tronc 2;;; 124 14)1 3)2 1)6 52
5+ada 2;;; 151 1; ; ; 42
7auser! 2;;; 21 ns ; 1)2 61)@AA
Rendina 2;;; 145 12)4 2)? 3 3?)@
Collaus 2;;1 15 26)6 6)6 ; 42AAA
A $rom 6 to 162 months, AA2 years, AAA52 months
TAB76 33 H Reconstruction o# the PA alone or associated .ith ronchial sleeve
Author Year Patients
%om&lications
'1(
Technical%om&lications
'1(
-ortality
'1(
Survival
'5 yrI 1(
Rendina 1@@@ 52 13)4 1)@ ; 32)3
3card 1@@@ 16 ns ns ns 3@A
Shra!er 2;;; 33 6)1 ns ns 46)6
7auser
!
2;;; 4 ns ; ns 61)@A
5+ada 2;;; 21 ns ; ; 42A
A 5verall survival o# PA and ronchial reconstruction
TAB76 333 H $ive and 1; year survival rates a#ter roncho&lastic &rocedures y lym&h
node status
Author Year Patients 5 year survival '1( 1; year survival '1(
/; /1 /2 /; /1 /2
Rea 1@@? 1?@ ?2 36 22 5@ 2? 14
3card 1@@@ 11; 5? 2@ 33 26 12 33
Tronc 2;;; 124 63 42 6 42 2? ;
8an
Schil
2;;; 145 62 2@ 31 53 21 6
5+ada 2;;; 6; ?; 21 55 ;
TAB76 38 H %om&arative results o# sleeve loectomy and &neumonectomy in /S%7%
Author Year Patients %om&lications '1( -ortality '1( 5 year survival '1(
Sl Pn Sl Pn Sl Pn Sl Pn
S
l
Yoshino 1@@?
2
@
2@
13)
?
24)1 ; 6)@
65)
?
52)2A "
Suen 1@@@
5
2
142 1)? ?); AA
5)
2
4)@
3?)
5
35)2 "
5+ada 2;;;
6
;
6; 13 22 ; 2 42 36 2
Sl : Sleeve 7oectomy Pn : Pneumonectomy
A 3 year survival AA only &osto&erative res&iratory #ailure