Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer

Major vascular reconstructions in thoracic oncological surgery

The replacement of the superior vena cava and thoracic outlet vessels for thoracic malignancies often becomes necessary for radical oncological surgery. The pulmonary artery can be directly infiltrated by the tumor or affected by metastatic hilar lymph nodes. In some cases, it must be resected and reconstructed to achieve oncological radicality and/or avoid pneumonectomy. This study reflects a single-surgeon, retrospective experience spanning 6 years (2017-2023). We reviewed data from patients undergoing early anticoagulant therapy after superior vena cava or thoracic outlet vessels bypass and from patients undergoing early antiaggregation therapy following pulmonary artery reconstruction or resection. This series comprises 41 patients treated by a single surgeon. Fourteen patients underwent superior vena cava and thoracic outlet vessel procedures. Among these, eight patients received superior vena cava replacement (six for thymic malignancies and two for lung cancer), and six patients underwent jugular and subclavian artery/vein resection or replacement (all six had sarcomas). There was one death due to respiratory failure, not associated with bleeding or bypass closure. Additionally, there was one graft closure in a patient with severe coagulopathy and three instances of hemothorax (two patients had undiagnosed complex coagulopathies not evident in pre-operative routine blood tests). Following bleeding incidents, anticoagulation was initiated the next day in one case and based on hematological indications in the two coagulopathic patients. In the pulmonary artery series, 27 patients were involved: 20 underwent direct suture after tangential resection, and 7 received pericardial patch reconstruction. Only one case experienced bleeding necessitating redo-surgery. All these patients received early and chronic antiaggregation therapy after pulmonary artery reconstruction. We conclude that major thoracic oncological vascular surgery is safe and feasible with appropriate technical skills. However, achieving optimal results requires integration with correct early anticoagulant therapy or antiaggregation to maintain the patency of bypasses/grafts and prevent life-threatening risks associated with closure of the "new vessels."

Arterial Sleeve Lobectomy: Does Pulmonary Artery Reconstruction Type Impact Lung Function?

BACKGROUND

The aim of this single-center retrospective cohort study was to assess the impact of arterial reconstruction technique on lung perfusion. The second objective was to ascertain the functional validity of arterial sleeve lobectomy.

METHOD

Between January 2001 and December 2020, a total of 81 patients underwent lobectomy with pulmonary artery (PA) reconstruction for lung cancer at the University Hospital of Montpellier. After excluding patients with an incomplete postoperative pulmonary function test, we conducted a comparative analysis of the preoperative and postoperative functional outcomes (FEV1) of 48 patients, as well as the preoperative and postoperative Technetium99m scintigraphic pulmonary perfusion results of 28 patients. Then, we analyzed postoperative perfusion results according to the pulmonary artery reconstruction techniques use.

RESULTS

PA reconstruction types were as follows: 9 direct angioplasties (19%), 14 patch angioplasties (29%), 7 end-to-end anastomoses (15%), 6 prosthetic bypasses (12%), 11 arterial allograft bypasses (23%), and 1 custom-made xenopericardial conduit bypass. Regardless of the type of vascular reconstruction performed, the comparative analysis of lung perfusion revealed no significant difference between the preoperative and postoperative perfusion ratio of the remaining parenchyma (median = 29.5% versus 32.5%, respectively; p = 0.47). Regarding the pulmonary functional test, postoperative predicted FEV1 significantly underestimated the actual postoperative measured FEV1 by about 260 mL (11.4%) of the preoperative value. The patency rate was 96% and the 5-year overall survival was 49% for a mean follow up period of 34 months.

CONCLUSION

Lobectomy with PA reconstruction is a valid parenchymal-sparing technique in terms of perfusion and respiratory function.

Pre-epithelialized cryopreserved tracheal allograft for neo-trachea flap engineering

Background: Tracheal reconstruction presents a challenge because of the difficulty in maintaining the rigidity of the trachea to ensure an open lumen and in achieving an intact luminal lining that secretes mucus to protect against infection. Methods: On the basis of the finding that tracheal cartilage has immune privilege, researchers recently started subjecting tracheal allografts to "partial decellularization" (in which only the epithelium and its antigenicity are removed), rather than complete decellularization, to maintain the tracheal cartilage as an ideal scaffold for tracheal tissue engineering and reconstruction. In the present study, we combined a bioengineering approach and a cryopreservation technique to fabricate a neo-trachea using pre-epithelialized cryopreserved tracheal allograft (ReCTA). Results: Our findings in rat heterotopic and orthotopic implantation models confirmed that tracheal cartilage has sufficient mechanical properties to bear neck movement and compression; indicated that pre-epithelialization with respiratory epithelial cells can prevent fibrosis obliteration and maintain lumen/airway patency; and showed that a pedicled adipose tissue flap can be easily integrated with a tracheal construct to achieve neovascularization. Conclusion: ReCTA can be pre-epithelialized and pre-vascularized using a 2-stage bioengineering approach and thus provides a promising strategy for tracheal tissue engineering.

Pulmonary sleeve resection complications and management

In tumors involving the central airway or vascular structures, achieving local control and preserving pulmonary function can be possible with a pulmonary sleeve resection. In this section, complications and management of pulmonary sleeve resections are discussed.

Double sleeve resections

Double sleeve lung resections are complex surgical procedures that require specialized surgical expertise and careful patient selection. These procedures allow for the preservation of lung tissue while still achieving complete tumor resection for central tumors. Although initially considered high-risk operations, double sleeve lung resections have become a viable option for central tumors. Recent studies have shown that double sleeve lung resections are associated with lower morbidity and mortality rates than pneumonectomy. Furthermore, double sleeve lung resections may be associated with similar or even better long-term oncological outcomes compared to pneumonectomy, with the added benefit of preserving lung parenchyma and reducing the incidence of postoperative complications.

Parenchymal Sparing Surgery for Lung Cancer: Focus on Pulmonary Artery Reconstruction

Reconstruction of the pulmonary artery (PA) associated with lobectomy for the radical resection of lung cancer has been progressively gaining diffusion in lung cancer surgery as a safe and effective therapeutic option that may allow radical resection when lobectomy is not technically feasible, avoiding pneumonectomy. There are some controversial aspects concerning the intraoperative and perioperative management of a sleeve resection with PA reconstruction that may influence the outcome. In the present article, the authors have analyzed some of the main technical and oncological aspects to take stock of what they have learned from their lung-sparing operations experience over time. PA reconstruction may require prosthetic materials including different options with variable cost. A main concern in vascular reconstructive procedures is avoiding tension on the anastomosis. When PA reconstruction is required, appropriate anticoagulation management is crucial. Results from the main literature data confirm the reliability of lobectomy associated with PA reconstruction in terms of perioperative morbidity and long-term survival. Sleeve lobectomy and PA reconstruction can be performed safely and effectively even after induction therapy.

Lobectomy with pulmonary artery angioplasty for lung cancer using video-assisted thoracic surgery versus open thoracotomy: a retrospective propensity matched analysis

Background

Pulmonary artery angioplasty (PAA) is an important surgical procedure to complete radical resection with maximum preservation of functioning pulmonary tissues when the pulmonary artery is involved. In this study, we aimed to evaluate the short- and long-term outcomes of PAA using video-assisted thoracic surgery (VATS) versus open thoracotomy (OT) in lung cancer surgery.

Methods

We retrospectively reviewed 214 patients who underwent PAA between November 2005 and October 2016. Propensity score matching (PSM) was applied to reduce confounding effects. The survival outcomes were assessed using Kaplan-Meier estimates and Cox regression analysis.

Results

The final sample included 203 patients (28 patients in the VATS group and 175 patients in the OT group). There were no differences between the two groups in operative time, blood loss, duration of chest tube drainage, postoperative hospital stays, margin status, postoperative morbidity and mortality, and number of N1 and N2 stations or number of N1 and N2 lymph nodes both before and after matching. At a median follow-up period of 43 (range, 6 to 158) months, the 5-year overall survival (OS) and recurrence-free survival (RFS) of the overall cohort were 47.9% and 42.1%, respectively. The 5-year OS and RFS were comparable between the VATS and OT groups both in the overall cohort and the matched cohort. The VATS procedure was found not to have a prognostic impact on either OS (hazard ratio, 1.17; 95% CI: 0.60 to 2.30, P=0.647) or RFS (hazard ratio, 1.14; 95% CI: 0.62 to 2.10, P=0.666).

Conclusions

VATS PAA is associated with comparable short- and long-term outcomes in selected patients with lung cancer compared with OT.

Extended Robotic Pulmonary Resections

While lung cancer remains the most common cause of cancer-related mortality in the United States, surgery for curative intent continues to be a mainstay of therapy. The robotic platform for pulmonary resection for non-small cell lung cancer (NSCLC) has been utilized for more than a decade now. With respect to more localized resections, such as wedge resection or lobectomy, considerable data exist demonstrating shorter length of stay, decreased postoperative pain, improved lymph node dissection, and overall lower complication rate. There are a multitude of technical advantages the robotic approach offers, such as improved optics, natural movement of the operator's hands to control the instruments, and precise identification of tissue planes leading to a more ergonomic and safe dissection. Due to the advantages, the scope of robotic resections is expanding. In this review, we will look at the existing data on extended robotic pulmonary resections, specifically post-induction therapy resection, sleeve lobectomy, and pneumonectomy. Additionally, this review will examine the indications for these more complex resections, as well as review the data and outcomes from other institutions' experience with performing them. Lastly, we will share the strategy and outlook of our own institution with respect to these three types of extended pulmonary resections. Though some controversy remains regarding the use and safety of robotic surgery in these complex pulmonary resections, we hope to shed some light on the existing evidence and evaluate the efficacy and safety for patients with NSCLC.

Standard and extended sleeve resections of the tracheobronchial tree

Anatomic resections with bronchial and/or vascular resections and reconstruction, so called sleeve resections were originally performed in patients with impaired cardio-pulmonary reserves. Nowadays, sleeve resections are established surgical procedures of first choice for tracheobronchial pathologies, whenever anatomically and oncologically feasible. Experienced thoracic surgeons have a broad surgical armentarium to avoid a pneumonectomy and the morbidity and mortality associated with it. Sleeve resections are associated with better outcomes in all aspects. Thus, sleeve resection is not an alternative for pneumonectomy and vice versa. In this review article we set out to provide a contemporary overview on this topic.

Pulmonary Artery Resection During Lung Resection for Malignancy

BACKGROUND

Complete resection of central tumors invading the main pulmonary artery (PA) requires arterial reconstruction to avoid pneumonectomy. Oncologic equivalence with pneumonectomy has been suggested. We review clinical selection and outcome for these uncommon procedures in the context of candidacy for pneumonectomy.

METHODS

From 2000 to 2018, 9 different surgeons performed 34 pulmonary arterial resections for primary or metastatic pulmonary malignancy, with independent determination of pneumonectomy candidacy and arterioplasty technique. Patients undergoing limited lateral stapled PA resection (n = 3) or resection for metastasis (n = 3) were excluded from survival analysis.

RESULTS

The PA was resected as a sleeve with primary anastomosis (14.7%) or noncircumferentially with primary (61.8%), stapled (8.8%), or patch (14.7%) closure. Arterial resections represented between 2.5% and 43% of each surgeon's pneumonectomy volume. Sixteen (47%) patients were candidates for pneumonectomy. There was no operative mortality and 1 death at 47 days. Postoperative complications occurred in 21 (61.8%) patients. No patient required completion pneumonectomy. Overall 5-year survival was 33% (95% confidence interval [CI], 12-53). Compared with pulmonary arterioplasty alone, patients undergoing bronchial sleeve resection and pulmonary arterioplasty had better disease-free 5-year survival (50% [95% CI, 18-82] vs 19% [95% CI, 5-43]; P = .04), higher complete resection rate (100% [95% CI, 83-100] vs 80% [95% CI, 56-94]; P = .23) and lower disease recurrence (8% [n = 1 of 13] vs 47% [n = 7 of 15]; P = .04); 80% of disease recurrence was distant.

CONCLUSIONS

Resection and reconstruction of the PA for malignant lung disease may be safely performed. In candidates for pneumonectomy, arterial resection offers low operative risk. Long-term survival is impaired by distant, not local, recurrence emphasizing the importance of systemic therapy.

Surgical outcome of pulmonary artery reconstruction using the expanded polytetrafluoroethylene patch in patients with lung cancer

PURPOSE

Pulmonary artery reconstruction is sometimes utilized as an alternative to pneumonectomy in lung cancer surgery. We herein report our experience of pulmonary artery reconstruction using an expanded polytetrafluoroethylene (ePTFE) patch based on the surgical results and long-term outcome.

METHODS

Clinical records of lung cancer patients who underwent patch plasty were reviewed retrospectively.

RESULTS

Between 2003 and 2017, pulmonary artery patch plasty were performed in 21 patients [18 males, 3 females; mean age 65 (range 47-79) years]. Induction chemoradiotherapy was performed in three patients. Bronchoplasty was performed in five patients. The pathologic stages were stage I in 3 patients, stage II in 6 and stage III in 12. Pneumonectomy, lobectomy and segmentectomy were performed in 2, 18 and 1 patient, respectively. The left upper lobe was the most frequent origin of lung cancer (15 patients). There was no reconstruction-related morbidity or mortality. The overall survival rate at 5 years was 64.1% with a mean follow-up of 39.5 months, and the survival rates for N0-1 and N2-3 were 80.8% and 28.6%, respectively.

CONCLUSION

Patch angioplasty using the ePTFE sheet is a reliable procedure in radical surgery for lung cancer.

Lobectomy with angioplasty: which is the best technique for pulmonary artery reconstruction?

Lobectomies with bronchial and/or vascular reconstruction are conservative procedures aimed at managing locally advanced lung cancer, avoiding a pneumonectomy. Considering morbidity, mortality and the functional consequences of a pneumonectomy, such procedures must be in the technical armamentarium of every thoracic surgeon. Vascular reconstruction of the pulmonary artery (PA) is seldom performed with or without the bronchial sleeve resection. Both functional and oncologic outcomes have been reported to be better than after a pneumonectomy. Different technical options are now available but some aspects and technical details are not standardized. Indications, possible complications, planning and even definitions need to be more solid to allow for definitive improvement in such procedures. This analysis is aimed at assessing the acquired technical data with special emphasis on the PA reconstruction with autologous tissues.

Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion

Video assisted thoracic surgery (VATS) has become a routinely utilized approach to complex procedures of the chest, such as pulmonary resection. It has been associated with decreased postoperative pain, shorter length of stay and lower incidence of complications such as pneumonia. Limitations to this modality may include limited exposure, lack of tactile feedback, and a two-dimensional view of the surgical field. Furthermore, the lack of an open incision may incur technical challenges in preventing and controlling operative misadventures leading to major hemorrhage or other intraoperative emergencies. While these events may occur in the best of circumstances, prevention strategies are the primary means of avoiding these injuries. Unplanned conversions for major intraoperative bleeding or airway injury during general thoracic surgical procedures are relatively rare and often can be avoided with careful preoperative planning, review of relevant imaging, and meticulous surgical technique. When these events occur, a pre-planned, methodical response with initial control of bleeding, assessment of injury, and appropriate repair and/or salvage procedures are necessary to maximize outcomes. The surgeon should be well versed in injury-specific incisions and approaches to maximize adequate exposure and when feasible, allow completion of the index operation. Decisions to continue with a minimally invasive approach should consider the comfort and experience level of the surgeon with these techniques, and the relative benefit gained against the risk incurred to the patient. These algorithms may be expected to shift in the future with increasing sophistication and capabilities of minimally invasive technologies and approaches.

Pericardial Conduit for Pulmonary Artery Reconstruction by Surgical Stapling

Pulmonary artery reconstruction in lung cancer surgery is an effective surgical method to avoid pneumonectomy that leads to longer survival times with few adverse effects. The pericardium is often used for the interposition of a prosthetic conduit. A pericardial conduit can be easily and precisely constructed by surgical stapling, which facilitates pulmonary artery reconstruction. In this report, the process and pitfalls of surgical stapling are described.

Bronchial and arterial sleeve resection for centrally-located lung cancers

The use of bronchial and arterial sleeve resections for the treatment of centrally-located lung cancers, when available, has become the option of choice in comparison with pneumonectomy (PN). Technical expertise, in particular in vascular reconstruction, and perioperative management improved over time allowing excellent short-term and long-term results. This is even truer if considering literature data from the main experiences published in the last years. These evidences have given to such lung sparing reconstructive procedures more and more acceptance among the surgical community. This article focuses on the main technical aspects and literature data regarding bronchovascular sleeve resections.

Pulmonary artery reconstruction using autologous pulmonary vein for surgical treatment of locally advanced lung cancer: a case report

Background

Resection and reconstruction of the pulmonary artery during lobectomy is a safe and effective procedure for centrally located lung cancer. We usually choose a pericardial conduit to repair a large defect of the pulmonary artery. The use of an autologous pulmonary vein conduit for reconstruction was first described in 2009.

Case presentation

A 64-year-old woman with left upper lung adenocarcinoma with mediastinal and hilar adenopathy was referred to our hospital. Hilar nodes had extensively infiltrated the pulmonary artery. We interposed an autologous superior pulmonary vein between the cut ends of the pulmonary artery. She was discharged without any complication on the ninth postoperative day.

Conclusions

A pulmonary vein conduit is a good option for reconstruction of the pulmonary artery. We report the successful use of an autologous pulmonary vein conduit.

Reconstruction of the bronchus and pulmonary artery

Bronchovascular reconstructive procedures employed in order to avoid pneumonectomy (PN) in patients functionally unsuitable have provided, over time, excellent results, similar or even better than those obtained by PN. In recent years, new successful techniques have been developed that pertain in particular the prevention of major complications and the reconstruction of the pulmonary artery (PA). Encouraging data from increasing number of published experiences support the choice of parenchymal sparing procedures for lung cancer also in patients with good functional reserve. This is even more true if considering trials published in the last 10 years, thus indicating that improved outcome can be achieved with increased experience in reconstructive techniques and perioperative management. This article discusses the main technical aspects and results of literature.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

Video-assisted thoracoscopic surgery after renal transplantation: A single-institution experience

INTRODUCTION

The number of renal transplantations performed for patients with chronic kidney disease has increased in Japan, but little is known about the outcomes in those who subsequently undergo video-assisted thoracoscopic surgery (VATS). We therefore investigated the outcomes of consecutive patients requiring VATS after renal transplantation at our institute.

METHODS

We retrospectively collected the clinical data for patients undergoing VATS after renal transplantation between January 2003 and September 2014. Specifically, we compared the serum creatinine level and estimated glomerular filtration rate preoperatively and postoperatively, and investigated the postoperative complications.

RESULTS

In total, 12 patients underwent VATS after renal transplantation during the study period. All patients received two or three immunosuppressive agents. Operative methods used included VATS wedge resection (n = 4), segmentectomy (n = 4), lobectomy (n = 2), mediastinal tumor resection (n = 1), and chest wall tumor resection (n = 1). No patients required perioperative hemodialysis. There were no intraoperative complications, but one patient developed postoperative hemorrhagic cystitis and another developed pneumonia. One patient developed pneumocystis pneumonia 2 months after left lower lobectomy and required hemodialysis. No further hemodialysis was required by any patient. Of note, no statistically significant differences were observed between the preoperative and postoperative serum creatinine level (P = 0.666) and estimated glomerular filtration rate (P = 0.388). There were no in-hospital deaths. Univariate analysis revealed no significant risk factors for postoperative complications.

CONCLUSION

This report showed favorable results for VATS after renal transplantation. However, clinicians must remain vigilant for complications because transplant recipients remain permanently immunocompromised.

Prognostic analysis of the bronchoplastic and broncho-arterioplastic lobectomy of non-small cell lung cancers-10-year experiences of 161 patients

BACKGROUND

Bronchoplastic and broncho-arterioplastic lobectomy is technically demanding. Present study performed a prognostic analysis of lobectomy patient based on 10-year data in a high-volume center.

METHODS

Overall, 161 non-small cell lung cancer (NSCLC) cases underwent bronchoplastic and broncho-arterioplastic lobectomy between January 2004 and November 2013. Follow-up information was obtained for 88.8% patients. Prognostic analysis was performed with the Cox proportional hazards model.

RESULTS

There were 133 bronchoplastic and 28 broncho-arterioplastic procedures. In detail, 97 sleeve and 64 wedge broncho-resection and reconstructions were conducted; pulmonary artery sleeve reconstructions were performed in 26 cases and tangential resection in 135 cases. 90-day post-operative mortality was 3.1% (5/161), and 24.8% (40/161) patients had post-operative complications. 5-year overall survival was 53.4% and 5-year disease-free survival (DFS) was 48.2% for the entire case series; these survival rates were 67.7% and 55.7% for stage I (n=31), 64.4% and 58.9% for stage II (n=62), and 36.9% and 31.9% for stage III disease, respectively. Univariate analysis revealed that age >65 and higher grade of pN were associated with worse overall survival while right side tumor, non-squamous histology type, and higher grade of pT and pN were associated with worse DFS. Multivariate analysis revealed that pN is the only independent factor of worse outcome.

CONCLUSIONS

Bronchoplastic and broncho-arterioplastic lobectomy are safe procedures for indicated NSCLC patients associated with a low rate of post-operative complications but favorable long-term survival. Recognition of prognostic factors helps improve outcomes for these patients.

Ex situ reimplantation technique, in central lung tumors

BACKGROUND

The parenchyma-sparing resection is most often performed in patients with impaired preoperative lung or cardiovascular function who would not be able to tolerate a pneumonectomy.

METHODS

Our experience on the ex situ reimplantation procedure and the outcome of patients with lung malignancies, who underwent upper or upper-middle lobectomy, with reimplantation of the lower lobe was reported.

RESULTS

We present 9 patients mean age 62.6+16.2 years (7 males/2 females) underwent ex situ reimplantation due to extensive lung tumor of upper lobes. The surgical technique precludes IV heparinization and then radical pneumonectomy. The entire lung was immersed in Ringer's solution (temperature 4 degrees centigrade) and bench surgery was performed. The involved upper (or upper-middle) lobes with involved lymph nodes were resected, thus leaving the healthy lower lobe of the lung. Pneumoplegia solution, named "Papworth pneumoplegia", was administered (1,473 mL) through catheterization of the pulmonary artery and vein stumps (ante grade and retrograde) along with 250 mL of prostaglandin E1. Re-implantation of the lower lobe was performed (I) on the right side, implantation involved the anastomosis of lower pulmonary vein in the site of the cuff of left atrium, followed by suturing the stump of the intermedius pulmonary artery to the right main pulmonary artery and finally the bronchial stumps-intermedius bronchus to the right main bronchus; (II) on the left side the pulmonary vein was anastomosed first, followed by the bronchial stumps and finally by the pulmonary artery. The graft ischemia time was 70.2+8.4 minutes ranged between 55 and 80 minutes.

CONCLUSIONS

Re-implantation or auto-transplantation should be considered as a safe option for the appropriate patient with lung cancer. The ex situ separation of the cancerous lobes is technically feasible and allows extensive pulmonary resection while minimizing the loss of pulmonary reserve. Based on our work, the major factors that play a role for the survival of initially resected and then re-implanted lung graft, are: (I) the ischemia time of the re-implanted lobe; (II) the proper use of pneumoplegia solutions, along with prostaglandin E1 and heparin; (III) the occurrence of pulmonary vein thrombosis; and (IV) the bronchial anastomosis.

Surgical Techniques and Long-Term Results of Pulmonary Artery Reconstruction in Patients With Lung Cancer

BACKGROUND

Pulmonary artery (PA) reconstruction for lung cancer is technically feasible with low morbidity and mortality. We assessed our experience with partial or circumferential resection of the PA during lung resection.

METHODS

Between 1998 and 2013, we performed PA angioplasty in 150 patients with lung cancer. Partial PA resection was performed in 146 patients. PA reconstruction was performed by running suture in 113 patients and by using a pericardial patch in 33. A circumferential PA resection was performed in 4 patients, and reconstruction was made with polytetrafluoroethylene and by a custom-made bovine pericardial conduit. Bronchial sleeve resection was associated in 56 patients. Stage I disease was present in 32 patients, stage II in 43, stage IIIA in 51, and stage IIIB in 17. Seventy-five patients received induction chemotherapy, and 7 patients had a complete response.

RESULTS

Thirty-day mortality was 3.3% (n = 5); two of these patients died of a massive hemoptysis. Pulmonary complications occurred in 33 patients, cardiac in 28, and air leaks in 17. Overall 5-year and 10-year survival was 50% and 39%, respectively. Survival at 5 and 10 years for stages I and II vs stage III was, respectively, 66% vs 32% and 56% vs 20% (p < 0.0001). Five-year survival was 61% for N0 and N1 nodal involvement vs 28% for N2, and the respective 10-year survival was 45% vs 28% (p = 0.001). Induction chemotherapy did not influence survival. Multivariate analysis yielded advanced stage, N2 status, and squamous cell carcinoma as negative prognostic factors.

CONCLUSIONS

PA reconstruction is safe, with excellent long-term survival. Our results support this technique as an effective option to pneumonectomy for patients with lung cancer.

Bronchial and arterial sleeve resection after induction therapy for lung cancer

Lobectomy with reconstruction of the bronchus and pulmonary artery is a viable therapeutic option for patients with centrally located non-small cell lung cancer. Preoperative chemotherapy or chemoradiotherapy may represent an additional risk factor for postoperative complications because of increased difficulty in surgical dissection and potential impairment of bronchial healing. Although limited data are available in the literature in this setting, a few published studies have reported the possibility of performing even complex bronchovascular reconstructions after neoadjuvant treatment with no increased morbidity and mortality. This article discusses the main technical details and data from the literature.

Pulmonary artery reconstruction with pulmonary vein conduit for lung cancer: medium-term results

BACKGROUND

The use of an autologous pulmonary vein (PV) conduit for reconstruction of the pulmonary artery (PA) in lung-sparing resections was first described in 2009, but to date only two case reports appeared and no medium-term and long-term results have been reported, to our knowledge. We present the first case series with medium-term follow-up.

METHODS

Between December 2009 and December 2012, 9 patients undergoing PA sleeve resection for centrally located lung cancer received reconstruction by this technique. Three of these patients underwent induction chemotherapy. The venous graft was obtained from the proximal extraparenchymal portion of the superior PV and was sutured to the proximal and distal PA stumps with the standard anastomotic technique.

RESULTS

All 9 patients underwent left upper lobectomy with sleeve resection of the PA without associated bronchoplasty. The postoperative morbidity rate was 33% (1 chylothorax, 1 atrial fibrillation, and 1 parenchymal atelectasis). No adverse events related to the reconstructive procedure occurred. There was no postoperative mortality. Complete patency of the reconstructed PA was shown in all patients by postoperative contrast computed tomography every 6 months. All patients are alive at a mean follow-up time of 32 ± 12.4 months (range, 6 to 42 months). Tumor recurrence has been observed in 2 patients (1 local, 1 systemic). The median survival time is 38 months. The median disease-free survival time is 33 months.

CONCLUSIONS

Reconstruction of the PA by a PV graft is a feasible and effective option for parenchymal-sparing resections. The PV conduit shows tissue characteristics similar to those of the arterial wall. This technique is safe and is supported by good medium-term results.

Advances in the use of video-assisted thoracoscopic lobectomy in lung cancer: sleeve bronchoplasty and arterioplasty

SUMMARY 

This article focuses on the technical strategies for performing sleeve bronchoplasty and pulmonary arterioplasty as advances in the application of video-assisted thoracoscopic surgery (VATS) as lobectomy with bronchovascular reconstruction is a favorable alternative to pneumonectomy in terms of the pulmonary function. When performing VATS sleeve bronchoplasty or arterioplasty, several technical issues should be discussed, including how to reduce the anastomotic tension of the airway, perform bronchial anastomosis, and clamp the pulmonary artery and select the type of vascular clamp. The traction device technique and continuous suture technique are thought to help surgeons perform VATS sleeve bronchoplasty, while cross-clamping of the pulmonary artery using thoracoscopic instruments aids in carrying out VATS arterioplasty.

Pulmonary artery reconstruction with a prosthetic conduit in lung cancer

In radical pulmonary resection for advanced lung cancer, reconstruction of the pulmonary artery (PA) can preserve the lung parenchyma. Reconstruction techniques have gained acceptance because they enable the surgeon to avoid pneumonectomy. Various techniques have been documented, such as direct suturing, end-to-end anastomosis, and a patch or conduit reconstruction. We present two lobectomy cases in which the patients underwent PA reconstruction with prosthetic conduits because they were unfit for other procedures. In both cases, the conduits showed good postoperative patency. When interposition of a conduit is required for PA reconstruction, the use of a prosthetic conduit should be considered in selected cases.

Long-term results after resection of bronchial carcinoid tumour: evaluation of survival and prognostic factors

OBJECTIVES

We retrospectively analysed morbidity, mortality and oncological results of patients who had undergone surgery for bronchial carcinoid tumours.

METHODS

Between 2002 and 2012, 65 patients with bronchial carcinoids underwent lobectomy (n = 34), sublobar resection (segmentectomy/wedge) (n = 18), sleeve lobectomy (n = 5) (reconstruction of the pulmonary artery was associated in 1 case), sleeve resection of the main bronchus (n = 4) or pneumonectomy (n = 4) (reconstruction of the carina was associated in 1 case).

RESULTS

Resection was radical with histologically negative margins in all patients (R0). Histology showed typical carcinoid (TC) in 55 (84.6%) patients and atypical carcinoid (AC) in 10 (15.4%) patients. Final pathological stages were Stage I in 42 (64.6%) patients, Stage II in 18 (27.7%) and Stage III in 5 (7.7%). No postoperative mortality was observed. The postoperative morbidity rate was 15.4% (no bronchial and/or vascular reconstructive-related complications occurred). The median follow-up was 58 (range 2-121) months. The overall recurrence rate was 12.3% (n = 8). The survival rate at 5 years was 100% for TC and 87% for AC. Disease-free survival rates at 3 and 5 years were 95 and 93% for TC and 78 and 44% for AC, respectively (P = 0.004). Pathological nodal involvement (pN1-N2) did not affect overall survival or recurrence.

CONCLUSIONS

The surgical treatment of bronchial carcinoids provides high long-term survival rates. Low postoperative morbidity and mortality can be expected even after bronchial reconstruction. The AC appears to be the main factor that determines the risk of recurrence. Bronchial reconstructive lung sparing operations are not related to an increased recurrence rate.

Bronchial and pulmonary arterial sleeve resection

This chapter deals with the indications and techniques of resection and reconstruction of the bronchi and pulmonary artery associated with sleeve lobectomy for lung cancer. The techniques of bronchial suture are described in detail, and the indications and the various techniques of pulmonary artery reconstruction, such as sleeve resection and end-to-end anastomosis, or partial resection and patch reconstruction are described and evaluated comparatively. Finally, the results of sleeve resection are reported, and a review of the literature on the subject is presented.

Surgical techniques and results of the pulmonary artery reconstruction for patients with central non-small cell lung cancer

Background

It is difficult to achieve a margin-negative resection (R0) for non-small cell lung cancer (NSCLC) patients with infiltration of the pulmonary artery. We report our experience of the pulmonary artery reconstruction with regard to long-term survival.

Methods

Clinical records of 118 patients with NSCLC who underwent partial or circumferential pulmonary artery resection during a 21-year period were reviewed retrospectively. Techniques and survival outcomes were analyzed.

Results

We performed 22 pulmonary artery sleeve resections, 51 reconstructions by autologous pericardial patch, 36 tangential resections, 3 left main pulmonary artery (PA) angioplasties during pneumonectomy without cardiopulmonary bypass, and 6 by only preserving the apical and anterior (1^st) branch of pulmonary arterial trunk. In 41 patients, bronchial sleeve resection was associated; in 7 cases, superior vena cava reconstruction was also required. Thirty-one patients received induction therapy. Thirteen patients had stage IB disease, 41 stage II, 53 IIIA, and 11 IIIB. Ninety-three patients had squamous cell carcinoma, 22 adenocarcinoma, 2 mixed and 1 large cell carcinoma. Negative vascular margins were achieved in all. 5 positive bronchial margins were due to limited lung function. The analysis of 118 cases yielded follow-up data in 94 cases. The mean follow-up was 70 months (range 1–156 months). There was no in hospital death, and the overall 5-year survival was 50.2%. Five-year survivals for stages I and II versus III were 63.9% versus 37.0% (p = 0.0059). Multivariate analysis yielded non-squamous cell carcinoma, stage III and patch pulmonary arterioplasty as negative prognosis factors. PA reconstruction associated with bronchial sleeve resection was the positive prognostic factor.

Conclusions

Pulmonary artery resection and reconstruction is feasible and safe, with favorable long-term survival. Our results support this technique as an effective alternative to selected patients with infiltration of the pulmonary artery, such as stage I and II and those who proved down-staged from stage III. Accurate preoperative evaluation, precise and suitable surgical techniques are crucial to achieve good results. Only preserving the anterior and apical pulmonary arteries and reconstruction of the main pulmonary artery by using the artery conduit technique without cardiopulmonary bypass in association with left pneumonectomy can be performed successfully. Postoperative anticoagulation is unnecessary.

Reconstruction of the bronchus and pulmonary artery

Sleeve lobectomy (SL) (lobectomy associated with resection and reconstruction of the bronchus, the pulmonary artery, or both) has proved to be a suitable choice for the treatment of centrally sited non-small cell lung cancer. SL for lung cancer is indicated when a tumor or an N1 lymph node infiltrates the origin of a lobar bronchus, the origin of the lobar branches of the pulmonary artery, or both but not to the extent that a pneumonectomy is required. SL can be performed safely and effectively, even after induction therapy, without an increased complication rate.

Surgery in 2013 and beyond

Lung cancer is a leading cause of cancer related mortality. The role of surgery continues to evolve and in the last ten years there have been a number of significant changes in the surgical management of lung cancer. These changes extend across the entire surgical spectrum of lung cancer management including diagnosis, staging, treatment and pathology. Positron Emission Tomography (PET) scanning and ultrasound (EBUS) have redefined traditional staging paradigms, and surgical techniques, including video-assisted thoracoscopy (VATS), robotic surgery and uniportal surgery, are now accepted as standard of care in many centers. The changing pathology of lung cancer, with more peripheral tumours and an increase in adenocarcinomas has important implications for the Thoracic surgeon. Screening, using Low-Dose CT scanning, is having an impact, with not only a higher percentage of lower stage cancers detected, but also redefining the role of sublobar resection. The incidence of pneumonectomy has reduced as have the rates of "exploratory thoracotomy". In general, lung resection is considered for stage I and II patients with a selected role in more advanced stage disease as part of a multimodality approach. This paper will look at these issues and how they impact on Thoracic Surgical practice in 2013 and beyond.

Pulmonary sleeve resection in locally advanced lung cancer using cryopreserved allograft for pulmonary artery replacement

BACKGROUND

During lobectomy, resection of pulmonary artery, followed by reconstruction or replacement with or without concomitant sleeve bronchial resection, is feasible in selected cases. We report morbidity, mortality, and technical issues in pulmonary artery replacement using a cryopreserved arterial allograft after sleeve resection for centrally located non-small cell lung carcinoma (NSCLC).

METHODS

We reviewed clinical and pathologic data of patients who underwent arterial sleeve lobectomy with pulmonary artery replacement in our institution from 2007 to 2012.

RESULTS

Of 178 centrally located NSCLCs, sleeve resections were performed in 92 (51%), pneumonectomies in 33 (18%), and lobectomies in 53 (31%). Of the 32 (34.7%) pulmonary) reconstructions (excluding tangential suture), 20 (21.7%) were end-to-end anastomosis, 2 (2.1%) were pericardial patch reconstructions, and 10 (11%) were PA replacements. Clinical T staging was cT2a in 4 patients, cT2b in 3, cT3 in 2, and cT4 in 1. Four patients received concurrent induction chemoradiotherapy. Three patients underwent a double-sleeve right lobectomy. Cryopreserved allografts used were descending thoracic aorta (n = 3) and pulmonary arteries (n = 7). Complete resection (R0) was achieved in all patients. Final N staging was pN0 (n = 4), pN1 (n = 5), and pN2 (n = 1). There was no operative mortality. Four patients had major morbidity, including 1 early conduit thrombosis treated by pneumonectomy completion. Graft patency, assessed by contrast-enhanced computed tomography scan, was 90%. Mean follow-up was 25 ± 14 (range, 8-47) months (30% for >36 months). Overall 5-year survival was 66.7%, and the estimated median disease-free survival was 42 months.

CONCLUSIONS

In central NSCLCs, conservative surgery using a cryopreserved arterial allograft to replace the pulmonary artery after extended segmental resection could avoid pneumonectomy in selected patients.

Bronchovascular reconstruction with a bovine pericardial conduit and surgical reintervention due to thrombosis with revascularisation

We present the case of a 57-year-old male with left hilar squamous cell carcinoma infiltrating the pulmonary artery and in whom a sleeve bronchoplasty and angioplasty were performed using a bovine pericardial conduit. Three days post-operatively, graft thrombosis was detected; thrombectomy and graft reconstruction were performed with revascularisation of the graft.

Partial removal of the pulmonary artery in video-assisted thoracic surgery for non-small cell lung cancer

Lobectomy with partial removal of the pulmonary artery in video-assisted thoracic surgery (VATS) currently remains a challenge for thoracic surgeons. We were interested in introducing pulmonary vessel blocking techniques in open thoracic surgery into video-assisted thoracic surgery (VATS) procedures. In this study, we reported a surgical technique simultaneously blocking the pulmonary artery and the pulmonary vein for partial removal of the pulmonary artery under VATS. Seven patients with non-small-cell lung cancer (NSCLC) received lobectomy with partial removal of the pulmonary artery using the technique between December 2007 and March 2012. Briefly, rather than using a small clamp on the distal pulmonary artery to the area of invading cancer, we replaced a vascular clamp with a ribbon and Hem-o-lock clip to block the preserved pulmonary veins so as to prevent back bleeding and yield a better view for surgeons. The mean occlusion time of the pulmonary artery and pulmonary veins were 44.0±10.0 and 41.3±9.7 minutes, respectively. The mean repair time of the pulmonary artery was 25.3±13.7 minutes. No complications occurred. No patients showed abnormal blood flow through the reconstructed vessel. There were no local recurrences on the pulmonary artery. In conclusion, the technique for blocking the pulmonary artery and veins is feasible and safe in VATS and reduces the risk of abrupt intraoperative bleeding and the chance of converting to open thoracotomy, and extends the indications of VATS lobectomy.

Pulmonary artery reconstruction using autologous pericardium or azygos venae substitute for surgical treatment of central non-small cell lung cancer

We evaluated the clinico-surgical significance of pulmonary artery (PA) reconstruction using a patch of autologous pericardium/azygos venae substitute to treat central non-small cell lung cancer in 62 patients with pulmonary arteries invaded by tumor. According to TNM-classification, four patients were stage IIb, 46 were stage IIIa, and 12 were stage IIIb. Depending on tumor infiltration, surgical procedures included partial PA tangential resections/reconstructions by a patch of autologous azygos venae, a patch of autologous pericardium and complete PA sleeve resection and reconstruction by a custom-made autologous pericardial conduit interposition. 47 patients received postoperative chemotherapy and 19 received radiotherapy. There were 2 (3.2%) postoperative early deaths due to bronchial anastomotic leakage. Postoperative complications occurred in 17.7% (11/62) patients and all recovered uneventfully. Mean follow-up time after surgical resection was 49.5 (6-12) months and overall ≤1-, 3-, 5-, and ≥10-year survival rates were 80.2, 44.7, 31.4, and 23.1%, respectively. It was concluded that autologous pericardial patch and azygos vein patch reconstruction of PA were safe and effective. Regarding extended circumferential defects after sleeve resection in which end-to-end anastomosis is not feasible, autologous pericardial conduit interposition may be useful for reconstruction when a tumor extensively infiltrates full circumference of the PA.

Techniques of Bronchial Sleeve Resection

A bronchial sleeve resection can be considered for lesions arising from a lobar bronchus so as to preclude a standard lobectomy, yet without enough distal involvement as to warrant a pneumonectomy. Limited bronchial resection allows maximal conservation of pulmonary function in patients with benign or malignant disease, without compromising oncologic outcome. This article defines the indications and preoperative management of candidate patients and discusses key anesthetic considerations and surgical techniques for this complex airway reconstruction. The essential component of a successful operation is a tension-free bronchial anastomosis. Open communication and careful discussion of airway management between anesthesiologist and surgeon will help ensure a good outcome.

Bronchovascular reconstruction for lung cancer: does induction chemotherapy influence the outcomes?

BACKGROUND

Bronchoangioplastic interventions (BAIs) for lung cancer are challenging procedures associated with a high risk of postoperative morbidity and mortality. The role of induction chemotherapy (IC) in these patients is debated.

METHODS

We reviewed clinical records of patients who underwent a BAI between 1998 and 2009 using a prospective clinical and operative database.

RESULTS

Among 47 patients (39 men; mean age, 66 years) who underwent BAI, 26 (55.3%) received IC for N2 disease or for locally advanced lung cancer. We performed 35 pulmonary artery (PA) sleeve resections (31 partial and 4 circumferential), 10 PA reconstructions with a pericardial patch (8 autologous, and 2 heterologous), and 2 PA reconstructions using heterologous conduit. The 30-day mortality rate was 4.2% (n=2). Morbidity occurred in 19 (40.4%) patients; 5 patients (10.6%) had major complications (3 [6.4%] patients with fatal bronchovascular fistulas and 1 patient each with cardiac dislocation and acute respiratory distress syndrome) (2.2%). Fourteen patients (29.8%) had minor complications: 6 (12.7%) cardiac, 7 (14.9%) pulmonary, and 1 (2.2%) stroke. IC did not influence the complication rate. Overall 5-year survival and disease-free survival was 39.2% and 36.9%, respectively. Early pathologic stage and the absence of nodal involvement significantly influenced survival (p=0.005 and p=0.002, respectively). Patients receiving IC had a better prognosis (62.7% versus 10.7%; p=0.0003). At multivariate analysis, IC influenced long-term survival (p=0.003 [95% CI, 2.92-8.56]).

CONCLUSIONS

BAIs are feasible and effective surgical procedures with acceptable morbidity and mortality. IC does not influence morbidity and allows good long-term outcomes.

Extensive resections: pancoast tumors, chest wall resections, en bloc vascular resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.

Inflow and outflow occlusion technique of the pulmonary artery and veins for the technically difficult left upper lobectomy

OBJECTIVE

Our objective is to assess the safety of a surgical technique applied to the difficult left upper lobectomy. The inflow-outflow occlusion technique features: dividing the superior pulmonary vein first, then proximal control by clamping the main pulmonary artery (PA), and then distal control by clamping the inferior pulmonary vein.

METHODS

A retrospective cohort study of a prospective database was carried out. Patients who underwent left upper lobectomy and required clamping of the vessels were compared to those that did not.

RESULTS

Between January 1999 and March 2010,1796 lobectomies were performed and 360 (23%) of these were left upper lobectomies. Of these, 84 (23%) required the inflow-outflow occlusion technique. There were 70 (83%) men (median age 65 years). Fifty-one patients (61%) required resection of the PA and 33 did not. Heparin was not used in the last 17 patients. These 84 patients were compared to the remaining 276 patients who underwent standard left upper lobectomy. Although the median operative time was longer (150 vs 105 min, p < 0.001) and the median blood loss was greater (120 vs 87 ml, p = 0.03) for the inflow-outflow technique, there were no significant differences in hospital length of stay, morbidity, or mortality between the two groups.

CONCLUSION

In our experience, clamping of the inferior pulmonary vein instead of the distal PA achieves safe distal vascular control. It affords greater PA mobility and assessment of the tumor and easier PA repair. This technique can be used even when PA resection is not required.

Experience with the autologous pulmonary vein for pulmonary arterioplasty

OBJECTIVE

Lobectomy with pulmonary artery resection and reconstruction is seldom performed in order to avoid pneumonectomy in selected cases. The aim of this study is to determine how safe and effective the graft reconstruction of the pulmonary artery is, using autologous tissue taken from the pulmonary vein.

METHODS

Eight patients with diagnosed non-small-cell lung cancer were treated by lobectomy with pulmonary artery reconstruction with curative intent. All patients could have tolerated pneumonectomy. Patch or conduit angioplasty was performed by using a tailored graft, harvested from the autologous pulmonary vein of the resected lobe. Patients were followed up and the clinical records were analyzed retrospectively. Long-term patency of the reconstructed pulmonary artery was investigated by computed tomographic pulmonary angiogram.

RESULTS

No procedure-related complications and no perioperative mortality were observed. No blood transfusion was required. Follow-up varied from 10 to 64 months. No local recurrences were found next to the angioplasty. Ideal long-term patency of the pulmonary artery was demonstrated in all cases. Two patients are alive with evidence of extrathoracic metastatic disease and four patients are apparently healthy. Two patients died of progressive disease.

CONCLUSIONS

The use of pulmonary vein tissue as a graft to repair the pulmonary artery is feasible, reproducible, and seems to be oncologically correct. Pulmonary vein tissue can be easily harvested during surgery and offers a high-quality vascular tissue for pulmonary angioplasty.

Long-term patency of the stapled bovine pericardial conduit for replacement of the superior vena cava

OBJECTIVE

Artificial prosthesis of the superior vena cava (SVC) may occlude with time. For this reason, we proposed in 2003 the use of a biological material (bovine pericardium) and devised an original technique to construct the prosthetic conduit. We hereby report the long-term results in 15 patients.

METHODS

The SVC prosthetic conduit is realized by wrapping a bovine pericardial leaflet around a 5 or 10 cm(3) syringe and stapling it on the side by a 60-80 linear stapler. This procedure is carried out intra-operatively after the size of the patient's SVC has been ascertained; the conduit is then cut to the appropriate length. We have employed this technique in 15 patients with lung (eight) or mediastinal (seven) tumors; after a minimum follow-up of 1 year, all patients underwent computed tomographic-volume rendering (CT-VR) studies of the SVC.

RESULTS

Technically, the stapled pericardial conduit has several advantages: (1) it is simple and expeditious; (2) it allows an even and regular suture line, which cannot be achieved by hand suturing; (3)'one size fits all': with one single pericardial leaflet, conduits of all sizes can be realized; this is important for an operation which is performed only few times per year; (4) patency is granted by the intrinsic rigidity of the pericardium and staple line, without the need for any reinforcement; (5) different calibers at the two extremities can be obtained by simply placing the stapler obliquely; and (6) the staple line is excellent for the orientation of the conduit while suturing. In our patients, SVC clamping time ranged between 18 and 50 min (mean 29 min); one patient needed cardiopulmonary bypass. Intra-operative anticoagulation (1.500-2.500 units of heparin) was continued postoperatively subcutaneously for 7 days and then shifted to oral anticoagulation for 6 months. One patient died postoperatively of heart failure (mortality 6%). One to 5 years after surgery, CT-VR showed full patency of the pericardial conduit, no clots or thrombus formation, and absence of collateral venous circulation in all 14 patients. One- and 5-year survival was 93% and 73%, respectively (Kaplan-Meier).

CONCLUSIONS

The stapled bovine pericardial conduit is a simple, expeditious, and economic solution to SVC replacement, and offers reliable long-term patency without permanent anticoagulation.

Sleeve resections for squamous cell carcinoma of the lung

BACKGROUND

Sleeve resection is an advanced technique that was developed as an alternative to pneumonectomy. This study evaluated our cases of sleeve resection for squamous cell carcinoma of the lung and compared the outcomes with the literature reports.

METHODS

In total, 26 bronchial, 5 bronchovascular, and 3 vascular sleeve lobectomies were performed between January 2000 and July 2005 in our clinic. Age, gender, operations, postoperative diagnosis and staging, and postoperative morbidity and mortality were evaluated.

RESULTS

Sleeve resections were performed in 34 patients. All patients were male, with a mean age of 59.4 years. The operations consisted of 16 right upper, 14 left upper, and 1 left lower sleeve lobectomies and 3 superior sleeve bilobectomies. The most common postoperative pathological staging group was stage IIb (32.3%). Operative mortality was 5.9% (n=2). Postoperative morbidity was 20.5% (n=7), including 4 prolonged air leaks plus empyema, 1 prolonged air leak, 1 postoperative bleeding needing revision, and 1 severe bronchostenosis; of these, 6 had persistent atelectasis. The local tumour recurrence rate was 11.7% (n=4). The median survival time and 5-year survival were 36 months and 42%, respectively.

CONCLUSIONS

Sleeve resection proved to be good therapy for lung cancer and has a lower morbidity and mortality than standard pneumonectomies and results in better lung function and quality of life. The anastomosis-related complications are experience-related technical complications and training thoracic surgeons to perform SRs at experienced centres will reduce the morbidity associated with SRs.

Lung parenchymal sparing using cryopreserved allografts for pulmonary artery reconstruction

This chapter details the indications, technique, and pitfalls of double sleeve resection with pulmonary artery (PA) replacement by a cryopreserved allograft. Both bronchial and vascular anastomoses are explained and intraoperative and postoperative allograft management are described, along with the pros and cons of each possible conduit for PA replacement.