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Ann Thorac Surg 2001;72:357-361
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria
Accepted for publication April 17, 2001.
Address reprint requests to Dr Hollaus, Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Sanatoriumstrasse 2, A-1145 Vienna, Austria
e-mail: peter.hollaus{at}pul.magwein.gv.at
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentReferences |
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Methods. The hospital charts of patients undergoing upper and lower sleeve bilobectomy and lower lobe lobectomy with replantation of the middle lobe or upper lobe into the mainstem bronchus were retrospectively reviewed. Age, sex, side, TNM stage, preoperative forced expiratory volume in 1 second (FEV1 [%]), preoperative risk factors, postoperative course, survival (months), and causes of death were recorded.
Results. Fifteen patients suffering from bronchial carcinoma were operated on. In 6 cases FEV1 was less than 2 L (FEV1 49% to 80%, mean 64.3, median 61). Three patients were 70 years and older. There were 7 high-risk cases presenting with coronary heart disease (n = 3), chronic alcoholism (n = 3), cerebrovascular disease (n = 1), and active tuberculosis (n = 1). Local radicality was achieved in all patients but 1, in whom pneumonectomy was contraindicated. There was no postoperative mortality. Early complications consisted of 1 anastomotic dehiscence successfully closed with an intercostal flap and 1 patient with bilateral pneumonia requiring mechanical ventilation for 5 days. One parenchymal fistula led to prolonged drainage; in 1 patient pneumothorax after removal of the chest tube required redrainage. There were no late complications, and no anastomotic stenosis developed. Survival ranged from 12 to 56 months (median 29.8, mean 30, SD 15.7). Seven patients died between 3.9 and 14 months postoperatively (mean 8.5, median 6.9) of intrabronchial local recurrence (n = 1), distant recurrence (n = 3), intrathoracic recurrence (n = 1), and nontumor-related causes (n = 2).
Conclusions. Telescope anastomosis is a safe and efficient technique of bronchial sleeve resection.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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The majority of cases are patients with carcinomas located in the right upper lobe orifice. The most popular techniques consist of simple wedge resection or removing the upper lobe and the part of the mainstem bronchus adjacent to the upper lobe orifice with an end-to-end anastomosis. In these cases the caliber mismatch is only modest and allows an easy end-to-end anastomosis. Anastomosis between the mainstem bronchus and a lobar bronchus is only rarely performed and poses the problem of strong caliber mismatch. Resections leading to this techniqual challenge comprise sleeve bilobectomy and lower lobe lobectomy with resection of the mainstem bronchus and replantation of the middle or upper lobe. This type of operation represents only 7% to 11% of all sleeve resections published [1–5]. Owing to the limited number of cases it is not mentioned separately and therefore no data on postoperative complications associated with such technically demanding resections are available. Only Okada and colleagues presented 15 cases with a low complication rate and without mortality [1]. They did not perform telescope technique. We report our experience with this kind of resection using the telescope technique for end-to-end anastomosis.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Preoperative workup included lung function, chest computed tomography (CT), and bronchoscopy. In case of limited pulmonary reserves contraindicating pneumonectomy, a ventilation-perfusion scan was performed. Patients with enlarged mediastinal lymph nodes on CT scan underwent preoperative mediastinoscopy to exclude N3 disease and multilevel N2 disease. No patient received preoperative chemotherapy or irradiation. The following variables were recorded: age, sex, side, TNM stage, preoperative forced expiratory volume at 1 second (FEV1 [%]), preoperative risk factors, postoperative course, survival (months), and causes of death.
Patients were intubated with a double lumen endobronchial tube under single shot antibiotic prophylaxis with a second generation cephalosporin. Operation was performed through a standard posterolateral thoracotomy. The pulmonary ligament was divided routinely.
Although CT scan and bronchoscopy provide information on the endobronchial and extrabronchial exent of the tumor, a final decision on the extent of the resection can only be achieved intraoperatively. When the local situation allowed sleeve resection, lymphadenctomy was completed and stay sutures were placed on the bronchus to orientate the distal and proximal lumina.
After resection the bronchial anastomosis was constructed with a single row of interrupted absorbable whole layer sutures (Vicryl; Ethicon, Somerville, NJ; Maxon, Braun-Dexon, Spangenberg, Germany). In the beginning two sutures were placed at the dorsal wall of the anastomosis and knotted. Further sutures were placed from posteriorly to anteriorly and knotted extraluminally. Marked caliber mismatch was adapted by drawing the distal smaller lumen into the proximal lumen like a telescope. To achieve the telescope effect it is necessary to place the stitches more distant from the resection margin in the larger lumen and less distant in the smaller lumen. Frozen sections were obtained of the distal and proximal margins to confirm local radicality.
After completion of the anastomosis a check for leaks was performed by the water test under ventilation. (p max = 40 cm) The anastomosis was not covered with autogenous tissue flaps, and a pericardial release was not necessary. At the end of the procedure the anastomosis was routinely inspected bronchoscopically through an adapter while ventilation was maintained. The patient was extubated in the operation room. During the postoperative course bronchoscopy was only performed in case of atelectasis, secretion retention, or suspected fistula.
Early complications were defined as complications occuring within 30 days of the operation. Operative mortality included all patients dying within 30 days of the procedure and patients dying of events directly related to the operation later on. Survival was compared with that for classic sleeve resections excluding bronchial wedge resections. During follow-up, bronchoscopy and CT scan was routinely performed every 6 months during the first 2 postoperative years and annually between the third and fifth postoperative year. Follow-up data were obtained from the most recent clinical visit or the family doctors.
Survival curves were obtained according to the Kaplan-Meier actuarial method. The log rank test was used to assess the difference in survival curves. A p value of less than 0.05 was considered significant.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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There were 11 men and 4 women aged between 40 and 76 years (mean 57.13; median 64). Three patients were 70 years or older. Since no patient showed preoperative radiologic evidence of N2 disease, no mediastinoscopy was performed. Seven high-risk cases presented with the following risk factors: coronary artery disease (n = 3), chronic alcoholism (n = 3), cerebrovascular disease (n = 1), and active tuberculosis (n = 1). In 6 cases FEV1 was less than 2 L (FEV1 ranging from 49% to 80%, mean 64.3, median 61).
In no case was the pulmonary artery infiltrated by tumor, and no kinking of the pulmonary artery occurred. Thus we refrained from additional pulmonary artery sleeve resection.
Nine patients had squamous cell carcinoma, 3 adenocarcinoma, 2 of typical carcinoid, and 1 polymorphcellular carcinoma. Four patients had tumor stage I, 3 had stage II, 6 had stage IIIa, and 1 after successful preoperative treatment of a single brain metastasis had stage IV. Local radicality was achieved in all patients but 1, in whom pneumonectomy was contraindicated owing to limited pulmonary reserves. Patient data are shown in Table 1.
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Early complications comprised one anastomotic dehiscence after lower sleeve bilobectomy that could be successfully closed with an intercostal flap. One case of postoperative bilateral pneumonia required mechanical ventilation over a period of 5 days. One patient developed postoperative delirium tremens. One parenchymal fistula led to prolonged drainage; and in 1 patient pneumothorax after removal of the chest tube occurred and required redrainage.
There were no late procedure-related complications, and during the observation period no anastomotic stenosis developed.
Surviving patients were observed 12 to 56 months (median 29.8, mean 30, SD 15.7). Seven patients died between 3.9 and 14 months postoperatively (mean 8.5, median 6.9, SD 4.7). Only 1 patient developed intrabronchial local recurrence, 3 patients distant recurrence, and 1 patient intrathoracic recurrence. Two patients died of nontumor-related causes (myocardial infarction, pulmonary embolism). Survival compared with classic sleeve resections performed during the same period is shown in Figure 1, and survival of high-risk patients in Figure 2. No differences were observed (log rank: p > 0.05).
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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The most dreaded complications of bronchial anastomosis, local dehiscence and stricture, are attributed to the disruption of local vascular supply and infection [10]. Technical causes are kinking of the anastomosis, tension, or granuloma formation at the suture line. The occurrence of suture granuloma has markedly diminished since silk has been replaced by modern suture materials for bronchial anastomoses [11]. Nevertheless the technique of bronchial anastomosis plays a crucial role in the prevention of complications and many variations have been described in the literature. The most popular technique is single interrupted sutures with absorbable monofilament sutures [1, 2, 9]. The use of nonabsorbable sutures has also been reported [3, 12]. The technical variants published comprise mainly all layer sutures [1, 2, 12, 13] or submucosal sutures [14]. Interrupted sutures are widely accepted [1–3, 9, 14–16], however, running sutures have been reported recently [12]. Another method is closure of the cartilagineous part of the bronchus with a running suture and closure of the membraneous part with interrupted sutures [13]. Interrupted sutures of the membraneous part are preferred because they allow the adaption of bronchial ends with different diameters by several adjusting stitches [3]. Caliber congruence may also be achieved by wedge resection of the membraneous part or by creation of a bigger diameter by oblique dissection of the smaller bronchus [5]. The majority of thoracic surgeons prefer extraluminal knotting, however, intraluminal knots have been described without adverse effects [1, 15]. Suen and colleagues [4] only place knots adjacent to the pulmonary artery intrabronchially.
The principle of telescope anastomosis is completion of an airtight anastomosis of two ends of different calibers without space suturing or caliber reduction of the bigger end by any surgical means. This can only be achieved by intussusception. In our experience a stump long enough can always be created to allow intussusception into the major lumen, which seems to us an ideal technique to compensate for massive caliber mismatch (Figs 3 and 4). The smaller bronchus is splinted by the larger one, and kinking is prevented. As there is no need to adapt the membraneous part of the distal end to a bigger diameter, tension is avoided.
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The majority of authors cover the bronchial anastomosis routinely with a pleural, pericardial, or muscular flap to prevent fistula formation [1–4, 6, 16]. This technique has never been proved to prevent anastomotic dehiscence and leads to a prolonged duration of operation [11]. Rea and coworkers [9] compared patients with (63 cases) and without pedicled flap coverage (154 cases) retrospectively and found no advantage.
During our whole experience with bronchoplastic procedures, routine coverage was only performed in double sleeve resection to protect the vascular anastomosis. No bronchovascular fistula was observed. Four anastomotic dehiscences occurred representing an overall fistula rate of 3.9%. Our learning curve is included in these numbers. The fact that one of the fistulas occurred within this small subset of patients does not necessarily imply the need for prophylactic coverage even in these extended resections. We think that muscles should be saved for the treatment of anastomotic dehiscence and not wasted for unproven prevention. Careful handling of the airways avoids the need for any soft tissue wrap after sleeve resection.
Although the number of patients presenting with N2 disease in this small subset seems high, considering our whole experience of bronchoplastic procedures the rate of N2 positive patients is 17% and lies within the range of the literature [1, 3, 4, 9].
Of course the small number of patients does not allow any statistical workup. Our data therefore must remain simply descriptive. The rate of severe complications is low. In case of edema at the site of anastomosis, patients are prone to secretion retention and atelectasis due to the small distal lumen. Whether the number of bronchoscopic lavages is high cannot be derived from our data. Tedder and coworkers [11] found a rate of postoperative atelectasis ranging from 2% to 20%. We favor early bronchoscopy, which might probably explain the high rate of endoscopic interventions. Nevertheless our results so far have not shown any disadvantage for our patients.
Comparing our numbers with the literature we have no explanation for our high proportion of sleeve resections with high-caliber mismatch related to the total number of sleeve resections. Our data suggest that they can be performed more frequently than the literature reports.
Sleeve lobectomy is a valuable alternative to pneumonectomy and should be performed whenever possible—also for patients with adequate pulmonary reserves to tolerate pneumonectomy. A strong caliber mismatch results in a technically demanding procedure; however, the mortality is low as is the rate of severe complications. Telescope anastomosis has proved to be an efficient technique, and no bronchial stenosis or stricture occurred [8].
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References |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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