Completion Pneumonectomy After Bronchial Sleeve Resection: Incidence, Indications, and Results Paul E. Van Schil, MD, Aart Brute1 de la Rivi&e, MD, Paul J. Knaepen, MD, Henry A. van Swieten, MD, Jo J. Defauw, MD, and Jules M. van den Bosch, MD Departments of Thoracic Surgery and Pulmonary Medicine, Antoniushospital, Nieuwegein, the Netherlands

During the years 1960 through 1989,145 patients under- went sleeve lobectomy or sleeve resection of a main bronchus. Completion pneumonectomy was performed in 19 patients (13.1%). Indications were bronchostenosis without malignancy in 10 patients, positive resection margins in 3, recurrent tumor in 5, and anastomotic dehiscence in 1. Mean age at sleeve operation was 59.3 years. In 18 patients the histology was squamous cell carcinoma and in 1 patient, carcinoid tumor. The mean

leeve resection has proved to be an adequate operation S for lung cancer and is an alternative to pneumonec- tomy in select patients with bronchogenic carcinoma [l]. It is a valuable method to preserve functional lung tissue, and patients in whom a second primary cancer develops may benefit from a second resection.

Contrary to standard resectional procedures, an end-to- end bronchial anastomosis is performed in full sleeve resections. This may cause anastomotic complications that eventually necessitate completion pneumonectomy [2], the incidence of which has been infrequently reported. The incidence and indications for completion pneumonec- tomy were studied in a series of 145 patients who under- went full bronchial sleeve resection. Mean follow-up after sleeve resection was 47.9 months (maximum follow-up, 223 months). The results and long-term survival accord- ing to the specific indication are discussed.

Material and Methods During the years 1960 through 1989, 145 patients under- went full bronchial sleeve lobectomy or sleeve resection of a main bronchus, which represents our total experience with bronchial sleeve resection. Follow-up was complete except for 1 patient, who was lost to follow-up 4 years after operation. Morbidity, mortality, and long-term sur- vival after sleeve resection were reported previously [3].

In total, 19 patients (13.1%), all men, underwent com- pletion pneumonectomy. A benign bronchostenosis was found as a late postoperative complication after sleeve resection in 13 patients (8.9%). In 3 of them, broncho- scopic dilation was successful; in 10, completion pneu- monectomy was eventually performed. Three patients

Accepted for publication Nov 27, 1991.

Address reprint requests to Dr Van Schil, Gerard Van Laethemlaan 3, 8-2650 Edegem, Belgium.

interval between sleeve resection and completion pneu- monectomy was 5.7 months (range, 3 to 16 months) for the patients with stenosis and 6.6 months (range, 1 to 17 months) for the others. There were 3 operative deaths (15.8%). The mean follow-up was 53.2 months. Five-year and 10-year survival rates after completion pneumonec- tomy for the patients with stenosis were 54% and 41%, respectively, and for the others, 52% and 52%.

(Ann Thorac Surg 1992;53:1042-5)

had positive resection margins at definitive pathological examination and underwent completion pneumonectomy within several weeks after the original sleeve resection; all were operated on before 1980. Five patients had recurrent tumor (Table 1): 4 had negative resection margins and 1, carcinoma in situ at the initial operation (patient 5). One patient had anastomotic dehiscence and underwent com- pletion pneumonectomy 6 days after sleeve right upper lobectomy. During the original operation, purulent secre- tions were noted in the reimplanted middle and lower lobes.

Mean age at sleeve operation was 59.3 f 9.3 years (range, 27 to 71 years). Sixteen patients initially had a sleeve resection of the right upper lobe; 1 patient, a sleeve lobectomy of the right upper and middle lobes; and 2 patients, a left upper sleeve lobectomy. The histology was squamous cell carcinoma in 18 patients and carcinoid tumor in 1 patient. The mean interval between sleeve operation and completion pneumonectomy was 5.7 months (range, 3 to 16 months) for the patients with bronchostenosis and 6.6 months (range, 1 to 17 months) for the others.

Follow-up data were obtained from a questionnaire sent to the referring pulmonary physicians or from the records of the patients followed up in our institution.

Actuarial survival curves were calculated according to the Kaplan-Meier method. Difference in survival was assessed by the Tarone-Ware test using BMDP statistical software (Los Angeles, CA, 1990). Comparison between qualitative data was made with the x2 test (with Yates’ continuity correction when necessary).

Results The main indication for completion pneumonectomy was stenosis of the bronchial anastomosis without recurrent tumor in 10 patients. In 4 of them, polypropylene

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Ann Thorac Surg 1992;53 1042-5

VAN SCHIL ET AL 1043 COMPLETION FNEUMONECTOMY

Table 1. Characteristics of Patients With Recurrent Tumor ~~ ~ ~~

Initial Tumor Patient No. TNM Stage Histology

Recurrent Tumor Interval (mo) TNM Stage

1 T2 N1 MO I1 Squamous 2 T4 N1 MO IIIb

2 T2 NO MO I Squamous 12 T3 NO MO IIIa

3 T2 N1 MO I1 Squamous 17 T3 NO MO IIIa

cell carcinoma

cell carcinoma

cell carcinoma

cell carcinoma

cell carcinoma

4 T2 N1 MO I1 Squamous 8 T2 NO MO I

5a T2 NO MO I Squamous 15 T3 NO MO IIIa

a In this patient, carcinoma in situ was found at the resection margin during sleeve operation.

(Prolene) or Teflon-coated polyester (Tevdek) had been used as the suture material, and a continuous suture, interrupted and knotted at three places 120 degrees apart, had been performed. In the 6 other patients, interrupted polyglactin (Vicryl) sutures had been used for the carti- laginous part of the anastomosis and continuous polypro- pylene (Prolene) for the membranous part.

In total, continuous polypropylene or Teflon-coated polyester sutures had been used in 28 patients, seen mainly before 1980. In this group, the incidence of com- pletion pneumonectomy for bronchostenosis was 14.3% (4/28). In 105 sleeve resections, interrupted polyglactin sutures had been used, and the incidence of completion pneumonectomy for bronchostenosis was 5.7% (6/105). However, this difference was not significant (p > 0.25).

The operative mortality rate for completion pneu- monectomy was 15.8% (3 patients). Two patients died of cardiac-related causes (myocardial infarction and ventric- ular fibrillation) and 1 of a fistula of the bronchial stump 4 days after completion pneumonectomy. The major post- operative complication was a bronchopleural fistula in 1 patient. It was treated by fenestration and secondary closure with omental transposition. This patient is doing well 9 months after completion pneumonectomy.

All survival and follow-up data include operative mor- tality. The mean follow-up after completion pneumonec- tomy for the 19 patients was 53.2 months. Maximum follow-up was 221 months. Six patients died during follow-up. The mean interval between completion pneu- monectomy and death was 39.8 months (range, 3 to 105 months). Causes of late death were local recurrence in 1 patient, distant metastases in 2 patients, cardiac-related cause in 1, respiratory insufficiency in 1, and unknown in 1 patient.

Ten patients are alive without signs of local recurrence or metastases after a mean follow-up of 77.1 months (range, 2 to 221 months). Five-year and 10-year survival rates after completion pneumonectomy for the 19 patients were 0.47 k 0.14 and 0.38 2 0.14, respectively (Fig 1). For the 10 patients undergoing completion pneumonectomy because of bronchostenosis, 5-year and 10-year survival rates were 0.54 k 0.14 and 0.41 ? 0.17, respectively, and

for the 9 others, 0.52 ? 0.18 and 0.52 ? 0.18 (Fig 2). The difference in survival between these two groups was not significant ( p = 0.24).

Comment In recent years, bronchial sleeve resection has proved to be an adequate operation for lung cancer and is an alternative to pneumonectomy for select types of bron- chogenic carcinoma, mostly centrally located squamous cell carcinoma [l]. Functional lung tissue is preserved, and this not only improves the quality of life [4] but may allow a subsequent resection in patients with develop- ment of a second primary lung cancer, the incidence of which has increased in recent years [5].

However, in sleeve or wedge resections, a full or partial bronchial anastomosis is created. This can cause addi- tional complications not encountered in standard resec- tional procedures [2]. In the so-called full sleeve resection, a portion of the main bronchus is removed with an end-to-end anastomosis of the remaining bronchial stump in the main bronchus. In this procedure, the bronchial arteries are usually completely interrupted, which can result in poor healing of the anastomosis.

survival rate 1

---- ---_ 0.3 - 0.2 - 0.1 1

O L I o 24 4a 72 96 120 144 168 192 216

months

Fig I . Actuarial survival curve with standard deviation (broken lines) for the 19 patients who underwent completion pneumonectomy.

1044 VAN SCHIL ET AL COMPLETION PNEUMONECTOMY

Ann Thorac Surg 1992;531042-5

survival rate 11 I

bronchoatsnoaia ---- other -

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4 -

In a canine experimental model (61 of lung reimplanta- tion with complete interruption of the bronchial arteries, a network of many fine arterial channels across the anasto- mosis could be demonstrated by selective bronchial arte- riography within 3 weeks of reimplantation. Reestablish- ment of distal bronchial arterial flow occurred within 4 weeks of bronchial artery division.

Whether it is necessary to cover the bronchial anasto- mosis with some viable tissue to reduce ischemic compli- cations after sleeve resection remains controversial [7]. In dogs, a pedicled pleural wrap did not significantly im- prove bronchial circulation [8].

As most sleeve resections are performed for centrally located bronchial tumors, residual malignant cells at the suture line can give rise to early recurrence. This under- scores the necessity for careful frozen-section examination of the bronchial marnins before the anastomosis is made 171.

These anastomotic complications after sleeve resection can eventually necessitate completion pneumonectomy, the incidence of which has been infrequently reported. In a series of 43 patients who underwent sleeve resection for different types of bronchial tumors, Huidekoper and van Ginneken [9] mentioned 2 patients with late complica- tions, one of which was a bronchial stenosis requiring completion pneumonectomy. Faber and colleagues [I, 101 described their experience with 118 sleeve lobectomies. Completion pneumonectomy was performed in 8 patients (6.8%) without operative mortality. Indications were mainly anastomotic complications, ie, stenosis and dehis- cence, in 6 patients, 4 of whom had received preoperative radiotherapy. The indication for completion pneumonec- tomy was residual tumor at the resection margin in 1 patient and recurrent tumor 16 months after sleeve lobec- tomy in another.

Watanabe and associates [4] presented a series of 76 bronchoplastic procedures for bronchogenic carcinoma without carinal involvement. One patient required com- pletion pneumonectomy because of thrombosis of the pulmonary artery after sleeve left upper lobectomy with sleeve resection of the pulmonary artery, a so-called double-sleeve resection.

In our series of 145 patients who underwent full bron- chial sleeve resection, completion pneumonectomy was necessary in 19 (13.1%), none of whom had received preoperative radiotherapy. The main indications were benign bronchostenosis and locally recurrent tumor. Five- year and 10-year survival rates after completion pneu- monectomy were 0.47 and 0.38 with no difference in survival according to the specific indication for comple- tion pneumonectomy. The mean interval between sleeve resection and completion pneumonectomy was relatively short, 5.7 months for the patients with stenosis and 6.6 months for the others.

Regarding suture material for the bronchial anastomo- sis, absorbable suture was found to be superior to nonab- sorbable suture in growing puppies [ll]. Absorbable sutures are also mainly used in humans [4, 7, 121. In our series, the incidence of bronchial stenosis necessitating completion pneumonectomy was 14.3% when nonabsorb- able polypropylene or Teflon-coated polyester was used as the suture material versus 5.7% when absorbable polyglactin was used. However, this difference was not significant.

After sleeve resection, repeat bronchoscopy is neces- sary to aspirate secretions, remove granulation tissue, and take biopsy specimens from the region of the anastomosis when suspicious tissue is found. In the case of stenosis of the bronchial anastomosis without recurrent tumor, bron- choscopic dilation is attempted. If this is not successful and persistent problems of atelectasis, infection, or sup- puration of the remaining lobe or lobes exist, a completion pneumonectomy is eventually performed.

In a recent report [13], 113 patients underwent comple- tion pneumonectomy after various operations, but none had an initial sleeve resection. The overall operative mortality rate was 12.4%. Patients were divided into three groups according to the specific indication for completion pneumonectomy. In 64 patients, the indication was lung cancer. The operative mortality rate in this group was 9.4% with a 5-year survival rate of 26.4%. The indication was pulmonary metastases in 20 patients. They under- went reoperation with no operative mortality and a 5-year survival rate of 40.8%. In 29 patients, the indication was a benign condition, including bronchial stenosis in 3. In this group, the operative mortality rate was 27.6%, and 55.2% had major complications related to an extensive inflam- matory process found during operation; the 5-year sur- vival rate was 27.2%.

In our series of 19 patients, the overall operative mor- tality rate was 15.8%. In 10 patients (52.6%), the indica- tion for completion pneumonectomy was benign bron- chostenosis. In this group, 1 patient died postoperatively of cardiac arrhythmia and ventricular fibrillation, giving an operative mortality rate of 10% for benign conditions.

Deslauriers [14] pointed out that completion pneu- monectomy is a technically difficult procedure that must be done by an experienced surgeon. The intrapleural plane should be followed as closely as possible during dissection. When the intrapericardial cavity has not been obliterated by previous radiotherapy or inflammation, intrapericardial vascular control is often helpful. Rein-

Ann Thorac Surg 1992;53:1042-5

VAN SCHIL ET AL 1045 COMPLETION PNEUMONECTOMY

forcement of the bronchial stump with viable tissue should be attempted to minimize postoperative stump complications.

In conclusion, in our series of 145 patients who under- went sleeve resection, completion pneumonectomy was necessary in 19 (13.1%). Frozen-section examination of the bronchial resection margins during sleeve operation is mandatory to obtain adequate tumor clearance. After sleeve resection, regular bronchoscopic control is neces- sary to detect early recurrent tumor or anastomotic com- plications and to treat them accordingly.

We thank Mrs R. Ruelle for typing the manuscript and Mrs M. Elseviers for statistical processing of the data.

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