Placement of sutures starting off the bronchial anastomosis in a typical right upper lobe sleeve lobectomy of this study. 

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Context 1

... resection for central bronchial carcinomas is a pulmonary parenchyma-preserving procedure, for which the alternative is pneumonectomy. Sir Clement Price Thomas is credited with the first bronchial sleeve resection performed for a carcinoid tumour in 1947 at the Brompton Hospital in London, UK. Allison, in 1952, performed a sleeve lobectomy for a lung carcinoma and, in 1955, Paulson and Shaw reported the first comprehensive review on the use of these techniques [1—4]. At that time, sleeve resections were considered compromised procedures indicated for patients who could not tolerate the pneumonectomy. Over the ensuing years, the oncological radicality and optimal results of bronchoplastic procedures became evident in comparison to the increased early and late morbidity and mortality of pneumonectomy [5—7]. Faber et al., in 1984, reported their extensive experience and concluded that sleeve lobectomy was a safe procedure, and, when technically feasible, it should be considered the procedure of choice for patients with lung cancer [8]. Recent studies have compared sleeve lobectomy and pneumonectomy in terms of late outcome and morbidity, and even for patients who can tolerate pneumonectomy they have suggested that sleeve lobectomy can achieve adequate curability rates with less mortality and better long-term survival and quality of life [9—12]. We undertook this study to review our experience with sleeve lobectomy, which although minimal in comparison to other centres, has allowed us to develop a minor modification of the technique. We focused on the surgical details and the outcome specific to this challenging, but common, procedure. In an effort to demystify it, we describe a ‘simplified’ operative and postoperative approach accomplished by us over time. During the period of January 2004 and January 2008, 45 patients underwent sleeve lobectomy for non-small-cell lung cancer (NSCLC), with a curative intent, at our general thoracic surgery department, which is considered one of the busiest in our country. We perform approximately 250 lobectomies and 50 pneumonectomies per year. Amongst them, we average 10—12 sleeve lobectomies per year, which constitutes about 4% of our major lung resections. Patients with bronchoplasties other than sleeve lobectomy were excluded from the study. All patients underwent double-lumen endotracheal intubation and posterolateral thoracotomy in the fifth intercostal space. Intra-operative frozen sections of the bronchial resection margins were sent for oncological resection confirmation. Preoperative evaluation included blood tests; chest X-ray; computed tomography (CT) of the chest, abdomen and brain; lung function tests; arterial blood gases and bronchoscopy in all patients. Magnetic resonance imaging, bone scan, Holter monitoring and cardiac stress testing was performed as needed. Mediastinoscopy was performed only in six patients who had mediastinal lymph nodes > 1 cm diameter, as revealed in the chest CT scan, but was negative for N 2 disease in all six patients (the findings were confirmed intra-operatively). In all patients, sleeve resection was decided intra- operatively if the lesion could be radically resected with it, since the majority of the patients included in the study would have been able to tolerate pneumonectomy. Although bronchoscopic findings identified the possible candidates for sleeve lobectomy, operative findings such as intraluminal or extraluminal extension of the tumour to the main bronchus, or the pulmonary artery, as well as presence of positive bronchopulmonary, along the fissure, or hilar lymph nodes, were crucial for the decision, regarding the type of sleeve resection. Radical lymph node dissection was routinely performed, and it was carried out before the bronchial reconstruction. Following double-lumen tube intubation and a standard posterolateral thoracotomy, we proceed with mediastinal lymph node dissection and frozen sections. Lobar vein ligation followed by pulmonary artery branches ligation and completion of the fissures are the usual next steps before bronchial reconstruction. Bronchial anastomosis is performed in an end-to-end fashion with two running, absorbable polyglactine (Vicril, Ethicon, Inc., Somerville, NJ, USA), 3/0 sutures (one for the cartilaginous portion and the other for the membranous portion). Two 3/0 non-absorbable polypropylene (Prolene, Ethicon, Inc., Somerville, NJ, USA) stay sutures are placed first in the proximal and distal end of the cartilaginous portions of the bronchi. Alongside each stay suture, we place and tie each of the two absorbable running 3/0 sutures to be used continuously and circumfer- entially for performing the bronchial anastomosis. As shown in Fig. 1, we begin with the first running suture from the distal end in order to suture and approximate the cartilaginous portion (anteriorly). Then the first running suture is tied to the second on the proximal end, and the membranous portion (posteriorly) is sutured with the second suture, which is then tied to the first suture on the distal end. Two or three additional, interrupted, 3/0 non-absorbable sutures may be required to reinforce the cartilaginous portion. In our case series we did not encounter large-calibre discrepancies where the classic technique with interrupted monofilament sutures would have been more appropriate. Apart from the division of the pulmonary ligament, we did not have to perform a pericardial U-incision around the inferior pulmonary vein in order to keep a tension-free anastomosis. Furthermore, even in patients with bronchovascular anastomoses, we did not use pleural, pericardial or intercostal muscle flap to cover them, because of their doubtful utility. As regards vascular anastomoses, pulmonary artery reconstruction was performed with a 4/0 non-absorbable suture either as an end-to-end anastomosis (in one patient) following proximal and distal occlusion of the pulmonary artery with vascular clamps and resection of the involved segment, or as suturing a bovine pericardial patch (in three patients) following partial clamping with a Satinsky clamp. In the case of total occlusion of the pulmonary artery, systemic anticoagulation with only 2000 units of heparin was given during the operation. Steroids were not given to these patients. Physical therapy and ambulation was started on the first postoperative day, but fibre optic bronchoscopy for aspiration of secretions was performed only as needed (only in seven patients), and not routinely. During the above-mentioned 4-year period, 40 men and five women with a median age of 64 years (range: 24—80 years) underwent sleeve lobectomy. Four patients with a central right upper lobe tumour underwent bronchovascular reconstructive procedures because of pulmonary artery infiltration. One patient had pulmonary artery resection and reconstruction and the remaining three had pulmonary artery patch reconstruction. Indications for sleeve lobectomy included a central bronchial tumour in 42 (93%) patients and a peripheral carcinoma with N 1 (hilar) lymph node involvement in three (7%). In all patients, with both peripheral and central tumours N 1 or N 2 (in two patients), lymph node involvement was found intra-operatively. A bronchial carcinoid tumour was diagnosed in five patients (11%; three women and two men), and it was atypical in one patient of each sex. All five patients with carcinoid tumours had negative regional lymph nodes. The majority of the sleeve resections were performed for tumours of the right hemithorax (91%) and particularly those involving the bronchus of the right upper lobe (67%), as detailed in Table 1. Pathological diagnosis and the TNM (tumour, nodes, metastases) staging as revised in 1997 by the American Joint Committee on Cancer and the International Union against Cancer, of all 45 patients is listed in Table 2 [13]. All 45 patients underwent oncological resections with negative results for malignancy bronchial resection margins. Neither bronchial nor vascular complications occurred with regard to the anastomoses. Postoperative complications occurred in seven patients (15%). They included prolonged (more than 7 days) air leak in three patients with emphyse- matous lungs, lobar atelectasis that needed daily bronchoscopy for aspiration of secretions in three and respiratory failure due to right middle lobe pneumonia in one, who needed intubation and transfer to the intensive care unit. He was a 72 years old patient who underwent a right upper lobe sleeve lobectomy and was suffering from chronic obstructive pulmonary disease treated with bronchodilators, and coronary artery disease treated with angioplasty. Repeated bronchoscopy did not reveal significant kinking or stenosis of the lobar bronchus. The patient died of respiratory failure 3 weeks later, accounting for a 30-day mortality rate of 2%. All others were treated conservatively with success. Interestingly, the patients with prohibitive pneumonectomy respiratory function had an unremarkable postoperative period. None of the 45 patients developed bronchial stricture, bronchopleural fistula or empyema, and none needed re- operation for completion pneumonectomy. All patients with pathological stage greater than I were given adjuvant chemotherapy. The two patients with N 2 disease were also offered chemotherapy plus radiation therapy of the mediastinum. Follow-up period ranged from 1 to 52 months, with a median of 26 months, and was complete for 43 patients (96%). Two patients were lost after 22 and 35 months. Follow- up was based on our clinical records and the information provided by the patients, their relatives or referring physicians. Survival was analysed ...

Context 2

... (Prolene, Ethicon, Inc., Somerville, NJ, USA) stay sutures are placed first in the proximal and distal end of the cartilaginous portions of the bronchi. Alongside each stay suture, we place and tie each of the two absorbable running 3/0 sutures to be used continuously and circumfer- entially for performing the bronchial anastomosis. As shown in Fig. 1, we begin with the first running suture from the distal end in order to suture and approximate the cartilaginous portion (anteriorly). Then the first running suture is tied to the second on the proximal end, and the membranous portion (posteriorly) is sutured with the second suture, which is then tied to the first suture on the distal ...