Bronchoplasty is a reconstruction or repair of the bronchus to restore the integrity of the lumen. Bronchoplasties have a remarkable role in management of benign and malignant pulmonary lesions. The first bronchoplasty was performed by Bigger in 1932. Various novel techniques have been used to treat a wide range of pathologic conditions. Bronchoplastic procedures for benign and low-grade malignant tumors of the airway and benign stenosis allow preservation of maximum amount of pulmonary parenchyma (see the image below). [1, 2] Benign and low-grade malignancies require only minimally clear margins for cure and are ideally suited to bronchoplastic resections. In typical lung resection procedures, any airway involved with tumor is resected with its associated lung parenchyma. This results in extensive resections in the setting of central tumors involving the proximal airways. With bronchoplastic techniques, the involved airway may be resected to negative margins and the remaining ends anastomosed, thus preserving the distal lung parenchyma. 
Bronchoplastic techniques can also be used to repair traumatic airway injuries and benign strictures.
Surgical bronchoplasty involves reconstruction or anastomosis of bronchus after lung procedures such as lobectomy, sleeve resection, wedge resection, and pulmonary artery angioplasty. In its most common form, this procedure involves resection of a portion of the airway without resection of the associated lung parenchyma and reconstruction of the airway with bronchial anastomosis (sleeve resection).
The typical scenario is a centrally located upper lobe lung cancer involving the origin of the right upper lobe bronchus and the origin of the bronchus intermedius. Without use of bronchoplastic techniques, a pneumonectomy would be required, but a right upper lobectomy may be performed with the resection extending to involve the proximal bronchus intermedius and reanastomosis of the right mainstem bronchus to the bronchus intermedius, thus preserving the right lower lobe. Tumors involving the main branches of the pulmonary artery can similarly be resected with pulmonary artery sleeve resection and reanastomosis.
Balloon bronchoplasty involves the use of balloons for symptomatic airway stenosis. Balloon bronchoplasty is a procedure essential to practice of interventional bronchoscopy. It is performed with both flexible and rigid bronchoscopy. This technique is generally used in conjunction with other techniques (eg, electrocautery, stent deployment).
Thermal bronchoplasty or bronchial thermoplasty (BT)
Severe asthmatics have increased airway smooth muscle (ASM) responsible for bronchoconstriction and increased resistance of airway. BT is a novel treatment modality that uses radiofrequency energy to reduce ASM mass and resistance of airway. It is safe, improves quality of life, and decreases severity and frequency of asthma exacerbations. 
Bronchoplasty is indicated for various benign and malignant pulmonary lesions. Surgical bronchoplasties are commonly performed in conjunction with lobectomy, wedge resection, and sleeve resection.
Open bronchoplasty is performed via open thoracotomy or thoracoscopic video-assisted thoracoscopic surgery (VATS). VATS provides adequate visualization despite limited access to the thorax, allowing the procedure to be performed in patients in a state of debilitation and in patients who have marginal pulmonary reserve. [5, 6]
The criteria for VATS lobectomy with bronchoplasty are as follows  :
Tumor size less than 5 cm
No evidence of vessel invasion
No direct invasion to the surrounding organs requiring reconstruction
Patient and family agree to procedure
Low-grade malignancy(most cases)
Carcinoid (typical/atypical; most common)
Non–small cell carcinoma (NSCLC)
Adenoid cystic carcinoma
Granular cell tumor
Mucous gland cystadenoma
Postinfectious stenosis due to histoplasmosis and bronchial tuberculosis
Balloon bronchoplasty is indicated in central airway obstructive lesions resulting in endoluminal stenosis due to endobronchial carcinoids, sarcoidosis, hamartoma, bronchogenic carcinoma, infections, Wegener granulomatosis, postintubation stenosis, idiopathic or posttraumatic stenosis, granulation tissue, and bronchial strictures after lung transplantation.
Bronchial thermoplasty is used for treatment of patients with symptomatic severe, persistent asthma who are 18 years and older.
Thoracic surgery is contraindicated in the following cases:
Markedly unstable or shocked patient
Poor cardiopulmonary reserve
Poor functional status
VATS is contraindicated for the following:
Extensive adhesions obliterating the pleural space (ie, prior talc pleurodesis, reoperation)
Extensive pleural diseases
Balloon bronchoplasty is contraindicated for the following:
Recent myocardial infarction or angina
Thermal bronchoplasty is contraindicated for the following:
Patients with a pacemaker, internal defibrillator, or other implantable electronic device
Patient with allergies to lidocaine, atropine, or benzodiazepines
Active respiratory infection
Recent changes in corticosteroid regimen (<2 weeks)
Surgical bronchoplastic procedures represent a fairly safe therapy in patients with centrally localized bronchial carcinoma and compromised pulmonary function. Complication rates are higher after sleeve resection of the bronchus as compared with wedge resection. 
Early pulmonary complications include the following:
Excessive bronchial secretions
Persistent air leak
Erosion and bleeding of vessels
Transient vocal cord paralysis
Late pulmonary complications include the following:
Dehiscence of bronchial anastomosis
Recurrence of malignancy
Cardiac complicatins include the following:
Other complications include the following:
Balloon bronchoplasty is generally safe, but complications such as chest pain, bronchospasm, airway rupture, pneumothorax, hemothorax, and mediastinitis are possible.
Late complications include recurrent stenosis and stent displacement.
Complications associated with thermal bronchoplasty include a transient and self-limited increase and worsening of respiratory symptoms, atelectasis, hemoptysis, anxiety, headaches, and nausea.
Multivariable analysis demonstrated the following 4 risk factors for poor survival:
High tumor stage
Type of bronchoplastic procedure
Impaired lung function
Presence of cardiovascular risk 
For patients with non–small cell lung cancer, 5-year actual survival rates were 60% in stage IB, 30% in stage IIB, and 27% in stage IIIA. [9, 10, 11] Published reports document a 30-day operative mortality of 0-5%. Most major reports document a 5-year survival of 40-50% and functional results that are significantly better than those obtained following pneumonectomy. 
Outcomes and survival are excellent. 
In a double-blind, randomized, sham-controlled clinical study of bronchial thermoplasty, patients with severe asthma that were treated with bronchial thermoplasty showed improvement on an asthma-related quality-of-life questionnaire (ARQLQ), as compared to control patients, and experienced the following significant benefits that were maintained for at least 2 years:
84% reduction in emergency room visits for respiratory symptoms
73% reduction in hospitalizations for respiratory symptoms
66% reduction in days lost from work or school due to asthma symptoms
32% reduction in asthma attacks
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Dharani Kumari Narendra, MD Assistant Professor of Medicine (Pulmonary Critical Care Medicine), Baylor College of Medicine
Disclosure: Nothing to disclose.
M Frances J Schmidt, MD Chief of Pulmonary Medicine, Pulmonary Fellowship Program, Teaching Attending Physician, Department of Medicine, Interfaith Medical Center
Disclosure: Nothing to disclose.
Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women’s Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine
Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society
Disclosure: Nothing to disclose.
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