Bronchoplasty

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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. ^[3]

Bronchoplastic techniques can also be used to repair traumatic airway injuries and benign strictures.

Surgical bronchoplasty

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

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. ^[4]

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 ^[5] :

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

Closed bronchoplasties are performed via bronchoscope (rigid or flexible) mainly in central airway obstructions. The distribution of pathology for bronchoplastic surgeries are listed below. ^{[1, 2]}

Low-grade malignancy(most cases)

Carcinoid (typical/atypical; most common)

Non–small cell carcinoma (NSCLC)

Adenoid cystic carcinoma

Granular cell tumor

Benign masses

Neuroendocrine tumors

Inflammatory pseudotumor

Mucous gland cystadenoma

Hamartoma

Lipoma

Stenosis

Postinfectious stenosis due to histoplasmosis and bronchial tuberculosis

Inflammatory

Idiopathic

Posttraumatic

Postoperative

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

Coagulopathy

High-dose steroids

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:

Refractory hypoxemia

Life-threatening arrhythmias

Recent myocardial infarction or angina

Coagulopathy

Uncooperative patient

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

Coagulopathy

Asthma exacerbations

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. ^[7]

Early pulmonary complications include the following:

Excessive bronchial secretions

Atelectasis

Persistent air leak

Erosion and bleeding of vessels

Hemothorax

Pneumonia

Transient vocal cord paralysis

Pulmonary embolism

Late pulmonary complications include the following:

Bronchial strictures

Bronchopleural fistulas

Bronchovascular fistulas

Dehiscence of bronchial anastomosis

Empyema

Bronchiectasis

Recurrent stenosis

Recurrence of malignancy

Cardiac complicatins include the following:

Arrhythmias

Angina

Myocardial infarction

Other complications include the following:

Anesthesia complications

Postoperative pain

Wound infections

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 ^[8]

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. ^[12]

Outcomes and survival are excellent. ^[13]

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

Raphael Bueno, MD, John C. Wain, MD, Cameron D. Wright, MD. Bronchoplasty in the Management of Low-Grade Airway Neoplasms and Benign Bronchial Stenoses. Ann Thorac Surg. 1996;62:824-828:[Medline].

Anjum Jalal, K. Jeyasingham. Bronchoplasty for malignant and benign conditions: a retrospectivestudy of 44 cases. European Journal of Cardio-thoracic Surgery. 2000; 370-376:[Full Text].

Nagayasu T, Yamasaki N, Tsuchiya T, Matsumoto K, Miyazaki T, Hatachi G, et al. The evolution of bronchoplasty and broncho-angioplasty as treatments for lung cancer: evaluation of 30 years of data from a single institution. Eur J Cardiothorac Surg. 2016 Jan. 49 (1):300-6. [Medline].

Cayetano KS, Chan AL, Albertson TE, Yoneda KY. Bronchial Thermoplasty: A New Treatment Paradigm for Severe Persistent Asthma. Clin Rev Allergy Immunol. 2011 Nov 22:[Medline].

Kozo Nakanishi, MD, PhD*. Video-Assisted Thoracic Surgery Lobectomy With Bronchoplasty for Lung Cancer: Initial Experience and Techniques. Ann Thorac Surg. 2007;84:191-195:[Medline].

Whitson BA, Andrade RS, Boettcher A, Bardales R, Kratzke RA, Dahlberg PS, et al. Video-assisted thoracoscopic surgery is more favorable than thoracotomy for resection of clinical stage I non-small cell lung cancer. Ann Thorac Surg. 2007 Jun;83(6):1965-70:[Medline].

Marcus Kru¨ger*, Klaus Uschinsky, Kathrin Ha¨ßler, Claus Engelmann. Postoperative complications after bronchoplastic procedures in thetreatment of bronchial malignancies. European Journal of Cardio-thoracic Surgery 14 (1998) 46–53. [Full Text].

Adelheid End, MDa, Peter Hollaus, MDb, Andreas Pentsch, MDa, et al. Bronchoplastic procedures in malignant and nonmalignant diseaseMultivariable analysis of 144 cases. J Thorac Cardiovasc Surg. 2000;120:119-127:[Full Text].

Eung-Sirk Lee, Seung-Il Park, Yong Hee Kim, Chi Hoon Bae, Hye Won Moon, Mi Sun Chun, et al. Comparison of Operative Mortality and Complications between Bronchoplastic Lobectomy and Pneumonectomy in Lung Cancer Patients. J Korean Med Sci. 2007 February; 22(1): 43–47:[Medline].

Ph. Icard, J.F. Regnard*, L. Guibert, P. Magdeleinat, B. Jauffret, Ph. Levasseur. Survival and prognostic factors in patients undergoing parenchymal savingbronchoplastic operation for primary lung cancer:a series of 110 consecutive cases. European Journal of Cardio-thoracic Surgery 15. (1999) 426–432:[Full Text].

Onaitis MW, Furnary AP, Kosinski AS, Kim S, Boffa D, Tong BC, et al. Prediction of Long-Term Survival After Lung Cancer Surgery for Elderly Patients in The Society of Thoracic Surgeons General Thoracic Surgery Database. Ann Thorac Surg. 2018 Jan. 105 (1):309-316. [Medline]. [Full Text].

Deslauriers J, Tronc F, Grégoire J. History and current status of bronchoplastic surgery for lung cancer. Gen Thorac Cardiovasc Surg. 2009 Jan;57(1):3-9. [Medline].

Francis D. Sheski, MD; and Praveen N. Mathur, MBBS, FCCP. Long-term Results of FiberopticBronchoscopic Balloon Dilation in theManagement of BenignTracheobronchial Stenosis. [Full Text].

Tedder M, Anstadt MP, Tedder SD, Lowe JE. Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. Ann Thorac Surg. 1992 Aug;54(2):387-91.:[Medline].

Kocher GJ, Gioutsos KP, Ahler M, Funke-Chambour M, Ott SR, Dorn P, et al. Perioperative Lung Function Monitoring for Anatomic Lung Resections. Ann Thorac Surg. 2017 Nov. 104 (5):1725-1732. [Medline]. [Full Text].

Christophoros Kotoulas, George Lazopoulos. Wedge resection of the bronchus: an alternative bronchoplastic technique for preservation of lung tissue. European Journal of Cardio-thoracic Surgery 20 (2001) 679–683. [Full Text].

Laursen LØ, Petersen RH, Hansen HJ, Jensen TK, Ravn J, Konge L. Video-assisted thoracoscopic surgery lobectomy for lung cancer is associated with a lower 30-day morbidity compared with lobectomy by thoracotomy. Eur J Cardiothorac Surg. 2016 Mar. 49 (3):870-5. [Medline]. [Full Text].

Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016 Jun. 17 (6):836-844. [Medline].

Agasthian T. Video-assisted thoracoscopic bronchoplasty. J Vis Surg. 2017. 3:12. [Medline].

Sandra C. Tomaszek, MD, Stephen D. Cassivi, MD, MSc, K. Robert Shen, et al. Clinical Outcomes of Video-Assisted Thoracoscopic Lobectomy. Mayo Clin Proc. 2009 June; 84(6): 509–513. [Medline].

Kamiyoshihara M, Nagashima T, Igai H, Atsumi J, Ibe T, Kakegawa S, et al. Video-assisted thoracic lobectomy with bronchoplasty for lung cancer, with special reference to methodology. Interact Cardiovasc Thorac Surg. 2011 Apr;12(4):534-8. [Medline].

[Guideline] C.T. Bolliger, P.N. Mathur. ERS/ATS statement on interventional pulmonology. ERJ February 1, 2002 vol. 19 no. 2 356-373. [Full Text].

Orons PD, Amesur NB, Dauber JH, Zajko AB, Keenan RJ, Iacono AT. Balloon dilation and endobronchial stent placement for bronchial strictures after lung transplantation. J Vasc Interv Radiol. 2000 Jan;11(1):89-99. [Medline].

Amesur NB, Orons PD, Iacono AT. Interventional techniques in the management of airway complications following lung transplantation. Semin Intervent Radiol. 2004 Dec;21(4):283-95. [Medline].

Mario Castro1, Adalberto S. Rubin2, Michel Laviolette3. Effectiveness and Safety of Bronchial Thermoplasty in the Treatment of Severe AsthmaA Multicenter, Randomized, Double-Blind, Sham-Controlled Clinical Trial. Am J Respir Crit Care Med Vol 181. pp 116–124, 2010. [Full Text].

Gerard Cox, M.B., Neil C. Thomson, M.D.,. Asthma Control during the Yearafter Bronchial Thermoplasty. [Full Text].

Lowe JE, Bridgman AH, Sabiston DC Jr. The role of bronchoplastic procedures in the surgical management of benign and malignant pulmonary lesions. J Thorac Cardiovasc Surg. 1982 Feb;83(2):227-34.:[Medline].

Torrego A, Solà I, Munoz AM, et al. Bronchial thermoplasty for moderate or severe persistent asthma in adults. Cochrane Database Syst Rev. 2014 Mar 3. 3:CD009910. [Medline].

Dharani Kumari Narendra, MD Assistant Professor of Medicine (Pulmonary Critical Care Medicine), Baylor College of Medicine

Dharani Kumari Narendra, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

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

M Frances J Schmidt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians

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.

Bronchoplasty

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