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Ann Thorac Surg 1996;62:824-828
© 1996 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Bronchoplasty in the Management of Low-Grade Airway Neoplasms and Benign Bronchial Stenoses

Raphael Bueno, MD, John C. Wain, MD, Cameron D. Wright, MD, Ashby C. Moncure, MD, Hermes C. Grillo, MD, Douglas J. Mathisen, MD

General Thoracic Surgical Unit, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
See also page 828

Background. Parenchyma-sparing bronchoplastic procedures have altered the management of benign bronchial stenoses and low-grade neoplasms of the airway. Reliable techniques are available to allow sleeve resection of any lobe or the main bronchus and thus maximize preservation of lung parenchyma.

Methods. Between 1972 and 1995 we performed 100 bronchoplastic procedures on 99 patients. Seventy-eight patients had low-grade or benign tumors including carcinoid, mucoepidermoid, and fibrous histiocytomas. Seven patients had inflammatory lesions including histoplasmosis and tuberculosis. Two patients had idiopathic stenosis. Thirteen patients had stenoses due to prior trauma or previous operation. Resection involved the bronchus alone in 51 cases. Sleeve lobectomies were done in 49 patients.

Results. There were two postoperative deaths in complicated patients. Major complications occurred in 3 patients. Sixteen patients presented preoperatively with postobstructive pneumonia but had no major postoperative complications. Long-term follow-up (mean, 88 months) reveals only one instance of tumor recurrence (adenoidcystic carcinoma) and progressive stenosis in 1 patient with idiopathic stenosis.

Conclusions. Lung-sparing bronchoplastic operations are the procedures of choice in anatomically suited patients with low-grade malignant tumors of the airway and benign bronchial stenosis.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
See also page 828.

Low-grade malignant bronchial tumors such as carcinoid and mucoepidermoid tumors frequently involve the origin of the major bronchi as do rare benign neoplasms. Wilkins and colleagues [1] recognized the impact of bronchoplastic procedures (sleeve resection) on the management of these tumors. Pneumonectomy should no longer be required for such tumors involving the lobar orifice or main bronchus. Because a minimal margin is all that is required for cure of most of these tumors, bronchoplastic procedures allow removal of the tumor and preservation of uninvolved lung, giving a better functional result for the patient. Any lobe of either lung is potentially suitable for such bronchoplastic procedures for appropriate low-grade malignancies.

Non-neoplastic stenosis of the airway occurs as well, but not as commonly. Posttraumatic stenosis of the bronchus after attempted repair or delayed presentation of unrecognized bronchial trauma weeks to months later are the most common causes of nonmalignant bronchial stenosis. Less common causes include infections, postsurgical stenosis, and idiopathic stenosis. When these lesions do occur, they tend to involve the main bronchus, sparing the lobar orifices. Because of the predilection for the main bronchus, bronchoplastic resection of such lesions has the potential to preserve all lung parenchyma.

We have used bronchoplastic procedures whenever possible to manage patients with anatomically suited low-grade neoplasms and benign stenosis of the airway. This report describes the outcome of 100 consecutive bronchoplastic resections in 99 patients.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patients
Ninety-nine consecutive patients underwent 100 bronchoplastic procedures for benign stenosis and low-grade tumors at the Massachusetts General Hospital from 1972 until 1995. Data were collected by review of hospital and office records, and by direct contact with patients and their local physicians. Forty-eight patients were male and 51 were female. The mean age was 42 years, with a range of 10 to 68 years.

Symptoms
Ninety-three patients were symptomatic and had an average of 2.5 symptoms. The presenting signs and symptoms were as follows:

Sixteen patients presented with acute postobstructive pneumonia. These patients were aggressively treated with bronchoscopic drainage and an average of 4.5 days of intravenous antibiotic therapy before resection. Acute sepsis was controlled with this approach.

Preoperative Laser Treatments
Six patients underwent bronchoscopic laser therapy before referral. One had laser treatment for squamous metaplasia of the left main bronchus, which resulted in left main bronchial stenosis. Four low-grade tumors were unsuccessfully treated by laser resection. These patients were referred for sleeve resection after recurrence. One patient unsuccessfully treated for inflammatory stenosis by laser resection was referred after stenosis recurred.

Operative Technique
Rigid and flexible bronchoscopy were undertaken to delineate the anatomy and degree of bronchial involvement. Biopsy specimens were taken for frozen section when the results could affect the operative strategy. Double-lumen endotracheal tubes were preferred whenever possible for safe conduct of anesthesia and protection of the opposite lung from contamination by purulent secretions. Standard surgical technique was used for lobectomy until the bronchus was encountered.

The area of involved bronchus was carefully dissected to preserve peribronchial blood supply. Proximal and distal points of transection were determined and the bronchus precisely divided. Additional pieces of proximal and distal margin were removed for frozen section evaluation when dealing with tumors. This avoided confusion, which may result from sections taken from the main specimen. Full-thickness traction sutures of 2-0 Vicryl (Ethicon, Somerville, NJ) were placed proximally and distally in the midlateral position of the bronchus. These approximated the airway, reduced tension during tying of the anastomotic sutures, and were left in place at the completion of the procedure. The anastomosis was performed in open fashion to allow precise placement of sutures commencing posteriorly. Anastomotic sutures of 4-0 Vicryl were placed so that the knots were outside of the lumen. They were placed 3 mm deep and spaced accordingly to accommodate any size discrepancy that existed between the bronchi. This resulted in some telescoping of the anastomosis, but this has not produced any problem. No attempt was made to tailor either end to make up for size discrepancy. It is our feeling that tailoring unnecessarily complicates the anastomosis. With the traction sutures pulled together and tied, each individual anastomotic suture was tied in the reverse order of placement. Once the anastomosis was completed, saline solution was placed in the pleural cavity, the lung re-expanded, and the anastomosis checked for air leaks. The anastomosis was wrapped with either pedicled pericardial fat or pleura. Flexible bronchoscopy was done at this time to confirm the alignment, patency, and adequacy of the anastomosis. It is better to identify any problem while in the operating room with the chest open rather than in the recovery room.

Tension was rarely a problem for sleeve resections of the bronchus, but needed to be avoided in every instance. Dividing the inferior pulmonary ligament was routine and was usually all that is needed. If tension existed, a U-shaped incision below the inferior pulmonary vein was usually sufficient to allow a tension-free anastomosis (Fig 1Go). This hilar release maneuver was used in 19 patients in our series (12 left, 7 right). When the entire left main bronchus is removed as in 1 of our patients, it may be necessary to completely incise the pericardium around the hilar vessels to give maximal mobility to the main bronchus. Exposure of the proximal left main bronchus for such an anastomosis was greatly enhanced by mobilizing the aorta and passing tapes around the trachea and right main bronchus to bring the left main bronchus more into the field (Fig 2Go).



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  		Fig 1. . Left-sided intrapericardial hilar release, showing the U-shaped pericardial incision allowing 1 to 2 cm of upward hilar mobility to facilitate tension-free anastomosis. (Reprinted with permission from The Society of Thoracic Surgeons [Ann Thorac Surg 1991;52:1272–80].)

 


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  		Fig 2. . Exposure for proximal left main bronchial resection. Note the tapes around the trachea, right main bronchus, right pulmonary artery, and descending aorta. These tapes provide for retraction of these structures, which allows improved exposure of the carina. (Reprinted with permission from The Society of Thoracic Surgeons [Ann Thorac Surg 1991;52:1272–80].)

 

   Results
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Indications for Operation
There were 78 benign or low-grade malignancies and 22 non-neoplastic stenoses (Table 1Go). Carcinoid was the most common tumor (n = 54). All but two were typical carcinoids, and 80% were 2 cm or smaller. Two patients with typical carcinoids and both patients with atypical carcinoids each had a single positive lymph node. Mucoepidermoid tumors, fibrous histiocytoma, adenoidcystic tumors, granular cell tumors, and hemangiopericytomas were seen much less frequently.


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  		Table 1. . Pathology of Bronchial Lesions
 
There were 22 benign stenoses in this series. Seven were the result of an infectious process, identified as histoplasmosis in 4; in 3 a specific organism could not be identified. There were 6 patients who had posttraumatic stenosis. All suffered closed chest injuries in motor vehicle accidents. Two underwent attempts at operative repair elsewhere that failed, and the other 4 were initially treated elsewhere without operation and had development of delayed stenosis. They were all operated on within a year of injury. Two women were characterized as having idiopathic stenosis because no causative agent could be identified.

Seven patients required sleeve resection for complications after prior pulmonary resection or laser treatment. Five of those patients had their initial treatment at other institutions. In 2 patients stenosis developed 4 and 5 months after prior sleeve resection. Aggressive laser treatment of squamous metaplasia of the left main bronchus resulted in bronchial stenosis in 1 patient. Postpneumonectomy syndrome with malacic compression of the left main bronchus was seen in 1 patient. In 1 patient a right middle lobe syndrome developed after right upper lobectomy for bronchiectasis. Left upper lobectomy resulted in narrowing of the left bronchus, requiring sleeve resection. Suspected residual stump cancer after right upper lobectomy for lung cancer was the indication in the final patient.

Type of Resection
Tumors can involve any bronchus or lobar orifice, but tended to involve the main bronchus or upper lobe orifice more commonly (50/78) (Table 2Go). Benign stenosis involved overwhelmingly the main bronchus (17/22). More than half of all resections (52%) were done without the need to sacrifice any lung parenchyma. In 2 patients sleeve resections of segmental bronchi were done, in 1 without loss of lung tissue (carina of upper and lower divisions of left upper lobe).


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  		Table 2. . Distribution of Resections
 
Mortality
There were two postoperative deaths, both in complex cases. In 1 patient a postpneumonectomy syndrome and compression of her main bronchus developed 8 years after a pneumonectomy for a carcinoid tumor [2]. The mediastinum was repositioned, but she continued to suffer from left main bronchial obstruction and required a stent and tracheostomy for adequate ventilation. The patient underwent a left main bronchial resection and aortic bypass graft to relieve compression, but died postoperatively. The second patient had sustained blunt traumatic injury to the left main bronchus, which was treated nonsurgically at another institution. Severe adult respiratory distress syndrome ensued. He was transferred to our institution with differential lung ventilation with one tube stenting the left main bronchus. Resection was performed, but sepsis developed and he died 2 weeks postoperatively.

Morbidity
Early postoperative problems developed in 2 patients secondary to excessive anastomotic tension. Early in our experience, 1 patient had resection of the entire left main bronchus for a mucoepidermoid tumor. Hilar release was not done. Anastomotic stenosis developed. The patient was managed with bronchoscopic dilations and successfully reoperated on 3 months later. A second patient underwent a complicated sleeve resection of the bronchus intermedius for stenosis secondary to infection from histoplasmosis. Excessive tension in a scarred and inflammed hilum resulted in anastomotic separation on postoperative day 14 requiring completion pneumonectomy. Two cases of delayed presentation of anastomotic stenosis occurred in 1 patient with recurrent adenoidcystic carcinoma and in another patient with idiopathic stenosis who had progressive stenosis and died 2 years later due to advance of her underlying disease.

Other complications that occurred in this group of patients were unrelated to the bronchoplastic repair itself:

The most common complications were prolonged air leak (greater than 7 days) and atrial fibrillation. Air leaks were parenchymal and not anastomotic. Postoperative pneumonia developed in 2 patients, but these were not patients presenting with postobstructive pneumonia.

Follow-up
Nine patients were lost to follow-up within the first postoperative year. Follow-up is complete for the remaining 90 patients (1 to 19 years). All patients had chest radiographs and bronchoscopy at 1 year and most annually thereafter until the most recent follow-up. With the exception of the 4 patients in whom early and late anastomotic problems developed as mentioned previously, all remaining anastomoses were found to be patent and without recurrence of tumor or stenosis. Three patients have died of unrelated causes and 1 died as a complication of progressive idiopathic airway stenosis. One patient is alive with recurrent adenoidcystic carcinoma, but all other patients are alive without recurrent disease.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Sleeve resection was first described by Price-Thomas [3] in England and Paulson and Shaw [4] in the United States about 40 years ago. There have been many published reports since then to support the use of bronchoplastic procedures for both benign and malignant lesions of the lung and airway [5–9]. Bronchoplastic procedures were initially developed for people with compromised lung function unable to tolerate pneumonectomy. It is now accepted as the procedure of choice for anatomically suited benign and malignant lesions regardless of pulmonary function. Survival after sleeve resection for cancer is similar to survival after pneumonectomy for similar malignant lesions [8]. Deslauriers and his colleagues [10] and our group [11] have demonstrated long-term preservation of lung function after sleeve lobectomy.

Bronchoplastic procedures for benign and low-grade malignant tumors of the airway and benign stenosis are indicated whenever anatomically suited lesions exist allowing preservation of maximum amount of pulmonary parenchyma. Benign and low-grade malignancies such as those encountered in our series require only minimal clear margins for cure and are ideally suited to bronchoplastic resections [1, 12, 13].

Postobstructive pneumonias are often encountered in patients with low-grade airway tumors or benign stenosis. This is not a contraindication to bronchoplastic procedures. Therapeutic aspiration bronchoscopy, chest physiotherapy, and appropriate antibiotic coverage as employed in our 16 patients presenting with postobstructive pneumonia should allow successful sleeve resection with no expected increase in complications.

The widespread availability of lasers has led to some enthusiasm to primarily treat low-grade airway malignancies and some benign stenoses [14, 15]. The biology of most benign stenoses does not lend itself to definitive correction by laser resection as seen in our 1 patient and the many patients we have seen with postintubation tracheal stenosis [16]. With rare exception, most low-grade malignant tumors of the airway are not amenable to curative laser resection. Most tumors (especially carcinoid) involve the airway to such an extent that full-thickness airway resection is required to remove the lesion completely. This is obviously not possible with the laser without causing serious complications. The laser in our opinion is suitable to debulk obstructing tumor to clear pneumonia, but not as definitive therapy. Such debulking can also be done by coring-out without the laser [17]. Low-grade malignant tumors of the airway as seen in our series are cured by appropriate bronchoplastic resection and reconstruction. The single recurrence in 78 patients was of adenoid cystic carcinoma, not truly a low-grade malignancy.

Precise attention to technical details and avoidance of extensive dissection and tension should provide excellent early and late results. We have preferred the open anastomotic technique described, using traction sutures and absorbable suture material. Other techniques have been described that achieve similar results [18]. For the right indications, sleeve resection of either main bronchus or any lobe is possible. Thoracic surgeons should be familiar with these techniques to provide their patients with the greatest possible chance of removal of obstructing lesions of the airway and preservation of lung parenchyma to provide optimal long-term functional results.


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   Footnotes
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Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Presented at the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29-31, 1996.

Address reprint requests to Dr Mathisen, General Thoracic Surgery, Massachusetts General Hospital, Boston, MA 02114.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Wilkins EW, Grillo HC, Moncure AC, Scannell JG. Changing times in surgical management of bronchopulmonary carcinoid tumor. Ann Thorac Surg 1984;38:339–44.[Abstract]
  2. Grillo HC, Shepard JAO, Mathisen DJ, Kanarek D. Postpneumonectomy syndrome: diagnosis, management and results. Ann Thorac Surg 1992;54:638–45.[Abstract]
  3. Price-Thomas C. Conservative resection of the bronchial tree. J R Coll Edin 1957;1:169–86.
  4. Paulson DL, Shaw RR. Bronchial anastomosis and bronchoplastic procedures in the interest of preservation of lung tissue. J Thorac Cardiovasc Surg 1955;29:238–59.
  5. Van Schil PE, Brutel de la Riviere A, Knaepen PJ, van Swieten HA, Defauw JJ, van den Bosch JM. TNM staging and long-term follow-up after sleeve resection for bronchogenic tumors. Ann Thorac Surg 1991;52:1096–101.[Abstract]
  6. Faber LP. Sleeve lobectomy. Chest Surg Clin North Am 1995;5:233–51.[Medline]
  7. Tedder M, Anstadt MP, Tedder SD, Lowe JE. Current morbidity, mortality and survival after bronchoplastic procedures for malignancy. Ann Thorac Surg 1992;54:387–91.[Abstract]
  8. Frist WH, Mathisen DJ, Hilgenberg AD, Grillo HC. Bronchial sleeve resection with and without pulmonary resection. J Thorac Cardiovasc Surg 1987;93:350–7.[Abstract]
  9. Newton JR, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation. Ann Thorac Surg 1991;52:1272–80.
  10. Deslauriers J, Gaulin P, Beaulier M, Praux M, Bernier R, Cormier Y. Long term clinical and functional results of sleeve lobectomy for primary lung cancer. J Thorac Cardiovasc Surg 1986;92:871–9.[Abstract]
  11. Gaissert HA, Mathisen DJ, Moncure AC, Hilgenberg AD, Grillo HC, Wain JC. Survival and function after sleeve lobectomy for lung cancer. J Thorac Cardiovasc Surg 1996;111:948–53.[Abstract/Free Full Text]
  12. Heitmiller RF, Mathisen DJ, Ferry JA, Mark EJ, Grillo HC. Mucoepidermoid lung tumors. Ann Thorac Surg 1989;47:394–9.[Abstract]
  13. Harpole DH, Fedman JM, Buchanan S, Young WG, Wolfe WG. Bronchial carcinoid tumors: a retrospective analysis of 126 patients. Ann Thorac Surg 1992;54:50–5.[Abstract]
  14. Cavaliere S, Foccoli P, Farina PL. Nd:YAG laser bronchoscopy: a five year experience with 1,396 applications in 1,000 patients. Chest 1988;94:15–21.[Abstract/Free Full Text]
  15. Jimenez JPD, Cardona MC, Alcacer JM. Nd:YAG laser photoresection of low-grade malignant tumors of the tracheobronchial tree. Chest 1990;97:920–2.[Abstract/Free Full Text]
  16. Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis-treatment and results. J Thorac Cardiovasc Surg 1995;109:486–93.[Abstract/Free Full Text]
  17. Mathisen DJ, Grillo HC. Endoscopic relief of malignant airway obstruction. Ann Thorac Surg 1989;46:469–75.
  18. Weisel RD, Cooper JD, Delarue NC, Theman TE, Todd TRJ, Pearson FG. Sleeve lobectomy for carcinoma of the lung. J Thorac Cardiovasc Surg 1979;78:839–49.[Abstract]

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