| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL ARTICLE |
Thoracic Surgery, Lungenklinik Merheim Kliniken der Stadt Köln gGmbH, Cologne, Germany
Corinna Ludwig, MD Tel: +49 221 89078640; Fax: +49 221 89073533; Email: ludwigc{at}kliniken-koeln.de, Lungenklinik Merheim, Kliniken der Stadt Köln gGmbH, Ostmerheimerstr. 200, 51109 Köln, Germany.
ABSTRACT
When a lung tumor arises in segment 6, the close anatomical relationship to the middle lobe bronchus may make a lower bilobectomy necessary. Sleeve lobectomy may be an alternative. These procedures were compared retrospectively in 36 patients operated on between January 2005 and December 2006 with non-small-cell lung cancer (stage I–IIIB) of the right lower lobe. Sleeve lobectomy was performed in 21 patients and bilobectomy in 15 (41%). Preoperative lung function was comparable in both groups. Radical resection was achieved in 34/36 patients. Operation time was 121 min for sleeve lobectomy and 144 min for bilobectomy. Chest tubes were removed after 5 days in both groups. Postoperative lung function was better after sleeve lobectomy than bilobectomy (forced expiratory volume in 1st sec: 78% vs. 69%). Preservation of the middle lobe by sleeve lobectomy is feasible. There was no evidence that this resection was less radical, and complication rates were similar in both groups.
Key Words: Lung Neoplasms • Pneumonectomy • Respiratory Function Tests
INTRODUCTION
Sleeve lobectomy was introduced to avoid extended resections, such as pneumonectomy, in patients with poor lung function. Today, it is an established method that is suitable for all patients, regardless of their pulmonary volume, without compromising oncological radicality.1–4 Ferguson and colleagues2 compared the results of sleeve lobectomy and pneumonectomy in a meta-analysis and concluded that sleeve lobectomy has not only better long-term survival and quality of life but it is also more cost-effective. The close anatomical relationship between the middle lobe and right lower lobe may make lower bilobectomy necessary in patients with a tumor arising in the 6th segment. Bilobectomy incurs higher morbidity and mortality than lobectomy.5 In this situation, sleeve lobectomy with preservation of the middle lobe may be an alternative. The objective of this study was to determine whether preservation of the middle lobe after right lower lobe sleeve lobectomy in patients with non-small-cell lung cancer stages I–IIIB influences postoperative lung volumes, complications, chest tube drainage, and oncological resectability.
PATIENTS AND METHODS
Between January 2005 and December 2006, 694 patients underwent anatomical pulmonary resection with curative intent for bronchial carcinoma. The pneumonectomy rate was 9%. There were 114 (16%) sleeve resections, of which 21 were right lower lobe sleeve resections with preservation of the middle lobe, and there were 15 bilobectomies. Data of these 36 patients were collected retrospectively. There were 24 men and 12 (33%) women. Their median age was 63 years. Preoperative staging included chest radiography, computed tomography of the chest and upper abdomen, lung function tests, arterial blood gases, and perfusion scintigraphy of the lung when the forced expiratory volume in 1st sec (FEV1) was <80%. Patients at high risk of coronary heart disease were screened by echocardiography, stress testing, or coronary arteriography. Bronchoscopy was performed for endobronchial staging and selection of candidates for sleeve lobectomy. Mediastinoscopy was undertaken when there was evidence of N2 disease on computed tomography; if positive, neoadjuvant therapy was given.
All patients underwent double-lumen endotracheal intubation. The routine approach was an anterolateral thoracotomy in the bed of the 5th rib. After complete exposure of the pulmonary artery, bronchus, and vein, the final decision was taken by the surgeon as to whether sleeve lobectomy was oncologically and technically feasible (minimum 5 mm). Care was taken to manipulate the tumor as little as possible and to preserve the bronchial blood supply. Resection of the bronchus was performed proximal (intermediate bronchus) and distal to the lobar orifice for sleeve resection (Figure 1
). Intraoperative frozen sections of the resection margins were examined when macroscopic resectability was in doubt. A tension-free bronchial anastomosis was made with a continuous suture, using absorbable 4/0 poly-dioxanone (Ethicon Products, GmbH, Germany), over the entire circumference. Care was taken to shorten the bronchus of the middle lobe just above the segmental orifice where the bronchus is widest. Any discrepancy in size between the intermediate bronchus and the lobar orifice of the middle lobe was corrected by adjusting the membranous part of the intermediate bronchus in the continuous suture. In all patients, the middle lobe was completely disconnected. In cases of bilobectomy, the bronchus was closed with a double row of continuous over-and-over running suture, using absorbable 4/0 polydioxanone. In both procedures, suture lines were checked for air leaks with airway pressure 
30 mm Hg. The anastomosis was not covered. Systematic lymphadenectomy was carried out for lymph node staging. Two chest tubes were placed: anterolateral and posterobasal. After sleeve resection, routine prophylactic tobramycin inhalation (2 x 80 mg) was given for 7 days. Bronchoscopy was undertaken routinely on postoperative day 8 in all patients who had sleeve lobectomy, for quality control.
|
RESULTS
Tumor size and pathological TNM classification were comparable in both groups (Table 1). Histological examination showed positive resection margins after bilobectomy in 2 patients (5%), and in none after sleeve lobectomy; both patients had microscopic tumor cells in the peribronchial lymphatic vessels, and were therefore considered as R1-resection. Angioplastic procedures were necessary in 12/36 (33%) cases. Perioperative variables were comparable in both groups (Table 2). After bilobectomy complications were observed in 53% (8/15) of patients: atrial fibrillation in 3; pneumonia in 3; pneumothorax in 1 after removal of the chest tube, requiring new drainage; and one with postoperative respiratory distress syndrome died during the hospital stay. Postoperative 30-day mortality after bilobectomy was 6.6% (1/15). No evidence of bronchial stump insufficiency was noted in this group. After sleeve lobectomy, complications were noted in 7/21 (33%) patients: atrial fibrillation in 2; prolonged chest tube drainage (>7 days) in 3; intermittent respiratory failure in 1; and re-intervention at 24 h due to technical failure of the anastomosis in 1. The rate of anastomotic leakage was 4.8% (1/21), and 30-day mortality was 0% after sleeve resection.
|
|
). Postoperative mean FEV1 was 69% after bilobectomy and 78% after sleeve lobectomy. More interesting was the loss or gain of lung function (
FEV1) after resection in each group (Figure 2). The 6-min walk test was performed in both groups: it was only slightly better in the sleeve lobectomy group (606 vs. 530 m).
|
Sleeve lobectomy is possible without loss of oncological resectability, and should be performed whenever possible to preserve lung function, regardless of preoperative lung function.7 This has led to a decrease in the number of pneumonectomies undertaken in our institution. In the past few years, pneumonectomy has been compared with sleeve lobectomy in terms of 30-day mortality, with meta-analyses favoring sleeve lobectomy for stages I–II.1,4,8 Long-term survival after bronchoplastic procedures is dependent on nodal status.9–11 Bilobectomy was an independent risk factor for morbidity and mortality in a study comparing it with other resections.5 Bronchoplastic procedures have been shown to offer better long-term survival and quality of life in terms of improved postoperative lung function.2,7,12
The decision to carry out bilobectomy or sleeve lobectomy can only be taken during surgery. We found that sleeve lobectomy was technically possible in almost 60% of patients. When comparing sleeve lobectomy with pneumonectomy, some reports have indicated that patients undergoing pneumonectomy have larger tumors and more advanced disease.8 Interestingly, we found little difference in mean tumor size or pathological TNM classification between the 2 groups. In a third of cases, angioplastic resection of the pulmonary artery was necessary, mainly partial resection as described by Cerfolio and Bryant.13 The major complication of sleeve lobectomy is anastomotic insufficiency, which occurred in 3.5% of a larger series.3 We had 1 (4.8%) case of anastomotic insufficiency due to technical failure, requiring re-intervention on the 1st postoperative day. No further postoperative complication was documented in this patient. Radical resection is mandatory, as incomplete resection is associated with a worse prognosis.14–17 In patients with a bronchial carcinoma in the 6th segment, preservation of the middle lobe is possible without loss of resectability. R0-resection was obtained in all patients in the sleeve lobectomy group, without routine fresh frozen section examination of the proximal and distal bronchus. Histology showed positive resection margins in the peribronchial lymphatic vessels after bilobectomy in 2/15 patients; they received adjuvant radiotherapy with 60 Gy.
Our complication rate was slightly higher after bilobectomy (53%) than after sleeve lobectomy (33%). One patient died after bilobectomy; due to the small number of patients, this was not statistically significant. Comparisons of sleeve lobectomy with pneumonectomy in terms of postoperative lung function and quality of life favor sleeve lobectomy.2,12 Although we were not sure whether preservation of the middle lobe (2 segments) would have an influence on postoperative lung function, the lung volumes at 3 months postoperatively showed an overall increase of FEV1 after sleeve lobectomy. This may be explained by a recovery of function of the preserved middle lobe after removal of the tumor in the lower lobe (better ventilation or perfusion on the right side). Cessation of smoking may also explain the improvement of lung function in both groups.
Despite the small numbers of patients in each group, these results demonstrate a tendency towards a lower complication rate and better postoperative lung function after right lower lobectomy with preservation of the middle lobe. This must be confirmed by further studies in a larger number of patients.
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:153-156
© 2009 by SAGE Publications
DOI: 10.1177/0218492309103296
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
