Eur J Cardiothorac Surg 2000;17:370-376
© 2000 Elsevier Science NL
Bronchoplasty for malignant and benign conditions: a retrospective study of 44 cases
Anjum Jalal,
K. Jeyasingham
Frenchay Hospital, Frenchay, Bristol, BS16 1LE, UK
Corresponding author. Tel.: +44-1454-773-691; fax: +44-117-970-1960
e-mail: jeyasingham{at}btinternet.com
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Abstract
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Objective: To study the different operative techniques employed, the problems encountered and the outcome in bronchoplastic procedures both during and after surgery. Patients and methods: Forty-four patients with a mean age of 51.6 years (range 15–80 years) underwent bronchoplastic procedures in the period from 1976 to 1998. There were 27 males and 17 females. Forty-two of these had planned surgery. Two trauma patients had emergency surgery. Out of 42 planned operations, 27 suffered from cancer and 15 had benign lesions. Amongst the non-small cell lung cancer (NSCLC) group, the nodal status was N0 in nine patients, N1 in 12 and N2 in six. Bronchial sleeve resection with lobectomy was performed in 24 patients. Six patients had sleeve pneumonectomies. Fourteen others had bronchial sleeve resections without lobectomies, and bronchoplasties for trauma and stricture. Reconstruction was performed in the earlier years with stainless steel wire of 38/40 SS gauge (n=22), vicryl (n=4) and prolene (n=1). More recently, ethibond (n=18) was routinely used for this purpose. Anaesthesia was maintained via oro-tracheal intubation, interrupted when necessary with a short period of intubation of one or the other bronchus through the thoracotomy incision. Results: The mean operating theatre time, including the anaesthesia, was 207 min (range 120–375 min). The duration of stay in the high dependency unit (HDU) was no longer than 3 days. Post-operative problems included excessive bronchial secretions and partial atelectasis (one patient requiring therapeutic bronchoscopy), prolonged mechanical ventilation (n=1) and prolonged air leak (n=1). There was no per-operative, hospital, or 30 day mortality. Four out of 27 cancer patients lived more than 5 years, 12 died between 2 and 5 years, and 11 lived less than 2 years. Conclusions: Whilst bronchoplasties require special anaesthetic techniques and stringent high dependency post-operative care, there is minimal operative morbidity and mortality. Acceptable duration of survival can be expected even in the cancer patients.
Key Words: Bronchoplasty • Carinoplasty • Sleeve pneumonectomy
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1. Introduction
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Bronchoplasties have a definite role in surgery of benign, as well as malignant, pulmonary lesions. Since the pioneer bronchoplastic procedure performed by Bigger [1] in 1932, a variety of new techniques have been used in a wide range of pathological conditions by surgeons from different parts of the world. The results have been repeatedly re-evaluated. The technical details and possible peri-operative problems are much better understood these days. Although these procedures require more experience and skill on the part of the surgical team, they provide superior post-operative pulmonary functions. The survival figures have been reported to be comparable with conventional extended resections [2]. We have reviewed the results of 44 such cases, operated over a period of 22 years. Our group of patients consisted of bronchoplasties for benign and malignant conditions, as well as for trauma. This report provides an overview of all these procedures and their technical details.
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2. Patients and methods
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2.1. Study design, data collection and analysis
This is a retrospective study of all patients who underwent carinoplasties, sleeve pneumonectomies sleeve lobectomies and bronchoplasties in one surgical firm from 1976 to 1998. There were no exclusion criteria for this study. Patients were identified from operation theatre registers and index cards. Data regarding individual patients was retrieved from operation records and discharge summaries, and the information regarding the post-operative follow-up was collected from the hospital notes. Therefore, the follow-up information used in this study is only up to the last visit of the patient to the hospital. The database was analyzed to calculate frequencies, medians, means and standard deviations.
2.2. Patient characteristics
The patient characteristics are summarized in Table 1. The categories of patients included
- benign conditions where a bronchoplasty could conserve healthy lung;
- malignant tumours where poor respiratory functions would have precluded a more extensive conventional resection;
- malignant tumours within 2 cm from carina in young patients.
Pre-operative evaluation of benign pathology included bronchoscopic biopsy to ascertain the histological nature of the lesion, radiological imaging to define the extent of the primary lesion and its secondary effects on the lung tissue distal to the lesion, and investigations aimed at assessing the cardiorespiratory and general health of the patient. Patients with malignant lesions were investigated with routine radiography, bronchoscopic evaluation, biopsy, and computed tomography of the chest, upper abdomen and the head. When indicated on tomography, mediastinoscopy and lymph nodal biopsy was performed. The patients’ suitability to undergo lung resection was further assessed with cardiac and respiratory function studies. When indicated on clinical grounds, isotope scans were completed to exclude bone metastasis.
Forty-two out of 44 patients had elective surgery. Amongst the 42 elective operations, 27 were carried out for cancer, 12 for benign tumours and three for strictures. Two patients underwent emergency operations for trauma. One of these had complete avulsion of the right main bronchus from the carina, and the other had injury around the origin of the right middle lobe bronchus (Table 2). Pre- and post-operative radiotherapy was used in only one patient. Post-operative radiotherapy was used in eight cases. Chemotherapy was employed only in cases with recurrence (n=2).
2.3. Anaesthetic techniques
For bronchoplastic procedures, anaesthesia was maintained with the double lumen tube. Single lung ventilation was started just before bronchotomy, and was switched back to normal ventilation after the bronchial continuity was restored. For carinal procedures, the patients were anaesthetized with an ordinary single lumen endotracheal tube. After surgical exposure of the trachea, the oxygen saturation was optimized and the tube was drawn above the site of intended tracheal incision. The trachea was then opened and resection was performed while the ventilation was maintained by direct surgical intubation of the distal trachea or opposite bronchus using a new sterile tube Fig. 1a.
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Fig. 1. (a) Ventilation of left lung by per-operative direct intubation of the left main bronchus, while resection of the right tracheobronchial junction is being carried out. (b–d) Resection of benign tumour from the left tracheobronchial region. The defect in the wall of left main bronchus repaired with a wire mesh.
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2.4. Surgical procedures
A standard posterolateral thoracotomy was employed for all bronchoplasties and carinal reconstructions. Release of the pulmonary ligament was also performed in most instances. Four different types of sutures were used for carinoplasties and bronchial reconstructions during different periods of times, in keeping with the prevalent practice at those times. Earlier in this series (1976–1985), stainless steel wire (gauge 38/40) was used in 22 patients. In a short intermediate period between 1985 and 1987, vicryl (n=4) and prolene (n=1) were also used. Thereafter, ethibond was used as a standard in all patients (n=18). Three patients required prosthetic material to patch the defects resulting from resection of pathological lesions. The prosthetic material included one wire mesh and two Dacron patches. In two of these three cases, a wide excision of pathology in the vicinity of the tracheobronchial junction resulted in a big gap. The options here were either to repair this gap with a patch, or to do a complete sleeve pneumonectomy after adequate mobilization. We adopted the former option (Fig. 1b–d). However, one of these two patients developed a pyogenic granuloma distal to the patched area over a period of 15 years. He was therefore operated on for the second time. During his second operation, the dissection was very tedious. This time, a sleeve resection of the left main bronchus was carried out with re-anastomosis of the remaining left bronchus to the carina. The operation remained uncomplicated. In the third patient, a Dacron patch was used to repair a stricture in the left main bronchus. This patient had a tuberculous stricture which was initially overcome with a metal stent. However, she continued to have significant clinical features of persistent stenosis, and was therefore operated on within 15 months. During her operation, it was noticed that a further stricture was located distal to the stent. The stent was therefore left in situ. The stenosed part was opened and repaired with a patch of Dacron. The types of bronchoplastic procedures used are listed in Table 3, and some of these are illustrated in Figs. 2–4. These diagrams have been made from the surgeon's perspective of the operative field. In all cases, routine flexible bronchoscopy was performed after extubation in order to ensure adequacy of the bronchial lumen. In the immediate post-operative period, all patients were treated in the thoracic surgical high dependency unit (HDU). Only those who required prolonged ventilation were sent to the intensive therapy unit (ITU). Follow-up inspection of the bronchial tree was performed in all patients at the time of their first visit to the out-patients’ department. Subsequent bronchoscopies were performed only for specific indications.
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Fig. 2. (a) Tumour in the right main bronchus involving the tracheal wall. (b) Right pneumonectomy and repair of the tracheobronchial junction by using a flap of postero-inferior wall of the right main bronchus.
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Fig. 3. (a) Tumour of the right main bronchus extending into the carina. (b) Right pneumonectomy and repair of the carina by using a flap of antero-superior wall of the right main bronchus.
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Fig. 4. (a) Tumour at the origin of the right upper lobe bronchus. (b) Right upper lobectomy with sleeve resection of the right main bronchus.
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3. Results
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3.1. Procedural difficulties
Most of the procedures remained fairly straight forward. Difficulties were encountered in trauma cases where the exact nature and extent of injury could not be envisaged as accurately as in neoplastic lesions. One trauma patient had injury of the bronchus intermedius. Initially, repair while conserving all three lobes was attempted. However, it was discovered per-operatively that there was also substantial damage in the proximal part of the middle lobe bronchus. Re-implantation of this traumatized bronchus would have resulted in stenosis, with or without bronchopleural fistula. A middle lobectomy was therefore performed with a sleeve resection of the damaged bronchus intermedius. In another patient, bronchoplasty was not possible without removing a sleeve of pulmonary artery, which was performed with a satisfactory outcome. Narrowing of the reconstructed bronchus was noticed during the operation in one patient where bronchoplasty was done after wedge sleeve resection of the right main bronchus. The bronchoplasty was therefore undone, and a complete sleeve resection was performed which resulted in satisfactory correction.
3.2. Operating time, HDU and hospital stay
The mean time in the operating theatre, i.e. from the induction of anaesthesia to the transfer of the patient to the recovery room, was 207 min (range 120–375 min). The duration of stay in the HDU was no longer than 3 days. The median hospital stay was 13 days (mean 16, range 6–35 days). Prolongation of the hospital stay, in those who stayed longer than 13 days, was necessitated by factors such as prolonged air leak, difficulty in weaning from the ventilator, and the need for orthopaedic management of concurrent trauma.
3.3. Morbidity and mortality
Amongst the post-operative complications excessive bronchial secretions and partial atelectasis were the most common. All except one of these patients were managed with physiotherapy, postural drainage, breathing exercises and bronchodilators. One patient required therapeutic bronchoscopy in addition to these measures. One other patient showed a prolonged air leak (>21 days) which healed spontaneously. Prolonged dependence on the mechanical ventilation was noticed in one female patient. Although her respiratory functions were within the acceptable range, she had poor muscle power and motivation or psychological drive. She therefore underwent tracheostomy which facilitated the process of weaning. After this, the respiratory functions remained satisfactory.
Amongst late complications, one pneumonectomy patient developed empyema after 24 months, and was initially treated with rib resection and drainage. However, it was later discovered that this patient had a recurrence of disease with the development of oesophago-pleural fistula. He died soon after this. There was no mortality during operations, or in the immediate post-operative period. The earliest mortality was noticed 6 months after operation due to recurrence of disease and respiratory failure.
3.4. Follow-up and survival figures
The survival figures in malignant tumours of the bronchial tree (non-small cell lung cancer (NSCLC)) are illustrated in Fig. 5. The length of these transverse bars represents the number of months from the date of operation until the last follow-up. It clearly demonstrates that the survival was much better in N0 disease. Four out of nine patients with N0 disease lived more than 5 years. The longest surviving patient in this group was alive 14 years after operation. In N1 disease, seven out of 12 patients lived between 2 and 5 years, while in N2 disease (n=6), all except two died within 2 years after operation.
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Fig. 5. Survival up to the last follow-up of 26 patients after bronchoplastic procedures for primary lung cancer. The nodal status has been plotted against survival.
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4. Discussion
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Sleeve resections [3], bronchoplasties [4] and Y-sleeve resections [5] require a thorough pre-operative appraisal of the whole clinical situation. In benign lesions, bronchoplasty should be the operation of choice whenever technically feasible. However, in malignant conditions, the two corner stones of decision making are long-term survival and good residual cardiopulmonary functions. The first factor is important in cases of a tumour located within 2 cm of the carina, where the alternatives are either a sleeve pneumonectomy or inoperability. The second factor is important when a pneumonectomy is desired, as well as technically feasible, but poor cardiopulmonary reserve does not permit it. In this clinical setting, a lobectomy with bronchoplasty is the most appropriate choice. Our present series demonstrates the advantage of bronchoplasties in both of these situations.
The type of bronchoplastic procedure in individual cases is selected according to the location and extent of the pathological lesion, and may need modifications according to the operative findings. The most commonly performed bronchoplastic procedure is a sleeve lobectomy. The principal aim of the procedure is to conserve as much of the healthy lung tissue as possible, while providing satisfactory cancer clearance. The surgical techniques for sleeve resections and bronchoplasties are well documented. The bronchus is dissected from the surrounding lung and major pulmonary vessels. Slings are passed around it and its branches. A longitudinal bronchotomy is made to expose the tumour. Once the extent of the tumour is fully defined, resection is carried out and specimens from the resection margins are sent for frozen sectioning to confirm complete removal of the involved area. The end-to-end anastomosis is then performed with interrupted sutures of non-absorbable material placed a few millimetres apart, taking good bites. In this series, interrupted stainless steel wire of grade 38/40 stainless steel wire gauge (SSWG) was used in earlier patients. Since stainless steel is a mono-filament and inert, it does not cause tissue reaction, formation of granulation tissue, development of bronchopleural fistulae or bronchial stenosis. In the later periods, interrupted vicryl, silk and ethibond were used in chronological order. Regardless of the type of suture material, the suture line is covered with a pleural or pericardial flap or a synthetic material, e.g. Dacron, to protect the anastomosis and to prevent erosion of pulmonary vessels by the suture knots. In our series of patients, a pleural flap was used preferentially, except in one case where a healthy pleural flap was not available because of previous surgery, and therefore, Dacron was wrapped around the bronchoplasty. The deployment of prosthetic materials, such as Dacron, to patch a defect in the bronchial wall did result in problems in one patient and is not recommended for routine bronchoplasty.
Bronchoplastic procedures are likely to be attended by a high rate of post-operative complications, and therefore require high dependency care in the immediate post-operative period. Some patients require elective admission to an intensive care ward. Intensive monitoring in these patients can avoid lethal complications, such as pulmonary oedema. Commonly observed early complications include partial pulmonary atelectasis or lobar collapse, pneumonia, pulmonary air leak suture erosion of vessels, and transient vocal cord paralysis. Atelectasis, which is the most common problem, is caused by the accumulation of bronchial secretions and of congealed blood. Flexible bronchoscopy at the end of the operation should obviate this problem. We routinely perform flexible bronchoscopy and bronchial toilet prior to extubation of the patient in the operating room. It is safe and easy to perform, and confirms the patency of the reconstructed bronchus. Post-operative bronchial clearance is not very efficient, especially in the older patients. Preventive measures, such as steam inhalations and physiotherapy, should help prevent complications due to this factor. The incidence of late complications, which include bronchial stricture, bronchiectasis, bronchopleural fistula and empyema, has been comprehensively reviewed by Tedder et al. [6].
Since sleeve lobectomies are performed as an alternative to pneumonectomy, morbidity and mortality figures are judged against those of standard pnuemonectomy procedures. In a series of 72 patients, Gaissert et al. [7] observed a mortality of 4%, with a survival at 1 and 5 years of 84 and 42%, respectively, compared to a 9% mortality observed in 56 pnuemonectomies performed during the same period, without a significant difference in the 1 and 5 year survival between the two series. They also found that poor lung function and nodal involvement were associated with much lower 5 year survival figures. Rendina et al. [8] have reported a comparable surgical outcome in their series of 44 sleeve resections for bronchogenic cancer with a 2 year survival of 72%. Kato et al. [9], reporting their experience of 25 cases of bronchoplastic procedures for tuberculous stenosis, experienced anastomotic stenosis in seven patients, requiring dilatation. One patient died of pulmonary oedema on the first post-operative day, and the other died 4 months after the operation due to massive bleeding during endoscopic dilatation.
An analysis of the long-term outcome and survival after bronchoplasty for NSCLC in our series showed that patients with N0 had good long-term survival. Those with N1 disease, in general, developed recurrence or distant metastases within 2–5 years, and those with N2 status died mostly within 2 years. However, two patients with N2 disease survived more than 2 years. One of these patients suffered from a small tumour at the origin of right main bronchus with metastasis in the carinal nodes. She survived more than 5 years. The other was a patient with N2 adenocarcinoma who remained asymptomatic for a good 3 years before he developed superior vena caval obstruction (SVCO) and died shortly after that.
Tumours involving the tracheobronchial junction, especially on the left side, are difficult to deal with. Muscolino and colleagues [10] reported their experience of using an anterior thoracotomy through the fourth intercostal space for right sleeve pneumonectomy in seven patients. They found this approach very convenient to carry out anastomosis, as well as paratracheal and subcarinal clearance. Maeda and colleagues [11], on the other hand, reported their experience of carinoplasty in 42 cases through a variety of exposures, including bilateral thoracotomies and combinations of thoracotomy with median sternotomy.
In a detailed review of the literature between 1966 and 1992, Watanabe [12] has summarized the results of all tracheal sleeve pneumonectomies performed by 13 groups. According to the results of the individual series, there is a wide variation in operative mortality (0–29%) and 5-year survival figures (up to 23%). After pooling the data of these 13 reports, we observe that there were 48 deaths in 253 patients (18.9%). The wide variation in the results is due to two main reasons, those being variation in the size of individual series (n=2–55) and differences in the selection of the patients. Roviaro et al. [13] have reported their experience with 28 patients in a 9-year period (1983–1992). They included 14 patients with N0 disease, nine with N1, and five with N2. One patient died of myocardial infarction within a month. Seven patients were alive 4 years after the operations, and one patient after 5 years.
All reports cited above confirm that sleeve pneumonectomy is not a commonly performed procedure in cancer patients. Although operative mortality has been reduced over the years, the 5-year survival has improved very little. Our series, which includes six sleeve pneumonectomies and seven carinoplasties, shows that the survival is mainly determined by the histological grade and pathological stage of the tumour, as the patients with well differentiated squamous cell carcinoma and N0/N1 status lived more than 5 years. Moreover, the results in cases with benign lesions were extremely good which again suggests that early mortality is due to the nature and stage of malignancy, and not to the complexity of the procedure.
In conclusion, whilst bronchoplastic procedures require high surgical skill, special anaesthetic techniques and stringent, high dependency post-operative care, the operative morbidity is very low, and mortality figures compare favourably with those of lung resection for malignant and benign conditions. Where the indications exist, they should be more freely practised.
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Received March 8, 1999;
received in revised form December 30, 1999;
accepted February 7, 2000.
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Abstract
1. Introduction
