Ann Thorac Surg 2009;88:1712-1713. doi:10.1016/j.athoracsur.2009.01.068
© 2009 The Society of Thoracic Surgeons
How To Do It
Bronchial Flap Closure of the Right Lower Lobe Bronchus
Richard J. McGregor, MbChBa,
Douglas West, FRCS (CTh)b,*,
William S. Walker, FRCSa
a Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
b Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
Accepted for publication January 22, 2009.
* Address correspondence to Dr West, Division of Thoracic Surgery, Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario, M5G 2C4, Canada (Email: dgwest{at}rcsed.ac.uk).
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Abstract
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We describe a novel method for closure of the bronchus intermedius, after right lower lobectomy, using a flap derived from the lower lobe apical segmental bronchus. We have successfully used this technique in an endobronchial carcinoid tumor occurring in a young man. It allowed middle lobe preservation despite a very proximal tumor position within the basal trunk bronchus. Adequate tumor margins were confirmed by on-table frozen section examination. This technique may have particular use in carcinoids or benign tumors.
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Introduction
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Right lower lobectomy is generally performed by either stapling or suturing the bronchial stump. A cuff of lower lobe bronchus extending several millimeters beyond the middle lobe orifice is needed for both techniques. In very proximal endobronchial lesions an adequate cuff is not available. In these situations lower and middle bilobectomy is often required for tumor clearance. This involves the loss of a further two bronchopulmonary segments, increasing the loss of lung parenchyma from 28% to 39% of total. Although it is far from catastrophic, we would argue that in fit and healthy individuals this lung-sparing technique could be useful in maintaining an active lifestyle.
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Technique
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A 19-year-old semi-professional sportsman with no significant past medical history presented to our unit with a biopsy-proven endobronchial typical carcinoid of the right lower lobe. On bronchoscopy, the tumor occluded the lower lobe bronchus immediately below the middle lobe bronchial orifice. The distal lung parenchyma was completely atelectatic. Staging with computed tomographic scanning and endobronchial ultrasound-guided transbronchial needle aspirate (EBUS-TBNA) showed no evidence of nodal involvement. Resection by right lower lobectomy was planned.
During surgery, after isolation of the bronchus, the lower lobe bronchus was opened. This revealed a tumor originating from the basal trunk lower lobe bronchus, just below the middle lobe orifice. Rather than sacrifice the middle lobe, a curved resection line, marked by the hatched area (Fig 1) was made. This created a flap derived from the (uninvolved) cartilaginous bronchus of the apical segment. The flap was fashioned to approximate the diameter of the bronchus intermedius defect.
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Fig 1. Diagram of the anatomy of the distal bronchus intermedius showing the line of incision and final appearance of the bronchial flap.
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A frozen section of the resection margin was examined, which provided confirmation of a clear margin. Then the defect in the distal bronchus intermedius was closed by folding the flap anteriorly. It was secured with interrupted 3.0 Vicryl sutures (Ethicon, Somerville, NJ). Therefore the native blood supply was preserved. Narrowing of the middle lobe bronchus was avoided (Fig 2).
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Fig 2. The completed flap from below with the right middle lobe bronchus (RMBr) extending to the right of the picture. The lung has been partially reinflated.
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The middle lobe re-inflated well with no air leak on underwater testing. We were able to remove the pleural drains 72 hours later, and he was discharged on postoperative day 5. Histopathologic examination confirmed a completely excised pT1pN0 typical carcinoid. The pathological margin was 10 mm. The middle and upper lobes remained fully aerated on follow-up radiology at 3 months.
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Comment
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Pulmonary carcinoid tumors are now recognized as low-grade malignant tumors that typically follow a relatively benign course, with only 10% having regional lymph node involvement at presentation [1]. Moreover, many patients are young and otherwise healthy individuals who at best suffer from lifelong decreased lung function and pulmonary reserve after bilobectomy, and at worst, the added cost of increased mortality, bronchopleural fistula and empyema, post-pneumonectomy. Thus, parenchyma-sparing surgery is appropriate, and bronchoplastic techniques are popular [2].
Our technique allows complete excision of the lower lobe bronchus; no residual stump is required to accommodate sutures or staples. Therefore, it is ideally suited to very proximal endobronchial tumors. The flap prevents narrowing or kinking of the middle lobe bronchial orifice, decreasing the risks of impaired aeration and sputum retention. Because it is not derived from the lower lobe bronchus, it can be harvested without any compromise to the resection margin.
An alternative to our technique is to detach the middle lobe altogether and perform a circumferential anastomosis to the distal bronchus intermedius. This may be essential if the tumor involves the distal bronchus intermedius but is not necessary if the disease is limited to the lower lobe bronchus. In the latter situation, our flap avoids the disruption to the blood supply, risk of sputum retention, and technical complexity of a circumferential anastomosis.
Bronchial flaps have been used for closure of the main bronchi after pneumonectomy [3, 4], but we do not believe they have been used in the situation we describe here.
Some patients have an unusually high or low takeoff of the apical segmental bronchus and will be unsuitable for this technique. Preoperative bronchoscopy and computed tomographic scan should identify patients with unsuitable anatomy. Other patients who have a relatively sedentary lifestyle and preserved lung function are already well served by conventional resection techniques.
This technique may have particular usefulness in active patients in which preservation of the two segments of the middle lobe may be preserve exercise tolerance. Similarly, borderline patients with low predicted postoperative forced expiratory volume in 1 second (FEV1) benefit from parenchyma-preserving techniques. We used frozen section pathologic examination to confirm adequacy of excision prior to completion of our flap, and we would advocate this whenever close margins are contemplated to ensure microscopically negative margins. Any compromise to this principle is, we believe, misjudged.
For the majority of right lower lobectomies, the tumor is sufficiently distal to allow conventional closure without any compromise to the resection margin. Stapled excision is a well established, safe, and reproducible technique applicable to the majority of patients [5, 6]. Our intention is not to replace these well-established techniques. We would reserve our flap closure for patients with unusually proximal tumors in which parenchymal preservation is of particular importance and standard closure would sacrifice the middle lobe.
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References
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- McMullan DM, Wood DE. Pulmonary carcinoid tumors Semin Thorac Cardiovasc Surg 2003;15:289-300.[Medline]
- Terzi A, Lonardoni A, Feil B, Spilimbergo I, Falezza G, Calabro F. Bronchoplastic procedures for central carcinoid tumors: clinical experience Eur J Cardiothorac Surg 2004;26:1196-1199.[Abstract/Free Full Text]
- Jack GD. Bronchial closure Thorax 1965;20:8-12.[Free Full Text]
- Kakadellis J, Karfis EA. The posterior membranous flap technique for bronchial closure after pneumonectomy Interact Cardiovasc Thorac Surg 2008;7:638-641.[Abstract/Free Full Text]
- Weissberg D, Kaufman M. Suture closure versus stapling of the bronchial stump in 304 lung cancer operations Scand J Thorac Cardiovasc Surg 1992;26:125-127.[Medline]
- Scott RN, Faraci RP, Hough A, Chretien PB. Bronchial stump closure techniques following pneumonectomy: a serial comparative study Ann Surg 1976;184:205-211.[Medline]
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Abstract
Introduction
