Ann Thorac Surg 2009;87:900-905. doi:10.1016/j.athoracsur.2008.12.023
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Extended Sleeve Lobectomy for Locally Advanced Lung Cancer
Masayuki Chida, MD, PhDa,*,
Muneo Minowa, MD, PhDb,
Shinichiro Miyoshi, MD, PhDa,
Takashi Kondo, MD, PhDc
a Department of Thoracic Surgery, Dokkyo Medical University, Mibu, Japan
b Department of Chest Surgery, Ohta-Nishinouchi Hospital, Koriyama, Japan
c Department of Chest Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
Accepted for publication December 5, 2008.
* Address correspondence to Dr Chida, Department of Thoracic Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi, 321-0293, Japan (Email: chida-ths{at}umin.ac.jp).
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Abstract
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Background: The risk of perioperative mortality is greater for patients undergoing a pneumonectomy than for a sleeve lobectomy. At our institution, we perform an extended sleeve lobectomy, an atypical sleeve resection of more than one lobe, to avoid a pneumonectomy in patients with locally advanced lung cancer. The purpose of this study was to analyze the risks of complications and local control in patients who underwent an extended sleeve lobectomy procedure.
Methods: Patients who underwent an extended sleeve lobectomy procedure were retrospectively analyzed in regard to operative mortality, complications, and local recurrence.
Results: A total of 23 patients underwent an extended sleeve lobectomy: one lobe + segment in 15, two lobes in 7, and two lobes + segment in 1. There were no operative deaths within 30 days or hospital deaths. Two (8.7%) of the 23 patients had complications at the anastomosis site, a stricture in 1 and bronchopleural fistula in 1, whereas 2 (8.7%) others had local control failure, relapse at the anastomosis site in 1 and staple line relapse in 1. Long-term survival was similar to that of those who underwent a pneumonectomy during the same period.
Conclusions: Our extended sleeve lobectomy procedure is useful to avoid a pneumonectomy in patients with locally advanced lung cancer.
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Introduction
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The mortality rate for patients with primary lung cancer who undergo a pneumonectomy is much greater than that for those who receive a lobectomy. In reports published in the 1980s and 1990s, some noted that the 30-day operative mortality rate after a pneumonectomy ranged from approximately 6% to 7% [1–3]. More recently, the Japanese Association for Thoracic Surgery reported a hospital death rate of 4.8% to 5.0% for a pneumonectomy, as compared with 0.8% for a lobectomy [4, 5]. A sleeve lobectomy was originally designed for patients with compromised lung function who were unable to tolerate a pneumonectomy, although it is now an accepted procedure to avoid a pneumonectomy in patients without compromised lung function. Although it seems to be a more technically demanding and compromising procedure, the risk of hospital death for a sleeve lobectomy is considered to be 1.6% to 2.0%, significantly lower than that for a pneumonectomy [4, 5].
An extended sleeve lobectomy, initially described by Johnston and colleagues in 1959 [6] and also recently reported by Okada and associates [7], is an alternative procedure to remove more than one lobe using a bronchoplasty technique in patients with locally advanced lung cancer [8–10]. The procedure is expected to decrease the risk of perioperative mortality for pneumonectomy, as with a sleeve lobectomy. However, the technique used is more demanding than that used for an ordinary sleeve lobectomy because the two bronchial stumps usually differ in size, with the distal one quite thin and fragile. Thus, tension between the stumps for an anastomosis is likely greater, and an angioplasty procedure associated with a bronchoplasty may be required. As a result, complications and local recurrence may occur more often in patients who receive an extended sleeve lobectomy as compared with an ordinary sleeve lobectomy or pneumonectomy.
In this study, we investigated complications, local control, and survival in patients who underwent an extended sleeve lobectomy. Based on our findings, we concluded that an extended sleeve lobectomy is a useful procedure to avoid a pneumonectomy in patients with locally advanced lung cancer.
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Patients and Methods
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Patients with primary lung cancer who underwent an atypical extended sleeve lobectomy at our institutions from April 1997 through August 2007 were retrospectively investigated. Each provided consent to undergo an atypical sleeve resection. An affiliated ethics committee approved the study and waived the need for patient consent for analysis of the results.
All patients who met the indications provided by cardiopulmonary function tests underwent surgery [11]. In this series, patient selection for an extended sleeve lobectomy was dependent on the balance between the extent of cancer and technical difficulty. Patients considered able to tolerate a pneumonectomy were also considered as candidates for an extended sleeve lobectomy.
The standard surgical technique used was performance of a lobectomy and segmentectomy until the bronchus was encountered. At that point, the proximal and distal points of transection were determined macroscopically based on the unaffected distance of the bronchus, then the proximal and distal portions of the margin were removed for frozen section evaluations. Next, an anastomosis was performed with a telescope technique using interrupted sutures with full-thickness bites and 3-0 monofilament absorbable materials. In cases that underwent a carinaplasty, an anastomosis between the trachea and left main bronchus was performed using figure-eight sutures to prevent cutting because of excessive tension encountered during tying. An angioplasty was performed when necessary using continuous sutures with 4-0 monofilament materials. We used an interposition of vascularized soft tissue to separate and protect the suture line between the bronchoplasty and angioplasty in some cases. When there was a discrepancy between the pleural space and residual basal segment, artificial phrenic palsy was used to reduce the thoracic cavity by diaphragm elevation. One week after the operation, a bronchoscopic examination was conducted to observe the status of the anastomosis. When ischemic change at the site was observed, 120 µg of prostaglandin E1 was intravenously infused daily for 2 weeks to induce angiogenesis in the ischemic tissue [12].
Complications, local control, and manner of recurrence were analyzed retrospectively. Survival rates were compared with those of patients with primary lung cancer who underwent a pneumonectomy during the same period.
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Results
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Among 454 patients who underwent surgery for primary lung cancer at our institutions, 55 bronchoplasty and 15 pneumonectomy procedures were performed. Furthermore, 23 (21 men, 2 women; mean age, 65.3 years old; range, 51 to 80 years) of the 55 who received a bronchoplasty underwent an extended sleeve lobectomy (Table 1). One patient who underwent a one-lobe sleeve lobectomy with conventional segmentectomy was not included in this series. Nineteen of those 23 cases were considered a good risk for a pneumonectomy, whereas the other 4 had compromised cardiopulmonary function. Four of the patients received induction therapy. There were no operative deaths within 30 days or any hospital deaths. A complete resection was performed in all except for 1 patient, who had subcarinal lymph node metastasis infiltrating in an extranodal manner into the esophagus in spite of induction therapy. The histopathologic diagnosis was squamous cell carcinoma in 18 (78%), adenocarcinoma in 4 (17%), and large cell carcinoma in 1 (4%). The procedures used were one lobe plus segment in 15, two lobes in 7, and two lobes plus segment in 1 (Fig 1). In addition, 2 patients underwent a carinaplasty. A pulmonary angioplasty was frequently performed (n = 18, 78%), including a pulmonary arterioplasty in 15 and pulmonary venoplasty in 3. Our desire for lung preservation prevented an excessive shift of the mediastinum during the procedure (Fig 2). None of the cases had dyspnea greater than Hugh-Jones grade 3.
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Fig 1. Schema of the present extended sleeve lobectomy procedures. (A) Right upper middle sleeve lobectomy (n = 1); (B) right middle lower sleeve lobectomy (n = 5); (C) right upper S6 sleeve lobectomy (n = 1); (D) left upper S6 sleeve lobectomy (n = 4); (E) left lower lingular sleeve lobectomy (n = 10); (F) right middle lower sleeve lobectomy plus carinaplasty (n = 1); (G) right upper middle S6 sleeve lobectomy plus carinaplasty (n = 1).
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Fig 2. Representative postoperative chest computed tomographic scan results. Patient 9 underwent a right upper middle S6 sleeve lobectomy plus carinaplasty. The bronchus of the right basal segment was anastomosed to the left main bronchus. The right basal segment was well expanded. The mediastinum was not shifted to the side of the operation.
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Complications in the anastomotic site were observed in 2 (8.7%) of the 23 cases. In 1 patient who underwent a left upper lobe plus S6 sleeve resection, a bronchial stricture occurred as a result of anastomotic dehiscence because of excessive tension between the left main bronchus and segmental bronchus; however, bronchoscopic ballooning achieved patency of the bronchus at the stenotic site. In another patient who underwent a left lower lobe plus lingular sleeve resection, a bronchopleural fistula occurred in the anastomosis section, and the resulting empyema was successfully resolved within a few months by continuous chest tube drainage. There were no complications in the 18 patients who underwent an angioplasty procedure.
Bronchial margins were investigated by frozen section examinations during the operation in most and were found to be negative in all examined cases. However, 1 patient (4%) who did not receive a bronchial margin examination during the operation had local recurrence develop at the anastomotic site. In that case, a completion pneumonectomy was not performed for lung cancer because of repeated severe aspiration pneumonia in the contralateral lung. Staple line recurrence in the lung periphery was also observed in 1 patient after obvious systemic metastasis to the adrenal gland and brain.
All patients with stage II and III disease except for poor-risk cases were recommended for adjuvant chemotherapy, of whom 9 gave consent to and received treatment. Eleven of 23 patients died during the follow-up period, which were composed of 10 cancer deaths, 9 of whom died as a result of extrathoracic metastasis and 1 with recurrence in multiple mediastinal lymph nodes, and 1 respiratory failure, in which severe contralateral pneumonia occurred and local recurrence developed in the area of a stenosis at the anastomotic site (Table 2). Survival for patients with primary lung cancer was compared with those who underwent a pneumonectomy (n = 15) during the same period (Fig 3). There was no difference in survival rate between patients who received an extended sleeve lobectomy and those who underwent a pneumonectomy. Of the patients who received a pneumonectomy, 1 (6.7%) died within 30 days of the operation owing to a cerebral infarction after atrial fibrillation.
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Fig 3. Cumulative survival curves for extended sleeve lobectomies (ESL; solid line) and pneumonectomies (Pn; dotted line).
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Comment
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When considering surgery for selected patients with locally advanced lung cancer, it is important to remember that the procedure choice must take into account an appropriate balance between mortality risk and local control. The risk of operative mortality for a pneumonectomy is considered to be much greater than that for a sleeve lobectomy (Table 3); however, long-term survival for both are similar at each stage [13–19]. Thus, a pneumonectomy may not always be the best choice, and an extended sleeve lobectomy is an alternative procedure for locally advanced lung cancer to avoid a pneumonectomy, when technically possible. In the present series of patients, we found that an extended sleeve lobectomy is a useful procedure for locally advanced lung cancer, although more technically demanding than an ordinary sleeve lobectomy.
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Table 3 Comparison of Operative Mortality Between Sleeve Resection and Pneumonectomy in Previously Reported and Present Cases
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There were no operative deaths in this study. One patient, who underwent a right upper lobe and S6 sleeve resection, experienced acute respiratory failure followed by severe aspiration pneumonia in the contralateral lung. Inasmuch as the resident right middle lobe and basal segment remained intact during the time of pneumonia, the patient recovered later after long-term control with a ventilator. Okada and coworkers [7] also reported good outcomes for patients who underwent an extended sleeve lobectomy (Table 3), which is considered to be superior to a pneumonectomy with regard to perioperative mortality.
Some authors [13, 14, 16, 18–20] reported complication rates ranging from 3.3% to 16.3% in the anastomotic site after ordinary sleeve lobectomy procedures (Table 4). Complications in the anastomotic site occurred in 8.7% (2 of 23) of the present patients who underwent an extended sleeve lobectomy. In 1 case, a bronchial stricture occurred owing to anastomotic dehiscence because of excessive tension between the left main bronchus and segmental bronchus. After that experience, we now perform a U-shaped incision in the pericardium to release the inferior pulmonary vein for distension of the basal segment [21]. In addition, a bronchopleural fistula occurred in 1 patient. The technique used for this procedure is more demanding than that for an ordinary sleeve lobectomy as the two bronchial stumps differ in size and tension between the stumps for an anastomosis is strong. In the present study, 78% of the patients with an extended sleeve lobectomy required an accompanying pulmonary angioplasty procedure. However, the rate of complications was similar to those who underwent an ordinary sleeve lobectomy (Table 4). Thus, we concluded that an extended sleeve lobectomy is a reasonable procedure for lung cancer patients.
In our series, 2 (8.7%) of the 23 patients had local control failure. However, both patients had compromised lung function and could not tolerate a pneumonectomy. In other reports that compared a sleeve lobectomy and pneumonectomy (Table 5), the rates of local relapse were 11.0% and 6.6%, respectively [15, 17, 18]. Local control in patients who undergo an extended sleeve lobectomy does not seem to be inferior to that in those who undergo an ordinary sleeve lobectomy or pneumonectomy. Further, the long-term survival in the present patients who underwent an extended sleeve lobectomy was similar to that in the patients who underwent the pneumonectomy because patients with advanced stage lung cancer were enrolled in this study.
In conclusion, our results show that an extended sleeve lobectomy is a useful procedure to avoid a pneumonectomy in patients with locally advanced lung cancer.
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Abstract
Introduction
