Ann Thorac Surg 2007;84:e19-e21
© 2007 The Society of Thoracic Surgeons
How To Do It
Bronchial Sleeve Resection Distal to the Main Bronchus With Complete Pulmonary Preservation for Benign or Low-Grade Malignant Tumors
Xingtao Jiang,
Xiaopeng Dong*,
Xiaogang Zhao,
Chuanliang Peng
Department of Thoracic Surgery, Second Hospital of Shandong University, Jinan, China
Accepted for publication April 16, 2007.
* Address correspondence to Dr Dong, Department of Thoracic Surgery, Second Hospital of Shandong University, 247 Beiyuan St, Jinan, 250033, China (Email: dxp3260{at}sohu.com).
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Abstract
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Three cases are presented with benign or low-grade malignant bronchial tumors managed by bronchial sleeve resection distal to the main bronchus. Bronchoplasty was accomplished by suturing the two distal bronchi together and then anastomosing them to the proximal bronchus. No pulmonary parenchyma was removed during the course of operation. All patients had excellent results. Bronchial sleeve resection distal to the main bronchus can be successfully performed; this is a safe and effective bronchoplastic technique for benign or low-grade malignant bronchial tumors.
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Introduction
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Although pulmonary sleeve resections have been widely accepted for the management of bronchial or pulmonary lesions, few series of bronchial resections with complete pulmonary preservation have been reported, almost all such procedures limited to the main bronchus. We present three cases with benign or low-grade malignant bronchial tumors involving the main or intermedius bronchus, which were successfully managed by distal bronchial sleeve resection without resection of any pulmonary parenchyma.
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Technique
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Patient 1
A 56-year-old man presented with a 5-month cough and shortness of breath history. A computed tomographic (CT) scan showed a mass in the left main bronchus; this was also confirmed by bronchoscopy, which revealed a lesion with a smooth surface and broad base that was located on the posterior wall of the left main bronchus, close to the origin of the upper lobar bronchi. Biopsy of the mass showed the possibility of smooth muscle origin. In August 1996, a thoracotomy was performed through the left fifth intercostals space. At operation, the distal end of the left main bronchus and origin of the two lobar bronchi were transected (Fig 1). Frozen sections of all resection margins proved to be tumor free. Then the reconstruction of the bronchial tree was accomplished by suturing the upper and lower lobar bronchi together and anastomosing them to the residual of the left main bronchus with Vicryl 4-0 sutures (Ethicon Inc, Piscataway, NJ) in an interrupted fashion. All knots were tied externally. A pleural flap was wrapped around the suture line to protect the anastomosis. A bronchoscopic examination performed at the end of the operation confirmed a patent anastomosis. Histopathology revealed a leiomyoma. This patient had an uneventful postoperative period and was discharged 11 days later. He was followed-up for 5 years after surgery with no recurrence of tumor.
Patient 2
A 36-year-old man was transferred to our hospital because of a 3-month cough history. A CT scan and bronchoscopy revealed a mass with a broad base that was located on the medial wall of the right bronchus, opposite to the orifice of the upper lobar bronchi. Biopsy revealed that it was carcinoid. A right thoracotomy was performed in October 2000. At operation, the distal end of the right main bronchus and the origins of the intermedius and upper bronchi were transected (Fig 2). Frozen sections of resection margins proved to be tumor free. Then the upper and intermedius bronchi were sutured together and they were anastomosed to the right main bronchus. Anastomosis was wrapped with a pleural flap; a bronchoscopy ensured the patency of the lumen. The patient had an uncomplicated postoperative course and was discharged 10 days later. He was followed-up for 5 years after surgery. No recurrence of the tumor was found.
Patient 3
A 52-year-old woman complained of fever, cough, and expectoration for 16 months. She once received a CT scan that revealed pneumonia in the right lower lobe. Her condition improved after antibiotic treatment. However, 8 months later the symptoms were aggravated again. Another CT scan revealed a mass in the intermedius bronchus with obstructive pneumonia in the right lower lobe. Bronchoscopy revealed a lesion on the lateral wall of the intermedius bronchus; the bronchoscopy could not traverse it. A biopsy showed that it was a benign lesion. Posterolateral thoracotomy was performed in November 2004. After opening the bronchus, we found the lesion was limited in the intermedius bronchus. Then the intermedius bronchus and origin of the middle and lower bronchi were transected (Fig 3). Frozen sections showed that it was a pseudotumor and tumor free of resection margins. The reconstruction of the bronchial tree was similar to the previously described cases. The middle and lower bronchi were anastomosed to the intermedius bronchus after they were sutured together. The patient had an uncomplicated postoperative course and remained symptom free to date.
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Comment
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Bronchial benign and low-grade malignant tumors are very rare. Their treatments include two possible alternatives (1) endoscopic resection (neodymium:yttrium-aluminum-garnet laser surgery) and bronchotomy. The latter seemed to be the better choice for tumors with a broad base or intraruminal origin tumors.
Bronchial sleeve resections are now widely adopted for selected patients with bronchial and pulmonary lesions, regardless of pulmonary function. Some reports suggest that whenever possible, sleeve resection should be performed to avoid pneumonectomy [1]. Several series have demonstrated the value of main bronchial sleeve resection with pulmonary conservation for benign or low-grade malignant bronchial diseases [2, 3]. However, when the lesion is located more distally, whether and how to conserve the pulmonary parenchyma may be difficult. Rare reports of this kind of operation have been presently reported [4, 5].
In the present cases, tumors located in the main or intermedius bronchus were close the origin of lobar bronchi, and mainstem bronchial sleeve resection could not be accomplished unless one lobe was simultaneously resected. We designed the technique of suturing two distal bronchus together and then anastomosing them to the proximal bronchus to conserve pulmonary parenchyma completely. Anastomosis was performed with interrupted and absorbable sutures and all knots were externally tied. Suture lines were routinely wrapped with the pleural flap to protect the anastomosis and to assess the patency of the lumen. All patients received a bronchoscopic examination at the time of operation. Division of the inferior pulmonary ligament and peritracheal mobilization were performed in all patients to relieve the tension of the anastomosis.
Successful application of the technique demands attention to several technical features. First, the key point in this operation is that two small bronchi are to be sutured together to create a double-barrel bronchus whose orifice should properly match the proximal single-lumen bronchus. This can be achieved by using not too tightened stitches and avoiding air leaks along the anastomosis at the same time. Second, extensive division of peribronchial tissue should be avoided to preserve the bronchial vascular system. Third, frozen sections of resection the margin are mandatory for all patients to ensure all resection margins are tumor free.
Obstructive pneumonias are often encountered in such patients, as in the case of the third patient, but in our opinion this is not a contraindication to bronchoplastic procedures [6]. Therapeutic aspiration, chest physiotherapy, and appropriate antibiotic should allow successful sleeve resection with no increase in complications.
In conclusion, bronchial sleeve resection distal to the main bronchus can be successfully performed. This is a safe and effective bronchoplastic technique for select patients with benign or low-grade malignant bronchial tumors, although it is complex in technique and may have an increased risk of complication than a standard sleeve resection.
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References
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Abstract
Introduction
