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Asian Cardiovasc Thorac Ann 2002;10:372-373
© 2002 Asia Publishing EXchange Pte Ltd

HOW TO DO IT

Bronchoplasty With Plication of The Proximal Bronchial Membranous Portion

Masato Kanzaki, MD, Kunihiro Oyama, MD, Masaki Nishiuchi, MD, Toyohide Ikeda, MD, Masahide Murasugi, MD, Takamasa Onuki, MD

Division of Chest Surgery Southern Tohoku Research Institute for Neuroscience Fukushima, Japan
For reprint information contact: Masato Kanzaki, MD Tel: 81 3 3353 8111 Fax: 81 3 5269 7333 email: kanzaki{at}chi.twmu.ac.jp Department of Surgery I, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan.

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 TECHNIQUE
 DISCUSSION
 REFERENCES
 
Bronchoplasty originally designed for patients with inadequate pulmonary function who cannot tolerate pneumonectomy, has recently yielded good results as well as offering an alternative to pneumonectomy. We describe a technique for plication of the proximal bronchial membranous portion when there is significant discrepancy in lumen size between the main and the segmental bronchi to allow precise end-to-end anastomosis. Plication helps prevent postoperative anastomotic stenosis and obstruction.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
TECHNIQUE
 DISCUSSION
 REFERENCES
 
Because of the gradual diminution in size of the bronchi away from the carina, bronchoplasty frequently makes use of the anastomotic technique of telescoping, which involves bringing the smaller distal bronchial segment up into the lumen of the larger proximal segment. Telescoping is not possible, however, when the bronchi are similar in size or where there is the potential of kinking or compression of the distal subsegmental bronchi telescoped into the proximal bronchus. In such cases, careful direct end-to-end anastomosis using interrupted sutures is preferred. As the 2 bronchial stumps usually differ in size, with the distal one often thin and frail, it is our experience that plicating the membranous part of the larger stump would facilitate anastomosis.


   TECHNIQUE
TOP
 ABSTRACT
 INTRODUCTION
 TECHNIQUE
DISCUSSION
 REFERENCES
 
After lobectomy and segmentectomy and the bronchus is exposed, a traction suture is placed at a site 2 cartilaginous rings from the resection line in the main bronchus (Figure 1Go). The bronchus is then resected at a site at least 1 cm macroscopic distance from the tumor. Biopsy of a frozen section is performed to determine whether the stump is free of tumor. During bronchoplasty, the larger stump is plicated by passing a 4/0 nonabsorbable monofilament suture (Prolene; Ethicon Inc., Somerville, NJ, USA) through the membranous portion and the adjacent 2 ends of the cartilaginous ring followed by the insertion of a few adjusting stitches in the membranous portion (Figure 2Go). Direct end-to-end anastomosis of the 2 stumps is then performed using interrupted sutures of a 4/0 absorbable monofilament material (PDS II; Ethicon Inc., Somerville, NJ, USA), beginning at the deepest site. Each suture is inserted through all layers of the mucosa. Traction sutures inserted in the stumps are pulled to reduce tension in the anastomotic sutures. Pulmonary artery resection and reconstruction often are necessary, and we prefer to complete bronchial anastomosis before performing arterial anastomosis. The fifth intercostal muscle is harvested during thoracotomy to be used as a pedicled flap to wrap the bronchial anastomosis.



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  		Figure 1. A traction suture is inserted 2 rings from the resection line in the main bronchus. The 2 bronchial stumps differ in size. AO = aorta, L = lung, LM = left main bronchus, P = pericardium, UD = upper division bronchus.

 


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  		Figure 2. (A) Bronchial stumps with different lumen sizes. (B) The suture is inserted through the membranous portion and the ends of the cartilaginous ring of the larger stump. (C) Direct end-to-end anastomosis with interrupted sutures.

 
A 69-year-old woman presenting with adenocarcinoma arising from the left lower anterior basal segment underwent extended bronchial sleeve resection where this technique was employed. Her forced expiratory volume in 1 second was less than 1.3 L. On days 1 and 8 of admission, she received 2 cycles of adjuvant chemotherapy intravenously (cisplatin 80 mg·m-2 and gemcitabine 1,000 mg·m-2) because of mediastinal lymph node involvement. Three weeks after the last chemotherapy, following left lower lobectomy and lingulectomy, end-to-end anastomosis was performed between the left main and upper division bronchi. Formal mediastinal lymph node dissection was also performed. Bronchoscopy revealed no complications 5 months postoperatively.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 TECHNIQUE
 DISCUSSION
REFERENCES
 
Bronchoplasty between the main and the segmental bronchi is performed in cases where preoperative evaluation suggests that pneumonectomy may not be endured by the patient because of pulmonary dysfunction.1–3 Once complications such as anastomotic insufficiency, stricture, and occlusion develop following bronchoplasty, pneumonectomy becomes unavoidable. Surgical techniques that prevent such complications thus deserve consideration. Complications relating to bronchoplasty can be traced mostly to the surgical technique.4 Results suggest that telescoping anastomosis may reduce complications, although complications including kinking and stenosis have been the direct results of distal-to-proximal bronchial telescoping. Nevertheless, end-to-end anastomosis is ideally suited to bronchoplasty between the main and the segmental bronchi.5

Wrapping of the bronchial anastomosis has also stirred controversy. Currently, malignancies constitute the most important indication for lung resection, and patients undergoing bronchoplasty are likely to receive radiotherapy and chemotherapy postoperatively.6 We therefore prefer to protect and revascularize the anastomotic site with a pedicled intercostal muscle flap. We believe that the anastomosis is not jeopardized by bronchial calcification if it is properly encircled by the well-vascularized thickness of a muscle flap.

In conclusion, the size difference between the main and the segmental bronchi can be overcome by plicating the larger bronchus. This will allow precise end-to-end anastomosis and help prevent postoperative anastomotic stenosis and obstruction.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 TECHNIQUE
 DISCUSSION
 REFERENCES
 

  1. Tedder M, Anstadt MP, Tedder SD, Lowe JE. Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. Ann Thorac Surg 1992;54:387–91.[Abstract]

  2. Mehran RJ, Deslauriers J, Piraux M, Beaulieu M, Guimont C, Brisson J. Survival related to nodal status after sleeve resection for lung cancer. J Thorac Cardiovasc Surg 1994;107:576–83.[Abstract/Free Full Text]

  3. Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Matsuoka H, Satake S, et al. Extended sleeve lobectomy for lung cancer: the avoidance of pneumonectomy. J Thorac Cardiovasc Surg 1999;118:710–4.[Abstract/Free Full Text]

  4. Belli L, Meroni A, Rondinara G, Beati CA. Bronchoplastic procedures and pulmonary artery reconstruction in the treatment of bronchogenic cancer. J Thorac Cardiovasc Surg 1985;90:167–71.[Abstract]

  5. Hollaus PH, Janakiev D, Pridun NS. Telescope anastomosis in bronchial sleeve resections with high-caliber mismatch. Ann Thorac Surg 2001;72:357–61.[Abstract/Free Full Text]

  6. Naruke T. Bronchoplastic and bronchovascular procedures of the tracheobronchial tree in the management of primary lung cancer. Chest 1989;96(Suppl):53–56.





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