Keywords sleeve resection - anastomotic dehiscence - complication
Bronchial sleeve resections are performed to avoid pneumonectomy in centrally located
lung tumors. These procedures are technically demanding compared with lobectomies.
Several studies have demonstrated an acceptable long-term survival following bronchial
sleeve resections with low mortality and bronchial anastomotic complication rates.[1 ]
[2 ] Here we first describe a technique of secondary lingular sleeve resection to avoid
pneumonectomy after bronchial anastomosis dehiscence following a sleeve resection
of the left lower lobe (LLL).
Case Presentation and Surgical Technique
A 36-year-old female patient was admitted to our hospital for recurrent pulmonary
infections. Flexible bronchoscopy revealed an exophytic tumor completely occluding
the left lower lobe bronchus (LLLB) ([Fig. 1A ]). Biopsy was performed. However, histological examination was highly suspicious
but not confirmatory for malignancy. Computed tomography (CT) scan of the chest showed
a total atelectasis of the LLL with the radiological signs of a destroyed lobe syndrome.
A positron emission tomography CT scan revealed purulent fusion of the LLL. Increased
fludeoxyglucose uptake was not observed otherwise. Despite antibiotic therapy, no
improvement occurred. Therefore, surgical resection was considered. Due to the exophytic
tumor in the LLB, full circumferential bronchial resection of the LLL was performed
in concordance with a standardized surgical approach.[3 ] Special care was taken to preserve the nutritional layer of the bronchi. Routinely,
full hilar release including semicircular pericardiotomy was performed to facilitate
tension-free anastomosis. Bronchial anastomosis between the left upper lobe and left
main bronchus (LMB) was achieved by interrupted 4–0 polydioxanone sutures (PDS, Ethicon,
Germany) tied at completion of the anastomosis ([Fig. 2A ], [B ]). The knots were placed outside the lumen. The patient was extubated at the operation
room and transferred to the intensive care unit. The postoperative X-ray showed a
fully expanded left upper lobe ([Fig. 3A ]).
Fig. 1 Flexible bronchoscopy showing the exophytic tumor occluding the left lower bronchus
(A ). Bronchial anastomosis dehiscence after left lower sleeve resection on postoperative
day 10 (B –C ). Endobronchial finding prior to discharge after secondary lingular sleeve resection
(D ).
Fig. 2 Schematic figure of the left lower sleeve resection (A , B ) and subsequent lingular sleeve resection (C , D ).
Fig. 3 Postoperative X-ray of the chest immediately after sleeve resection of the left lower
lobe (A ) and before discharge after the redo-sleeve resection (B ).
Final pathohistological examination revealed destroyed lung syndrome due to endobronchial
pseudotumor. We routinely perform two postoperative bronchoscopies to monitor the
bronchial healing.[3 ] The first bronchoscopy on postoperative day (POD) 7 showed an intact bronchial anastomosis
with slight fibrin deposits. The healing was classified as grade 2 according to the
classification of tracheobronchial anastomoses.[4 ] On POD 10, bronchial anastomotic dehiscence at the medial wall of the anastomosis
was detected during second routine bronchoscopy ([Fig. 1B ], [C ]). Therefore, surgical revision was indicated. Intraoperatively, the ischemic and
inflamed bronchial edges from the LMB and left upper bronchus (LUB) were resected
as described elsewhere.[5 ] However, the distal LUB was still edematous and inflamed. Under these circumstances,
reanastomosis of the LUB with the LMB was not favored. To avoid pneumonectomy, anatomical
lingular resection with subsequent telescope anastomosis of the apical trisegment
group (B1–3) with the LMB was performed. Bronchial anastomosis was achieved as described
above ([Fig. 2C ], [D ]). The postoperative course was uneventful. Flexible bronchoscopy revealed healing
of the anastomosis ([Fig. 1D ]) and the patient was discharged uneventfully ([Fig. 3B ]).
Comment
Bronchial anastomotic dehiscence represents one of the major and often lethal complications
after bronchial sleeve resection. In a meta-analysis, mortality and morbidity after
sleeve lobectomy varied between 0% to 10.5% and 11.1% to 59.7%, respectively.[6 ] Bronchial anastomotic dehiscence might be found in 5% to 8.7% after sleeve lobectomy.[7 ] The risk might be enhanced especially in inflammatory conditions or after induction
treatment for nonsmall cell lung cancer. However, if the surgeon is concerned about
the bronchial healing, vascularized tissue might be used to wrap and protect the anastomosis,
for example, pedicle flap of the omentum, intercostal muscle flaps, pleural flaps,
or pericardial flaps.[8 ]
Secondary completion pneumonectomy is generally the treatment of choice for anastomotic
dehiscence. However, completion pneumonectomy is usually associated with high operative
mortality of up to 67%.[1 ]
[2 ]
[8 ] Furthermore, completion pneumonectomy might be contraindicated due to loss of pulmonary
reserves and functional reasons.
To the best of our knowledge, this is the first report of secondary lingular sleeve
resection following bronchial anastomotic dehiscence after LLL sleeve resection. We
sacrificed the lingula to rescue the apical trisegment group (B1–3). This extended
redo-sleeve resection enabled the avoidance of pneumonectomy, hence reducing the possible
pneumonectomy-associated complications as well as saving pulmonary reserves and quality
of life. In experienced hands, redo-sleeve resections might be an option for the management
of postoperative bronchial anastomotic dehiscence.
