Keywords
lung cancer - right sleeve lower lobectomy - bilobectomy - thoracotomy
Introduction
The bronchial sleeve resection was developed as an alternative to pneumonectomy for patients with lung cancer generally originating from the bronchus lobe. This method is recommended particularly for patients with restricted cardiopulmonary reserves.[1] Today, sleeve resections are also used in patients who can tolerate a pneumonectomy.[2]
[3]
[4]
[5]
[6] The survival rate after sleeve resections is similar to or better than that following a pneumonectomy. The right sleeve lower lobectomy is the least used of the bronchial sleeve operations. This technique can be used in patients with non-small cell lung cancer (NSCLC) that originates from the right lower lobe, invades the intermediary bronchus, and enters the middle bronchial lobe. Mostly case-based studies are found in the literature.[7] In this study, we compared a right sleeve lower lobectomy to patients who underwent a right lower bilobectomy in terms of morbidity, hospitalization time, mortality, histopathology, recurrence, and survival.
Materials and Methods
Our Institutional Review Board approved this study (version number 2561).
We retrospectively reviewed the data of patients who had been operated on due to NSCLC from January 2005 to December 2015 from a dataset that was formed prospectively. Of the 4,166 patients who had resections due to NSCLC, the files of those who had a right sleeve lower lobectomy and those who had a right lower bilobectomy were evaluated in detail. Preoperative computed tomography (CT) scans and bronchoscopies, as well as the surgical results and postoperative pathology reports, of group B patients were reviewed. Accordingly, exclusion criteria included the presence of fissure invasion, middle lobe vascular structure invasion, macroscopic tumor invasion in the intermediary bronchus, or interlobar lymph node involvement ([Fig. 1]).
Fig. 1 Patient group selection.
Five surgeons who specialize in thoracic surgery were present in our clinic during the above-mentioned period and completed the operations. All surgeons had at least 10 years of experience in surgical oncology. Two of these surgeons performed the right sleeve lower lobectomies for the patients meeting the criteria, and the remaining three performed the right lower bilobectomy. The operations performed and their distributions through the years are shown in [Fig. 2].
Fig. 2 Distribution of operations through the years.
The demographic data, morbidity, hospitalization time, mortality, histopathological characteristics, development of relapses, and 2- and 5-year survival rates were analyzed. Morbidities were considered undesired conditions that developed during hospitalization or within the first 30 days following the operation. Atelectasis, atrial fibrillation, pneumonia, and prolonged air leakage (>7 days) were investigated. Mortality was considered death occurring within the first 30 days postoperatively or during hospitalization. All patients were assessed in the presence of an oncologist during the postoperative period. The VII TNM staging was used for staging. Chemotherapy was administered if needed. The patients were checked with a physical examination and CT scan every 6 months within the first postoperative 5 years and every year thereafter. Fiber optic bronchoscopy and positron emission tomography CT were requested for patients who were suspected of relapse.
Operative Technique
Anesthesia was administered to all patients using double-lumen intubation. The patients underwent a thoracotomy in the left lateral decubitus position. Each patient was staged intraoperatively. Their fissures were opened and lymph nodes assessed. The vascular and bronchial structures were prepared. The intermediary bronchus was cut immediately after the end of the upper lobe and the middle lobe bronchi were cut in patients who underwent a sleeve lobectomy ([Fig. 3A]). After ensuring negative surgical bronchial margins with a frozen section examination, an anastomosis was performed continuously with 4/0 propylene sutures ([Fig. 3B]). A parietal pleural flap was passed between the bronchus and the pulmonary artery. The mediastinal lymph nodes were sampled systematically in patients from both groups, and the operation ended after placing the drain. The patients were awakened in the operating room and taken to the surgical intensive care unit. A parenchymal linear stapler was used for separation when the minor fissure was incomplete on the bilobectomies. After resection, the air leaks were repaired with 3/0 polyglactin. Fibrin glue was used for a persistent air leak.
Fig. 3 Illustration of the surgical technique.
Statistical Analysis
Continuous variables are presented as mean ± standard deviation and discrete variables are presented as frequencies. The demographic and clinical characteristics of the patients and variables, such as age and hospitalization time, were tested for a normal distribution using the Kolmogorov–Smirnov's test. The t-test was used to calculate the means of these variables in the two groups, and the chi-square test was used to compare morbidity between the two groups. The calculations were performed using SPSS software (SPSS Inc., Chicago, Illinois, United States). A p-value of < 0.05 was considered significant.
Results
The patients were divided into two groups: the bilobectomy group (group B; n = 93) and the right sleeve lower lobectomy group (group S; n = 25). Of the 93 patients in group B, 68 were excluded because they did not meet the relevant criteria and could not undergo a right sleeve lobectomy. Seven patients in group S were excluded; five underwent surgery for carcinoid tumors and two had missing data. Twenty-five patients were included in group B compared with 18 patients in group S. In the end, the cohorts were formed from patients in the two groups who underwent a right sleeve lower lobectomy.
The mean age of group B was 56.8 ± 9.8 (range, 37–77) years and that of group S was 55.8 ± 13.7 (range, 25–79) years (p = 0.784). No females were in group B, whereas 11.1% (n = 2) of group S consisted of females (p = 0.169). No significant differences were found in the demographic characteristics of the patients between the groups ([Table 1]).
Table 1
Demographic characteristics of patients
|
Variables
|
Group B, n (%)
|
Group S, n (%)
|
p-Value
|
|
Gender
|
|
Male
|
25 (100)
|
16 (88.9)
|
0.169
|
|
Female
|
0
|
2 (11.1)
|
|
Comorbidity
|
18 (72)
|
12 (66.7)
|
0.707
|
|
Cardiac problems (arrhythmia/CF)
|
8 (32)
|
5 (27.8)
|
0.766
|
|
COPD
|
9 (36)
|
8 (44.4)
|
0.576
|
|
CRF
|
2 (8)
|
1 (5.6)
|
1
|
|
Diabetes mellitus
|
3 (12)
|
5 (27.8)
|
0.247
|
|
Hypertension
|
6 (24)
|
4 (22.2)
|
1
|
|
Previous surgery
|
2 (8)
|
5 (27.8)
|
0.112
|
|
Smoking habits
|
|
Smoker
|
19 (76)
|
14 (77.8)
|
1
|
|
Nonsmoker
|
6 (24)
|
4 (22.2)
|
Abbreviations: CF, cardiac failure; COPD, chronic obstructive pulmonary disease; CRF, chronic renal failure.
Complications developed in 13 patients in group B (52%) during the postoperative period (prolonged air leak in 11 patients, pneumonia in 1, and atrial fibrillation in 1). Complications developed in two patients in group S (11.1%) (atelectasis in one patient and granulation in the middle lobe entry in one) (p = 0.006) ([Table 2]).
Table 2
Postoperative complications and hospitalization
|
Variables
|
Group B
|
Group S
|
p-Value
|
|
Operation time (min)
|
155 ± 20
|
176 ± 24
|
0.005
|
|
Postoperative complication
|
|
Yes, n (%)
|
13 (52%)
|
2 (11.1%)
|
0.006
|
|
No, n (%)
|
12 (48%)
|
16 (88.9%)
|
|
Hospitalization (d)
|
9.6 ± 3.3
|
6.72 ± 1.5
|
0.001
|
The mean postoperative hospitalization time was 9.6 ± 3.3 (range, 6–19) days in group B and 6.72 ± 1.5 (range, 4–9) days in group S (p = 0.001). No operative mortality was observed in either group. Mean operation time was 155 ± 20 minutes in group B and 176 ± 24 minutes in group S (p = 0.005) ([Table 1]).
The groups comprised mostly stage 1B patients (p = 0.443) and the histopathological assessments revealed that squamous cell carcinoma was the most common cancer in both groups (group B: 80% and group S: 83.3%) ([Table 3]).
Table 3
Histopathological comparisons
|
Variables
|
Group B, n (%)
|
Group S, n (%)
|
p-Value
|
|
Tumor histology
|
|
Squamous cell carcinoma
|
20 (80%)
|
15 (83.3%)
|
1
|
|
Adenocarcinoma
|
5 (20%)
|
3 (16.7%)
|
|
Pathological stage
|
|
1A
|
1 (4%)
|
1 (5.6%)
|
0.443
|
|
1B
|
10 (40%)
|
9 (50%)
|
|
2A
|
4 (16%)
|
2 (8.7%)
|
|
2B
|
9 (36.0%)
|
4 (22.2%)
|
|
3A
|
1 (4%)
|
3 (16%)
|
All patients received a complete resection (R0). Mean patient follow-up time was 42.9 (median, 36) months. During this time, local recurrence developed in 8% (n = 2) (postoperative 42 and 66 months) of patients in group B and in 5.6% (n = 1) (postoperative 46 months) of patients in group S (p = 1). The distant recurrence rates in groups B and S were 24% (n = 6) and 11.1% (n = 2), respectively (p = 0.432) ([Table 4]).
Table 4
Comparison of the lower bilobectomy group and the right sleeve lower lobectomy group in terms of local and distance recurrences
|
Variables
|
Group B, n (%)
|
Group S, n (%)
|
p-Value
|
|
Local recurrence
|
|
Yes
|
2 (8%)
|
1 (4.3%)
|
1
|
|
No
|
23 (92%)
|
22 (95.7%)
|
|
Distant recurrence
|
|
Yes
|
6 (24%)
|
2 (11.1%)
|
0.432
|
|
No
|
19 (76%)
|
16 (88.9%)
|
A Kaplan–Meier's analysis was performed for 25 patients in group B and 18 patients in group S. Mean survival was 90.6 months (95% confidence interval [CI], 73.2–108). Five-year survival was 75.3% in group B (63.1 months) (95% CI, 52.4–73.8) and 69.3% in group S (p = 0.82) ([Fig. 4]).
Fig. 4 Survival curves of the bilobectomy and the right sleeve lower lobectomy groups.
Discussion
Sleeve lobectomy is a surgical technique that can generally be used in patients whose disease originates from the lobed bronchi. This technique allows for better protection of the parenchyma and reduces postoperative complications. This option should be used regardless of the patient's age or respiratory/cardiac function. Sleeve resections are preferred in all cases where a complete resection is possible. In their meta-analysis, Shi et al[8] showed that sleeve lobectomies are preferred more than pneumonectomies for early-stage lung cancers.
Fewer complications developed in group S in our study. Fewer incidences of prolonged air leak, in particular, can be explained by the presence of a smaller residual space in the thorax. In their bilobectomy series involving 146 patients, Galetta et al[9] reported a morbidity rate of 47% and a mortality rate of 1.4%, stating that the most frequently experienced morbidity was prolonged air leak in the thoracic space. In their study where they reviewed 1,831 bilobectomy cases, Thomas et al[10] reported that a lower bilobectomy has a threefold higher risk for developing a fistula than an upper bilobectomy. Kim et al[11] reported in their bilobectomy series of 92 patients that mortality rate was 4.3% and morbidity rate was 31%. They stressed that more problems occur in a lower bilobectomy. A retrospective study by Gómez-Caro et al[12] in which lobectomy and bilobectomy were compared showed that 7.9-fold more cardiopulmonary complications developed in patients who underwent lower bilobectomy compared with those who underwent a lower lobectomy. In a study performed by Ludwig et al,[13] complication rates of bilobectomy and sleeve lobectomy were 53 versus 33%. Respiratory function 3 months postoperatively was not significantly different between the groups.
In our study, the complications that developed in group S were associated with anastomosis-related problems. These complications likely developed due to temporary bronchial edema occurring in the anastomotic line and the difficulty in clearing drainage associated with repositioning of the middle bronchial lobe. All of these complications were treated with fiberoptic bronchoscopy. The hospitalization time of group S patients was shorter due to fewer complications. Postoperative air leaks occurred less frequently due to sleeve resection because the minor fissure did not need to be separated in this group. Our previous study showed that sleeve resection has complications.[14]
No operative mortality was seen in our study. As there are no series related to right sleeve lower lobectomy in the literature, no mortality comparison could be made. However, the absence of any mortality suggests that the sleeve resections had no negative effect on mortality.
No significant difference in recurrence was found between the groups. The prerequisite for performing a sleeve resection is the ability to perform a complete resection. R0 resections were performed in both groups. The absence of any difference between the local recurrences of the groups is promising for a right sleeve lower lobectomy to be performed with an appropriate indication. Similarly, no difference was found between the groups with respect to distant recurrences. Local tumor control, which is the main concern in bronchoplasty, is reportedly acceptable.[2]
[4]
[6]
[15] While the recurrence rate ranges between 8 and 23% after a sleeve lobectomy, it has been reported to be 10 to 14% in pneumonectomies. Park et al[16] found no difference in local recurrences between the two groups.
Parenchymal protective surgery is associated with better prognosis and survival, particularly for early-stage lung cancers. The studies of Okada et al,[4] Deslauriers et al,[5] and Takeda et al[3] reported better survival rates after sleeve lobectomy administered to stage 1 and stage 2 patients. Lobectomy and pneumonectomy have been compared for survival in sleeve studies. No difference was found in our study between 5-year survival of the bilobectomy group and survival of the sleeve lower lobectomy group.
Limitations
The limitations of our study are that it was retrospective; the number of patients was small because a right sleeve lobectomy can only be applied to a relatively limited number of patients; the operations were performed by different surgeons; and general survival was calculated rather than survival by stages, as the number of patients was small. In many series, male sex is a risk factor for complications. However, it was not evaluated in our study because of the absence of females in group B. The mean age of patients in our study was lower than in oncological surgery patients in the literature. The reason for this is that the mean age of patients with NSLC treated with surgery between these years was 56 ± 15.2 years. Therefore, our age-related complication rate was low. The patients' postoperative lung function was not compared between the groups due to missing data.
Conclusion
Our study showed that due to protection of the middle lobe, it was easier for the lung to fill the thoracic cavity, leading to reduced rates of prolonged air leakage and other complications. Consequently, hospitalization time was shortened. The surgical technique did not bring an additional mortality burden and the survival rate and oncological outcomes were reliable. Therefore, we believe that this method should be preferred for appropriate patients at experienced centers.
