Abstract
Background/Aim: The surgical techniques of pulmonary resection with bronchoplasty for right lower lobe lung cancer are not well investigated. This study aimed to provide a detailed description of the pulmonary resection with bronchoplasty technique, including the appropriate patient selection process, in right lower lobe lung cancer patients. Patients and Methods: The clinical courses of 17 right lower lobe lung cancer patients who had undergone pulmonary resection with bronchoplasty were retrospectively investigated. Results: Of the 17 patients, 9 had right lower sleeve lobectomy, 5 had right middle and lower sleeve lobectomy, and 3 had right lower sleeve lobectomy with double-barreled bronchoplasty. The median follow-up period was 26 months. There were no treatment-related deaths. Distant organ recurrence was observed in 5 patients and local recurrence was identified in 3. One patient had pneumonia and another had prolonged air leak. Two patients, each of whom had either lower sleeve lobectomy or lower sleeve lobectomy with double-barreled bronchoplasty, developed bronchopleural fistula, and both patients were treated with additional surgery. Conclusion: Pulmonary resection with bronchoplasty should be performed only in oncologically and anatomically select patients. Our findings can be used as a guide to select the optimal treatments for this subgroup of patients.
Right lower lobectomy is a standard procedure for primary lung cancer in the right lower lobe. However, in case of infiltration of the primary tumors or metastatic hilar lymph nodes into the central airway, pulmonary resection with bronchoplasty is performed to achieve complete tumor resection and preserve the peripheral lung tissue. Kocaturk et al. (1) investigated the clinical outcomes of patients following right middle-lower bilobectomy and lower sleeve lobectomy for right lower lobe lung cancer, reporting that the preserved middle lobe could fill the residual thoracic cavity, thereby reducing prolonged air leak and other complications. Pneumonectomy should be avoided as excessive pulmonary resection can negatively affect cardiorespiratory function (2, 3). In addition, the quality of life following pneumonectomy is substantially poorer compared to that after surgery aiming to preserve pulmonary function (4). In general, right middle and lower sleeve lobectomy is selected over pneumonectomy in cases where the tumor is located in the right lower lobe and when the right second carina is infiltrated by cancer cells. Similarly, if the right middle lobe is not infiltrated by cancer cells, both the right upper and middle lobes can be preserved by performing right lower sleeve lobectomy with double-barreled bronchoplasty (5). To the best of our knowledge, no study has provided a detailed report regarding the surgical techniques of pulmonary resection with bronchoplasty for right lower lobe lung cancer.
This study aimed to illustrate the details of surgical techniques and appropriate patient selection for pulmonary resection with bronchoplasty for right lower lobe lung cancer.
Patients and Methods
Between January 2018 and December 2021, 50 patients with primary lung cancer underwent pulmonary resection with bronchoplasty at the Osaka Metropolitan University Hospital, Osaka, Japan. The surgical techniques of pulmonary resection with bronchoplasty for right lower lobe lung cancer and the clinical course of each patient after surgery were investigated. The local Institutional Ethics Committee approved this study (approval no. 4403; approval date, October 3, 2019).
Enhanced computed tomography (CT) scans identified mediastinal lymph nodes with a short axis of ≥10 mm that were clinically positive for metastasis. The inclusion criteria of selecting patients for surgical resection included the absence of distant metastasis, cancer cell-positive pleural or pericardial effusion, bulky N2 disease, N3 disease, and a predicted postoperative vital capacity of ≥40%. Patients with pathological stage II or III lung cancer underwent adjuvant platinum-based doublet chemotherapy, while patients with stage I lung cancer received oral tegafur–uracil adjuvant chemotherapy.
Bronchoplasty was performed using 4-0 absorbable monofilament sutures. The deepest part was anastomosed using continuous sutures, whereas the other parts were anastomosed using interrupted suture. To correct caliber mismatch, a large-caliber bronchial stump was sewed with wide pitches and a small-caliber bronchial stump was sewed with narrow pitches; however, no other special methods were performed to correct this mismatch. Intraoperative pathological examination confirmed the absence of cancer cell infiltration in bronchial stumps, and each anastomotic site was circumferentially covered with a pedicle pericardial fat pad. In right lower sleeve lobectomy, the middle lobe was rotated dorsally to bring the middle lobe bronchus to the trunk intermedius (Figure 1A). In this method, it is essential to separate the right upper and middle lobes to mobilize the right middle lobe. Furthermore, the axes of both bronchi are irregular because the middle lobe bronchus needs to be anastomosed to the trunk intermedius in the natural position (Figure 1B). Pericardiotomy at the inferior edge of the superior pulmonary vein is also useful for mobilizing the right middle lobe (6). In right middle and lower sleeve lobectomy, because the pulmonary artery and vein can be avoided ventrally, the anastomosis between the right main and upper bronchi can be performed in a good surgical field (Figure 2A). However, following airway reconstruction, the direction of the distal stump changes considerably. To identify the lumens during the suturing process, both stumps were opened (Figure 2B). Conversely, during the ligation process, the peripheral lung tissue was displaced to ensure that both stumps were closed, thereby eliminating the possibility of tension at the ligature points (Figure 2C). The appropriate position of the peripheral lung during surgery was very important for this method. Owing to the absence of a cartilaginous ring in the right upper bronchus, the distal stump is expanded to fit the proximal stump (7). In cases where the middle lobe is not infiltrated by cancer cells and anastomosis can be performed without tension, both the right and middle lobes can be preserved using the right lower sleeve lobectomy with double-barreled bronchoplasty (5). Ensuring that both bronchi are bound in the natural position, the upper and middle lobe bronchi were bounded by three or four intraluminal interrupted sutures to create a new second carina, which was anastomosed to the right main bronchus (Figure 3A). Both bronchi are usually bound horizontally to the membranous portion (Figure 3B). Pericardiotomy at the inferior edge of the superior pulmonary vein is useful for reducing tension at the anastomotic site between the new second carina and right main bronchus.
(A) In right lower sleeve lobectomy, the middle lobe is rotated dorsally to bring the middle lobe bronchus to the trunk intermedius. The deepest part was anastomosed using continuous sutures. We sewed a large-caliber bronchial stump with wide pitches and a small-caliber bronchial stump with narrow pitches to correct the caliber mismatch. PA, pulmonary artery. (B) The axes of both bronchi were irregular in each patient because the middle lobe bronchus had to be anastomosed to the trunk intermedius in the natural position.
(A) In right middle and lower sleeve lobectomy, anastomosis between the right main and upper bronchi could be performed in a good surgical field because the pulmonary artery and vein are able to be avoided ventrally. PA: Pulmonary artery; PV: pulmonary vein. (B) The direction of the distal stump changes significantly following bronchoplasty. During the suturing process, both stumps were opened to recognize the lumens. (C) During ligation, both stumps were closed by displacing the peripheral lung tissue to avoid tension at the ligature points.
(A) In right lower sleeve lobectomy with double-barreled bronchoplasty, the upper and middle lobe bronchi are bounded by three or four intraluminal interrupted sutures to create a new second carina, which is anastomosed to the right main bronchus. (B) Both bronchi are usually bound horizontally to the membranous portion.
A standard bronchoscopic examination was performed 1 week postoperatively. When wound healing at the anastomotic site was markedly prolonged, the bronchoscopic examination was repeated until complete healing. Adverse events that occurred within 3 months postoperatively were evaluated according to the Common Terminology Criteria for Adverse Events (version 5.0). Adverse events of more than grade 3 were recorded. Following discharge, all patients underwent follow-up chest radiographs and tumor markers measurements every 2-4 months. Furthermore, CT scans were performed after 6 months and annually thereafter.
Results
Of the 17 patients included in this study (Table I), 9 underwent right lower sleeve lobectomy, 5 right middle and lower sleeve lobectomy, and 3 right lower sleeve lobectomy with double-barreled bronchoplasty. Following definitive treatment via platinum doublet chemotherapy with immunotherapy, one patient was diagnosed with a tumor in the right lower lobe and mass formation in the left atrium who underwent right middle and lower sleeve lobectomy with combined resection of the left atrium. Nine patients (53%) underwent adjuvant chemotherapy. The median follow-up period was 26 months, and eight patients (47%) exhibited recurrence. Distant organ recurrence was common. Two patients showed recurrence at the anastomotic site following right middle and lower sleeve lobectomy, while one patient showed recurrence at the resected edge of the preserved lung following right lower sleeve lobectomy with double-barreled bronchoplasty.
Characteristics of patients included in the study.
Table II demonstrates the details of postsurgical adverse events. One patient developed pneumonia following right lower sleeve lobectomy, which could be due to the retention of sputum caused by a narrow anastomotic site. Because both bronchi were anastomosed in an unnatural position, the middle lobe bronchus became kinked and constricted. This patient was treated via repeated bronchoscopy and antibiotic therapy. Additionally, one patient developed bronchopleural fistula (BPF) following right lower sleeve lobectomy. Bronchoscopic examinations revealed ischemic changes of the proximal mucosa at the anastomotic area. He had completion middle lobe lobectomy. Following middle and lower sleeve lobectomy, a large residual thoracic cavity remained due to the insufficient volume of the right upper lobe. One patient was diagnosed with prolonged air leak following middle and lower sleeve lobectomy, eventually alleviated by pleurodesis. Finally, one patient developed BPF following lower sleeve lobectomy with double-barreled bronchoplasty and underwent completion pneumonectomy.
Details of adverse events after the surgery.
Discussion
This study demonstrated the surgical techniques and outcomes of pulmonary resection with bronchoplasty for right lower lobe lung cancer. Because of negative effects on cardiorespiratory function (2, 3), we should avoid pneumonectomy. Right middle and lower sleeve lobectomy and lower sleeve lobectomy with double-barreled bronchoplasty are performed to avoid pneumonectomy. However, right lower sleeve lobectomy with double-barreled bronchoplasty can be performed only in selected patients. Consequently, right middle and lower sleeve lobectomy may have the best profile with regard to patient survival between the three procedures. Intraoperative pathological examination confirmed the absence of cancer cell infiltration in both bronchial stumps in all cases. However, two of five patients exhibited local recurrence near the anastomotic site following right middle and lower sleeve lobectomy. As indicated, the right middle and lower sleeve lobectomy should be selected to avoid pneumonectomy. It is essential to acquire sufficient surgical margin at the right main bronchus during the right middle and lower sleeve lobectomy.
Between the three procedures, right lower sleeve lobectomy with double-barreled bronchoplasty may be the most technically demanding. This method can achieve complete cancer resection and preserve both the upper and middle lobes. However, this surgical method can be extensively complex for several reasons. The pulmonary artery, usually located between the right upper and middle bronchi, prevents the natural and tensionless bundling of the bronchi. In addition, the stump of the middle bronchus is anatomically distant from that of the main bronchus. Consequently, this method must be rejected to avoid serious complications in cases where severe tension at the anastomotic site persists following pericardiotomy at the inferior edge of the superior pulmonary vein. Hence, right lower sleeve lobectomy with double-barreled bronchoplasty must be performed oncologically and anatomically, only in selected patients.
In right lower sleeve lobectomy, the long stump of the trunk intermedius causes ischemia at the proximal side of the anastomotic site. With the object of blood supply, an appropriate cut line of the proximal edge might be at the two cartilaginous rings from the right second carina. Furthermore, care must be taken to avoid devascularization of the bronchus during bronchial or lymph node dissection (8). A significant caliber mismatch exists between the right middle bronchus and trunk intermedius. It was previously reported that the use of a bronchial flap was very beneficial in adjusting this caliber mismatch (9). However, we considered that the long stump of the right middle bronchus could be easily kinked because of the absence of a cartilaginous ring. In our study, one patient developed pneumonia owing to the kinking of the distal bronchus following right lower sleeve lobectomy. We suggest that a special technique is not required to correct the caliber mismatch between the middle bronchus and trunk intermedius. In this method, long bronchial stumps may be more appropriate to correlate with airway complications as opposed to short ones. A preserved middle lobe can fill the residual thoracic cavity and reduce complications, such as prolonged air leak and empyema. Although an anastomosis between the right middle bronchus and intermedius trunk requires highly advanced surgical techniques and careful perioperative management, this procedure is recommended to avoid right middle-lower bilobectomy (1).
Because of its less invasive nature, easy management, and reliable residual thoracic cavity, we usually cover the anastomotic site with pedicle pericardial fat tissue to avoid broncho-pulmonary artery fistula, which is the most severe complication after BPF (10). Following right middle and lower sleeve lobectomy, the right upper lobe tends to rotate dorsocaudally. This squeezes the pulmonary vein, which could impair postoperative venous return (11). In right middle and lower sleeve lobectomy, the fat tissue is not directly located around the pulmonary vein. However, we believe that a sufficient amount of inserted fat tissue around the anastomosis site prevents excessive dorsocaudal rotation of the right upper lobe and avoids the kinking of the pulmonary vein. In our patients, complications of the major vessel flow were not observed.
This study has several limitations. First, it was a small, retrospective study. The accumulation of data from more patients and further analyses are currently ongoing. Second, treatments were selected at the discretion of the physician in charge of each case. The selection criteria for surgical procedures should be established in future studies. Third, because the follow-up period was short, we could not actually evaluate the profiles with regard to patient survival after the three procedures. We will present long-term outcomes after a sufficient follow-up period. Finally, because pneumonectomy or bilobectomy were very rarely performed in our Institute, the positive effects of lung-preserving surgeries could not be investigated compared to those of less beneficial surgeries.
In conclusion, we delineated the details of surgical techniques and outcomes of pulmonary resection with bronchoplasty for right lower lobe lung cancer. Furthermore, we illustrated the manner of appropriate patient selection for these surgical methods. These findings can be used to guide the selection of optimal treatments for this subgroup of patients with lung cancer.
Footnotes
Authors’ Contributions
Takuma Tsukioka designed the study, analyzed the data, prepared the figures and wrote original draft. Nobuhiro Izumi and Noritoshi Nishiyama oversaw the study and revised the article. All Authors reviewed the article.
Conflicts of Interest
The Authors have no conflicts of interest to declare regarding this study.
- Received September 25, 2022.
- Revision received October 4, 2022.
- Accepted October 11, 2022.
- Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
