Chinese-German J Clin Oncol
June 2013, Vol. 12, No. 6, P261–P264
DOI 10.1007/s10330-011-0913-5
Clinical experience of double sleeve lobectomy of the bronchus and the pulmonary artery in patients with central lung cancer Yukang Kuang, Laiduo Zeng, Dongsheng Wang, Binglin Yin, Jiufa Wu, Jian Huang, Zhisheng He, Jianfeng Zhu, Feng Jiang, Changying Guo Thoracic Surgery, Jiangxi Province Tumor Hospital, Nanchang 330029, China Received: 5 November 2011 / Revised: 19 April 2013 / Accepted: 25 May 2013 © Huazhong University of Science and Technology and Springer-Verlag Berlin Heidelberg 2013 Abstract Objective: The aim of our study was to introduce the surgical method and evaluate the efficacy of double sleeve lobectomy of the bronchus and the pulmonary artery in treatment for the central lung cancer. Method: From March 1995 to October 2010, double sleeve lobectomy of the bronchus and the pulmonary artery was performed in 45 cases with central lung cancer that involved the bronchial opening of an upper lobe of the lungs or the main bronchus and pulmonary artery but didn’t involve any lower lobes. Among them, left upper lobectomy was performed in 37 cases, right medium-upper lobectomy was performed in 6 cases and right upper lobectomy was performed in 2 cases. Results: Postoperative complications were found in 12 cases. Among them, 3 cases were arrhythmia, 1 case was acute heart failure, 6 cases were obstructive pneumonia and pulmonary atelectasis, 2 cases were bronchial anastomotic fistula. Two cases died of cerebral infarction and massive hemoptysis respectively. Thirty-one cases were squamous carcinoma, 7 cases were adenocarcinoma, 4 cases were small cell lung cancer, 1 case was adenosquamous carcinoma, 1 case was sarcomatoid carcinomas, 1 case was mucinous adenocarcinoma. Ten cases were T3N0M0, 11 cases were T3N1M0, 17 cases were T3N2M0, 2 cases were T4N1M0, 5 cases were T4N2M0. The 1-year, 3-year, 5-year survival rates were 84.4% (38/45), 51.7% (15/29), 53.8% (7/13) respectively. Conclusion: The double sleeve lobectomy of the bronchus and the pulmonary artery can maximumly reserve the normal lung tissues while removing tumors, and avoid pneumonectomy. The surgery was safe and effective, while it required a high technique. Key words
lung cancer; sleeve lobectomy of the bronchus; sleeve lobectomy of the pulmonary artery
In March 1995, the double sleeve lobectomy of the bronchus and the pulmonary artery was firstly used to treat the central lung cancer in our department. A total of 45 cases were performed with good outcomes until now.
Patients and methods Patients Forty-five patients were entered in our study. Among them, 42 cases were male, 3 cases were female. Patients had a median age of 60 years (range, 40 to 82 years). Thiry-nine patients had cough on admission. Among them, 21 cases with bloody sputum, 10 cases with chest distress, 3 cases with chest pain, 3 cases with fever, 2 cases with pain of the limbs, 1 case with hoarseness, and 1 case with history of asthma. One case had joint sore, 2 cases had chest distress, 1 case had chest pain and fever. Two cases Correspondence to: Kuang Yukang. Email:
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were found during physical examination. The period of symptoms ranged from 7 days to more than 2 years. Chest CT proved all patients had masses in the superior hilus pulmonis (7 cases in right upper lobe, 1 case in right middle lobe, 37 cases in left upper lobe). Eighteen cases had pulmonary atelectasis, 1 case had obstructive pneumonia. During the fibrobronchoscopy, 37 cases had tumor at the opening of superior lobar bronchus, 5 cases had bronchial constriction with congestion and erosion, 2 cases had bloody excretion in bronchus, 1 case had no abnormal changes. Cancer cells were found in 37 cases by way of biopsy and brush, 2 cases had abnormal cells (the cytology of 1 case proved to be small cell carcinoma after surgery). No abnormal cells were found in 6 cases (the cytology of 2 case proved to be small cell carcinoma after surgery). Twenty-one cases were normal during the examination of preoperative lung function, 13 cases were mildly abnormal, 11 cases were moderately abnormal (MVV of 1 case was 40.4%).
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Treatment Two cases were underwent 1 period of neoadjuant chemotherapy (cyclophosphamide 600 mg/m2, i.v, d1; doxorubicine 40 mg/m2, i.v, d1; cisplatin 60 mg/m2 i.v, d1). The tumors shrank after chemotherapy and then were removed. The other 43 cases were not received treatment before surgery and had surgical removal directly. All of the patients were received double sleeve lobectomy of the bronchus and the pulmonary artery. Among them, 37 cases were operated at the left upper lobe (2 cases were combined with partial resection of left atrium, 1 case were combined with resection of aortal adventitia), 6 cases were operated at right upper and middle lobes (3 cases were combined with partial resection of left atrium, 2 cases were combined with lateral resection of superior vena cava), 2 cases were operated at right upper lobe. Pulmonary arteries and veins were operated in pericardium for 7 cases. All the patients were treated with endotracheal incubation of dual chamber after general anesthesia. The surgical incision was in the 5th intercostal space on the lateral posterior chest wall. Firstly, dissociate the hilus pulmonis and oblique fissure, then release the inferior pulmonary ligament. The pulmonary trunk was released inside or outside of pericardium and blocked by auricular appendage clamp. The inferior pulmonary artery was dissociated and blocked at the level of oblique fissure. The pulmonary trunk and the inferior pulmonary artery were cut 0.2–0.5 cm distant from tumor. 2–4.5 cm of pulmonary artery was cut away. Clean up the blood clot with heparin saline. Dissociate and ligate the superior pulmonary vein (or the middle pulmonary vein). Sweep the lymph nodes of zone 7, 10, 11. Dissociate the main bronchus and lower lobe bronchus. Stitch a traction thread 0.3–0.5 cm lateral. Cut down curvedly the inferior pulmonary bronchus 0.5–1.0 cm away from the lower margin of the tumor. Cut down parallelly the main bronchus 1.0–2.0 cm away from the upper margin of the tumor. Remove the tumor. Stop bleeding of the wound. Clean up the excretion of the lower lobe bronchus. Sterilize the lumen with mucous sterilizing solution. In 44 cases the bronchus was anastomosed firstly; the other 1 case dealt with pulmonary artery at the first step. Intermittently anastomose bronchus with 3–0 polyester suture and localize the knots outside of the lumen. Continuously plus intermittently or continuously anastomose bronchus with 3-0 polyester suture or 4–0 prolene suture and localize the knots inside of the lumen. Aspirate the sputum and inflate the lung in order to check whether there was no air leakage. Continuously anastomose pulmonary artery with 4–0 or 5–0 prolene suture. Wash the artery with heparin saline and deflate. Loose the clamp blocking inferior pulmonary artery and tie knots. Check whether there was blood leakage and if, stitch the artery. Loose the clamp blocking pulmonary
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trunk. 12 cases had blood leakage at the anastomotic stoma of the artery. Block the artery again and stitch. Loose the clamp and check again. Sweep lymph nodes within the mediastinum. Separate the two anastomotic stomas with fascia or gelatin sponge. Thirty-seven cases were received chemotherapy after surgery. Thirty-three cases with NSCLC of them underwent CAP/MVP regimen (mitomycin 6 mg/m2, i.v, d1; vincristine 3 mg/m2, i.v, d1; cisplatin 60 mg/m2, i.v, d1) or NP regimen (vinorelbine 25 mg/m2, i.v, d1; cisplatin 60 mg/m2, i.v, d1). Four cases with SCLC received CE regimen (carboplatin 500 mg, i.vgtt, d1; etoposide 100 mg, i.vgtt, d1–5) or EP regimen (etoposide 100 mg, i.vgtt, d1–5; cisplatin 60 mg/m2, i.v, d1). Eight cases did not receive chemotherapy. Three cases received radiotherapy for metastatic sites.
Results Pathological examination Thirty-one cases were squamous carcinoma, 7 cases were adenocarcinoma, 4 cases were small cell carcinoma, 1 case was adenosquamous carcinoma, 1 case was sarcomatoid carcinoma, 1 case was mucinous adenocarcinoma. Ten cases were T3N0M0, 11 cases were T3N1M0, 17 cases were T3N2M0, 2 cases were T4N1M0, 5 cases were T4N2M0. After the biopsy of pulmonary artery in 17 cases, 13 cases of them were found the outer membrane of pulmonary artery invasion, 4 cases were not found tumor invasion. The marginal of bronchus and pulmonary trunk were negative for all cases. Complications Twelve cases (26.7%) had postoperative complications, including 3 cases of arrhythmia occurred after surgery and yield after treatment, 1 case of acute heart failure occurred and yield after treatment, 6 cases suffered cough and sputum, obstructive pneumonia and pulmonary atelectasis (2 cases had lung recruitment after sputum suction with bronchofiberscope; 2 cases was healed by way of endotracheal intubation and assisted breathing with ventilator; 1 case was taken back to local hospital after the patient was given tracheotomy and assisted breathing with ventilator; 1 case died because of massive hemoptysis). Two cases of bronchial anastomotic fistula were relieved after sufficient drainage. The other 33 cases were recovered smoothly after surgery. Follow-up The follow-up rate was 100%. Four of 10 cases at stage N0 had survived for more than 5 years. Three of 13 cases at stage N1 had survived for more than 5 years, while 1 case survived for more than 10 years. Two of 22 cases at stage N2 had survived for more than 3 years, while no
Chinese-German J Clin Oncol, June 2013, Vol. 12, No. 6
cases survived for more than 5 years. The 1-year, 3-year, 5-year survival rate were 84.4% (38/45), 51.7% (15/29), 53.8% (7/13) respectively.
Discussion The indications of double sleeve lobectomy of the bronchus and the pulmonary artery are certain types of central lung cancer in which the tumor occurs at the upper lobe and could not be completely resected by way of traditional lobectomy or bronchial sleeve lobectomy [1]. The tumor invades openings of the superior lobar bronchus, the main bronchus and pulmonary trunk. The inferior lobar bronchus is intact and should be reserved in the surgery. The surgical technique is important for patients suffering central lung cancer, especially for those patients who suffer moderate to severe pulmonary dysfunction and could not tolerate unilateral pneumonectomy. The lower lobe, which is reserved by way of double sleeve lobectomy, could guarantee the patients’ pulmonary function for postoperative life quality, by providing 25%–35% more pulmonary tissue [2]. Therefore, these patients gained the opportunity to be healed by these surgical technique. The theory of double sleeve lobectomy of the bronchus and the pulmonary artery is based what we learn from bronchial sleeve lobectomy. The pulmonary arterial sleeve resection is the new concept. In our study, we took the traditional procedures to deal with bronchus [3, 4], that is, we cut down parallelly the main bronchus 1.0 cm away from the upper margin of the tumor and cut down curvedly the inferior pulmonary bronchus 0.5 cm away from the lower margin of the tumor. The cutting edge is wide enough for anastomosis. The bronchus should be cut longer than artery. Therefore the anastomosis of pulmonary artery is more convenient with a lower tension of stoma. The cutting edge is much shorter for pulmonary arterial sleeve resection since the tumor could not invade the submucosa of artery. In our study, we cut down the artery 0.2–0.5 cm away from the margin of the tumor, considering the cutting edge of bronchus. Previous study proved that 4.5–5.0 cm of pulmonary artery could be resected. Zhou et al [5] exposed intrapericardial pulmonary vein by way of cutting open the pericardial tissue surrounding the vein. Therefore more than 6 cm of pulmonary artery could be resected, with the maximum of 7.2 cm. In our study 2–4.5 cm of artery could be resected and there was no tension at the anastomotic stoma. The blood is easily to clot and the endarterium is dry after the pulmonary artery is cut open. The heparin saline is important, since it could wash and moist the wound in order to clean up the blood clot. We prepared 1 ampoule of heparin in 300 mL saline before we cut down the pulmonary artery. Then we washed and moisted the wound with heparin saline. No pulmonary thrombus was found in our study. The arterial
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anastomotic stoma was smooth. The bronchus should be anastomosed before artery because of anatomy [2, 6]. The suture should be smooth, moderately intensive and thin, which fits 4–0 or 5–0 prolene suture in our study. Previous study [7, 8] proved the safety of 2 h pulmonary arterial blockage. Reperfusion injury of lung may happen if the blockage was more than 2 h. Zhang et al [9] found that the replanting lung could also survive even at the condition in which the longest isolated time of replanting lung was 233 min and the longest blocking time of pulmonary artery was 340 min. However, inflammation happened 3–15 days after surgery. The blocking time of pulmonary artery was no less than 120 min in 17 cases of our study. Among them, 6 cases were more than 180 min. Inflammation occurred in 4 cases. In 1 case the blocking time of pulmonary artery was 75 min. The patients could not cough violently after surgery and he refused suction under fibrobronchoscopy. Then he had to incubate again, and his lung function was under the help of ventilator. The blocking time of One 82-year-old patient was 120 min. The patient was treated with tracheotomy and assisted breathing with ventilator. In another case the blocking time was 130 min. The patient suffered cerebral infarction after surgery and could not cough autonomously, thus the patient was treated with tracheotomy and assisted breathing with ventilator. In the forth case the blocking time was more than 300 min. The patient was treated with tracheotomy and assisted breathing with ventilator. A massive hemoptysis occurred 15 days after surgery and the patient died. We could not make sure whether the inflammation of those 4 cases was associated with reperfusion injury of lung, since the incidence rate was 8.0%, which was equal to other types of lobectomy. Besides, the blocking time of the first case was only 75 min. And what could not be overlooked was there were 14 cases in our study, in which the blocking time was more than 120 min and no inflammation happened. In fact, bronchial arteries still supply the bronchus and lung tissue after the blockage of pulmonary artery. Therefore there is still some blood supply for lung tissue before the bronchial arteries were cut off. In order to shorten the blocking time and reduce reperfusion injury of lung, the surgeon should perform the following steps before the blockage of pulmonary artery: the surgeon should dissociate the hilus, oblique fissure and inferior pulmonary artery. Release the inferior pulmonary ligament, sweep lymph nodes at zone 7. Then the surgeon could block pulmonary artery and perform bronchial and pulmonary arterial double sleeve lobectomy with ease. The tumor could be completely resected and the intact lower lobe could be reserved by way of the bronchial and pulmonary arterial double sleeve lobectomy. The pneumonectomy could be avoided. The patients’ life quality is good after surgery. Therefore, this surgical technique
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follows the surgical principles, and the outcomes are good. In our study, the 5-year postoperative survival rate was 53.8% (7/13). Therefore, for patients in whom the tumor occurs at the upper lobe and invades openings of the superior lobar bronchus, the main bronchus and pulmonary trunk, bronchial and pulmonary arterial double sleeve lobectomy, instead of pneumonectomy, should be performed if only the lower lobe is intact and suitable to be reserved, in order to improve patients’ postoperative life quality.
4. 5.
6.
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1. Fang YP, Li ST, Ni YJ, et al. Bronchoplasty and Pulmonary Arterioplasty in the Surgical Treatment of Central Lung Cancer. Chin J Clin Oncol (Chinese), 2007, 34: 1168–1170. 2. Hamad AM. Short-term outcome of bronchial sleeve lobectomy. Indian J Thorac Cardiovasc Surg, 2009, 25: 63–67. 3. Kuang YK, Zeng LD. The application of bronchoplasty and carinal
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resection in pulmonary surgery. Pract J Cancer (Chinese), 1995, 10: 280. Wang CL, Zhang SP, Ma YY, et al. Bronchoplasty and pulmonary arterioplasty for central-type lung cancer. Chin J Lung Cancer (Chinese), 2006, 9: 22–24. Zhou QH, Liu LX, Yang JJ, et al. Bronchoplastic procedures and pulmonary artery reconstruction in the treatment of stage III lung cancer invading pulmonary artery. Chin J Lung Cancer (Chinese), 2002, 5: 403–407. Vogt-Moykopf I, Toomes H, Heinrich S. Sleeve resection of the bronchus and pulmonary artery for pulmonary lesions. Thorac Cardiovasc Surg, 1983, 31: 193–198. Zhang P, Chen G, Liu YM, et al. Bronchoplasties and pulmonary arterioplasties in the treatment of central-type bronchogenic carcinoma. Chin J Lung Cancer (Chinese), 2006, 9: 25–27. Hu YX, Li HW, Yang ZS, et al. The application of pulmonary arterioplasty for treatment of l bronchogenic carcinoma. Cancer Res Prev Treat (Chinese), 1990, 2: 112–113. Zhang GL, Liu J, Jiang GC, et al. Surgical treatment of central lung cancer by lobar replantation. Chin J Lung Cancer (Chinese), 2001, 4: 416–419.
《中德临床肿瘤学杂志》2013年征订启事 《中德临床肿瘤学杂志》(英文)系中华人民共和国教育部主管,华中科技大学同济医学院主办,中德合作出 版的医学学术期刊,并作为中德医学协会与德中医学协会的联合刊物出版发行。
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