bronchial and pulmonary arterial sleeve resection

8/11/2019 Bronchial and Pulmonary Arterial Sleeve Resection

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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 torule 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 #or5 to o# &atients .ith resectale lun! cancer ut rates as hi!h as 13 have eenre&orted recently) t is im&ortant to &oint out that this increased rate o# sleeve loectomy

is achieved at the e&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 .hocannot .ithstand &neumonectomy, ut recent e&eriences have sho.n that the

advanta!es o# s&arin! one lun! loe are evident also in &atients .ithout cardio"

&ulmonary im&airment)

ncolo!ically, the &rimary !oal o# sur!ery is com&lete resection o# lun! cancer .ithade0uate resection mar!ins #ree o# tumor) This is all the more true #or carcinoid tumors

or eni!n lesions) vidence has een otained that there is little i# any !ain in etendin!

the resection as #ar as &neumonectomy) These considerations a&&ly also to &atients .ithnodal involvement limited to hilar lym&h nodes '/1()
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Reconstructive sur!ery o# the &ulmonary artery has eactly the same indications,

althou!h this o&eration has een less #re0uently &er#ormed to date)

&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 andthe 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 &roimal mar!in on the trachea have een

otained) t is im&ortant that the suture line is tension"#ree) This can e achieved ydividin! the &ulmonary li!ament and, more o#ten on the ri!ht side, y incisin! the

&ericardium around the in#erior &ulmonary vein)

ectomy has een com&leted, as has &atch

e a9y!os vein arch has een resected) The mar!ins o# the

ius are lyin! in close &roimity, indicatin! the asence o#

e the anastomosis)

$i!ure 3: The initial ronchial cartila!in

tied, and the memranous &ortion sutures have een &l

o# the cartila!inous &ortions into closer a&&roimation

$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 etramucosally on the cartila!inous &ortion) n 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) nitially, t.o sutures are &laced on the #ar

'mediastinal( end o# the cartila!inous &ortion and are tied etraluminally) The sur!eonties the suture on his side .hile the assistant a&&roimates 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


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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 ais 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&erativecourse .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) ts shortlen!th e#ore 'le#t( and a#ter 'ri!ht( division is evident)


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e ronchus 'ri!ht( and ri!ht mainstem ronchial

ose a&&roimation) /ote the &roimity o# the a9y!osn! &arenchyma)

$i!ure ?: The anastomosis et.een the ri!ht u&&

mainstem ronchus is &er#ormed)

$i!ure : %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

etended lon!itudinally on the PA '$i!ures , @() 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)

$i!ure 1;: val de#ect in the interloar &ortion o# the le#t &ulmonary artery a#ter
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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#ectoriented alon! the PA ais 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 thanaccordin! 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 ree&ansion o# the lo.erloe, #or +in+in! mi!ht occur)

o# the &ericardium is harvested #or use in &atch

artery de#ect)

$i!ure 12: The &ulmonary artery de#ect has een

autolo!ous &ericardium)

!e o# a lun! cancer o# the &osterior se!ment o# the

&ulmonary artery) The u&&er loe is retracted u&.ard

vein has een divided and the artery to the middle loe ishe ima!e)

$i!ure 14: A#ter ri!ht u&&er sleeve loectom

the PA, the stum& o# the main ronchus and the PA de#

n#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 conunction .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()

on o# the &ulmonary artery is com&leted e#ore the

rmed)

$i!ure 16: A#ter a sleeve resection o# the le#t u&&e

the entire circum#erence o# the &ulmonary artery, the d


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Ri!ht

ulmonary artery re&lacement conduit usin! a &iece o# autolo!ous &ericardium) The &iece is si9ed to match the de#ec

s are a&&roimated .ith 6; or ?; mono#ilament suture 'ri!ht()

$i!ure 1: The ronchial anastomosis

is com&leted #irst)

n 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 asdescried 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&&roimated closer than it seems, and the conduit .ill stretch morethan &redicted) t 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 1() The

PA is reconstructed y end"to"end anastomosis .ith runnin! 5; or 6; mono#ilamentsuture '$i!ure 1@()


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7e

#t

Ri!ht

$i!ure 1@: The arterial conduit is inter&osed 'le#t( and the &roimal and distalanastomoses have een com&leted 'ri!ht()

$i!ure @ Re&rinted .ith &ermission o# Rendina A and 8enuta $


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steroids is ene#icial ecause it reduces secretion retention and atelectasis, it

#acilitates &arenchymal ree&ansion, and it minimi9es the ris+ o# dehiscence and

!ranuloma #ormation) Aerosoli9ed steroids 'methyl&rednisolone 5m! t.ice a day( arealso &art o# our &reo&erative treatment .hen sleeve loectomy can e &redicted

e#ore hand) t is our e&erience that &atients treated .ith steroids do not need

ronchosco&y or close oservation in the &osto&erative &eriod) They recover #asterand 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 vascularundle) 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 adacent PA is also minimi9ed) n addition, the revasculari9ation o# the distal

ronchus avoids &rolems related to ischemia) The &osto&erative course o# ronchial sleeve resection de&ends to some etent on

&atient com&liance and udicious clinical mana!ement) The short"term results o# PAreconstruction de&end mostly on o&erative ud!ment and techni0ue) # the o&eration

has een correctly &er#ormed, s&eci#ic com&lications may e e&ected in no morethan 5 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 ;;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 e&lanation is

that the autolo!ous &ericardium shrin+s and curls mar+edly a#ter harvestin!, and it isdi##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, andsim&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 ree&ansion o# the lo.er loe

elevates the hilum, the rotation and +in+in! o# the PA may distort the suture line ando&en a leedin! site) t 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

ree&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 ais 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 theree&ansion o# the lo.er loe #urther increases the ris+) m&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) n the ri!ht side, the same

&rolem may arise .hen the &osterolateral as&ect o# the PA is in#iltrated #rom the


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u&&er division artery to the artery #or the su&erior se!ment o# the lo.er loe) Sleeve resection is sometime ecessive i# the artery is only &artially in#iltrated) An end"to"end anastomosis can e technically di##icult, o.in! to une&ectedtraction 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) n 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 to 8) All the 0uoted &a&ers a&&earin the n!lish literature and can easily een #ound in -edline)

TAB7 H Bronchial sleeve resection

Author Year Patients %om&lications'(

Technical

%om&lications'(

-ortality'( Survival'5 yrI (

Ja.ahara

1@@4 112 ns 15)6 ns ns

8an

Schil1@@6 145 1)6 ns 4) 46

Kaissert 1@@6 ?2 11 1)3 4 42

Rea 1@@? 21? 12)5 ns 6)2 4@

card 1@@@ 11; 5; 4)5 2)?5 3@

Jutlu 1@@@ 1;; 12 2 2 4@

-assard 1@@@ 63 2)5 @)5 1)6 43

Suen 1@@@ ?? 41)3 3) 5)2 3?)5

Tronc 2;;; 14 14)1 3)2 1)6 52

+ada 2;;; 151 1; ; ; 4


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7auser! 2;;; 1 ns ; 1)2 61)@

Rendina 2;;; 145 12)4 2)? 3 3?)@

Collaus 2;;1 15 26)6 6)6 ; 4

$rom 6 to 16 months, 2 years, 5 months

TAB7 H Reconstruction o# the PA alone or associated .ith ronchial sleeve

Author Year Patients%om&lications

'(

Technical%om&lications

'(

-ortality

'(

Rendina 1@@@ 52 13)4 1)@ ;

card 1@@@ 16 ns ns nsShra!er 2;;; 33 6)1 ns ns

7auser

!2;;; 4 ns ; ns

+ada 2;;; 21 ns ; ;

verall survival o# PA and ronchial reconstruction

TAB7 H $ive and 1; year survival rates a#ter roncho&lastic &rocedures y lym&h

node status

Author Year Patients 5 year survival '( 1; year survival '(

/; /1 /2 /; /1 /2

Rea 1@@? 1?@ ?2 36 22 5@ 2? 14

card 1@@@ 11; 5? 2@ 33 26 1 33

Tronc 2;;; 14 63 4 6 4 2? ;

8anSchil

2;;; 145 62 2@ 31 53 21 6

+ada 2;;; 6; ?; 21 55 ;

TAB7 8 H %om&arative results o# sleeve loectomy and &neumonectomy in /S%7%


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Author Year Patients %om&lications '( -ortality '( 5 year survival '

Sl Pn Sl Pn Sl Pn Sl Pn

Yoshino 1@@?2

@2@

13)

?24)1 ; 6)@

65)

?5)

Suen 1@@@5

142 1)? ?);

5)

24)@

3?)

535)

+ada 2;;;6

;6; 13 22 ; 2 4 36

Sl : Sleeve 7oectomy Pn : Pneumonectomy

3 year survival only &osto&erative res&iratory #ailure

bronchial and pulmonary arterial sleeve resection

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