Tracheobronchial Sleeve Resection

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Masses located in the proximal airway remain a challenge for the thoracic surgeon. Because of the proximal location, the tenets of preservation of lung function and oncologic resection would seem to be at odds, and in many cases, traditional resection (often meaning pneumonectomy) is not a feasible option for patients who have poor pulmonary reserve at baseline. Additionally, masses located at the level of the carina would be unresectable without a tracheoplastic procedure to restore airway patency.

The presence of such complicated problems resulted in the creation of specialized surgical procedures, pioneered first by Price-Thomas in 1947 ^[1] to meet the need of a right main bronchus carcinoid mass, and further advanced and popularized by Mathey ^[2]  and then by Paulson and Shaw. ^[3] The current derivation of these techniques is surgical resection that allows both adherence to oncologic principles and preservation of airway anatomy and lung parenchyma, which has been shown to be a valid option in most cases. ^[4]

Tracheobronchial sleeve resection has made great strides as a viable surgical option for patients requiring extensive pulmonary resections. The benefits make it a desirable surgical approach for many individuals in whom a larger resection either would not be feasible or would cause significant residual morbidity. As with any pulmonary resection, successful management of these patients requires utilization of a team composed of experienced surgeons, oncologists, clinic staff, and hospital nurses.

The primary indication for bronchial or carinal sleeve resection is lung cancer, with a full preoperative workup indicating both (1) that the patient is a suitable surgical candidate from a medical standpoint and (2) that surgical resection is indicated (ie, no indication of distant disease). If these requirements are not met but the patient has an obstructing or near-obstructing lesion that must be addressed, palliation with stenting or other options may be considered, including nononcologic palliative operations; however, discussion of these approaches is beyond the scope of this article.

When surgical resection for neoplastic processes within the lung is indicated, the traditional teaching has been that lobectomy or pneumonectomy is the standard of care. In many patients with baseline lung disease, however, pneumonectomy or bilobectomy may impose too large a burden on an already taxed pulmonary system. Traditional resection would not be an option for these patients, and sleeve resection provides an avenue for surgical excision.

Additionally, pneumonectomy has been shown to have a higher mortality than sleeve resection in all patients, ^[5]  though sleeve resection has been shown to have a slightly higher mortality than routine lobectomy. Pneumonectomy patients also appear to have a worse quality of life than lobectomy patients do, and they appear to have a higher risk of death from cardiopulmonary factors. ^[6]

Moreover, evidence exists that sleeve lobectomy is ultimately more cost-effective than pneumonectomy. ^[5] Because of the possibility of preserving increased amounts of native lung function, the authors typically attempt to offer sleeve resection to all patients who are candidates, as supported by others. ^{[6, 7, 8, 9]}

Contraindications for bronchial or carinal sleeve resection include the following:

With operations that are both physiologically (for the patient) and technically (for the surgeon) difficult, the need for careful patient selection is all the greater, and any concerns raised during preoperative evaluation should prompt further workup.

Patients can expect a recovery at home that lasts several weeks, with a gradual return to normal function.

With appropriate management through all stages of their care, including the preoperative and postoperative setting, these individuals stand to have good outcomes with potential for curative resections or meaningful extension of healthy years.

Pagès et al used a decade of data from a French national database to compare outcomes following sleeve lobectomy (n = 941) and pneumonectomy (n = 5318) for non-small cell lung cancer (NSCLC). ^[10] ​ Although early differences in perioperative pulmonary outcomes favored pneumonectomy, early overall and disease-free survival differences favored sleeve lobectomy in the matched analysis (though not in the weighted analysis). The authors suggested that sleeve lobectomy, when technically feasible, should be the preferred technique.

In a retrospective study, Wang et al compared the outcomes of left sleeve lobectomy (n = 87) and left pneumonectomy (n = 48) in 135 patients with NSCLC. ^[11] There were no significant differences in general clinicopathologic features between the two groups. Operating time was longer and the extent of bleeding greater for sleeve lobectomy; however, overall survival was significantly longer with sleeve lobectomy. The outcomes of left sleeve lobectomy were associated only with pathologic stage. The authors suggested that left sleeve lobectomy, if anatomically feasible, may be a preferred alternative to left pneumonectomy for NSCLC patients.

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Gaissert HA, Mathisen DJ, Moncure AC, Hilgenberg AD, Grillo HC, Wain JC. Survival and function after sleeve lobectomy for lung cancer. J Thorac Cardiovasc Surg. 1996 May. 111 (5):948-53. [Medline].

Ferguson MK, Lehman AG. Sleeve lobectomy or pneumonectomy: optimal management strategy using decision analysis techniques. Ann Thorac Surg. 2003 Dec. 76 (6):1782-8. [Medline].

Okada M, Yamagishi H, Satake S, Matsuoka H, Miyamoto Y, Yoshimura M, et al. Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy. J Thorac Cardiovasc Surg. 2000 Apr. 119 (4 Pt 1):814-9. [Medline].

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Yildizeli B, Fadel E, Mussot S, Fabre D, Chataigner O, Dartevelle PG. Morbidity, mortality, and long-term survival after sleeve lobectomy for non-small cell lung cancer. Eur J Cardiothorac Surg. 2007 Jan. 31 (1):95-102. [Medline].

Ma QL, Guo YQ, Shi B, Tian YC, Song ZY, Liu DR. For non-small cell lung cancer with T3 (central) disease, sleeve lobectomy or pneumonectomy?. J Thorac Dis. 2016 Jun. 8 (6):1227-33. [Medline]. [Full Text].

Pagès PB, Mordant P, Renaud S, Brouchet L, Thomas PA, Dahan M, et al. Sleeve lobectomy may provide better outcomes than pneumonectomy for non-small cell lung cancer. A decade in a nationwide study. J Thorac Cardiovasc Surg. 2017 Jan. 153 (1):184-195.e3. [Medline].

Wang L, Pei Y, Li S, Zhang S, Yang Y. Left sleeve lobectomy versus left pneumonectomy for the management of patients with non-small cell lung cancer. Thorac Cancer. 2018 Mar. 9 (3):348-352. [Medline]. [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].

Ma Z, Dong A, Fan J, Cheng H. Does sleeve lobectomy concomitant with or without pulmonary artery reconstruction (double sleeve) have favorable results for non-small cell lung cancer compared with pneumonectomy? A meta-analysis. Eur J Cardiothorac Surg. 2007 Jul. 32 (1):20-8. [Medline].

Cerfolio RJ, Bryant AS, Eloubeidi MA. Routine mediastinoscopy and esophageal ultrasound fine-needle aspiration in patients with non-small cell lung cancer who are clinically N2 negative: a prospective study. Chest. 2006 Dec. 130 (6):1791-5. [Medline].

Defranchi SA, Cassivi SD, Nichols FC, Allen MS, Shen KR, Deschamps C, et al. N2 disease in T1 non-small cell lung cancer. Ann Thorac Surg. 2009 Sep. 88 (3):924-8. [Medline].

Jyoti A, Maheshwari A, Shivnani G, Kumar A. Management of a case of left tracheal sleeve pneumonectomy under cardiopulmonary bypass: anesthesia perspectives. Ann Card Anaesth. 2014 Jan-Mar. 17 (1):62-6. [Medline].

Kaya SO, Sevinc S, Ceylan KC, Usluer O, Unsal S. One-stoma carinoplasty: right upper sleeve lobectomy with hemicarinectomy for resection of right-tracheobronchial-angle tumors. Tex Heart Inst J. 2013. 40 (4):435-8. [Medline]. [Full Text].

Huang J, Li S, Hao Z, Chen H, He J, Xu X, et al. Complete video-assisted thoracoscopic surgery (VATS) bronchial sleeve lobectomy. J Thorac Dis. 2016 Mar. 8 (3):553-74. [Medline]. [Full Text].

Chen H, Xu G, Zheng B, Zheng W, Zhu Y, Guo Z, et al. Initial experience of single-port video-assisted thoracoscopic surgery sleeve lobectomy and systematic mediastinal lymphadenectomy for non-small-cell lung cancer. J Thorac Dis. 2016 Aug. 8 (8):2196-202. [Medline]. [Full Text].

Pan X, Gu C, Wang R, Zhao H, Shi J, Chen H. Initial Experience of Robotic Sleeve Resection for Lung Cancer Patients. Ann Thorac Surg. 2016 Dec. 102 (6):1892-1897. [Medline].

Egberts JH, Möller T, Becker T. Robotic-Assisted Sleeve Lobectomy Using the Four-Arm Technique in the DaVinci Si® and Xi® Systems. Thorac Cardiovasc Surg. 2018 Jun 16. [Medline].

Merchant NN, McKenna R Jr, Onugha O. Is There a Role for VATS Sleeve Lobectomy in Lung Cancer?. Surg Technol Int. 2018 Jun 1. 32:225-229. [Medline].

Dominic Emerson, MD Resident Physician, Department of Surgery, Georgetown University Hospital

Dominic Emerson, MD is a member of the following medical societies: American Burn Association, American College of Surgeons, Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

M Blair Marshall, MD Chief, Division of Thoracic Surgery, Department of Surgery, Georgetown University Hospital; Professor, Department of Surgery, Georgetown University School of Medicine

M Blair Marshall, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Medical Association, Society of Thoracic Surgeons, Southern Thoracic Surgical Association, Association of Women Surgeons

Disclosure: Received consulting fee from Thoracic Surgery Clinics for consulting; Received consulting fee from ClinicalKey for board membership; Received consulting fee from Ethicon Inc. for consulting.

Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society

Disclosure: Received consulting fee from Provation Medical for writing.

Tracheobronchial Sleeve Resection

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