JTCS Click here to go to SJM website.
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Shinichiro Miyoshi
Noriyoshi Sawabata
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Miyoshi, S.
Right arrow Articles by Sawabata, N.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Miyoshi, S.
Right arrow Articles by Sawabata, N.
Related Collections
Right arrow Trachea and bronchi

J Thorac Cardiovasc Surg 2006;132:978-980
© 2006 The American Association for Thoracic Surgery

Brief Communication

Telescoping bronchial anastomosis for extended sleeve lobectomy

Shinichiro Miyoshi, MD, PhD*, Motohiko Tamura, MD, PhD, Osamu Araki, MD, Naoko Yoshii, MD, PhD, Yoko Karube, MD, PhD, Norio Seki, MD, Hideo Umezu, MD, Satoru Kobayashi, MD, PhD, Hiromi Ishihama, MD, Sensuke Nagai, MD, PhD, Noriyoshi Sawabata, MD, PhD

Department of Cardiothoracic Surgery, Dokkyo University School of Medicine, Tochigi, Japan.

Received for publication April 27, 2006; revisions received May 1, 2006; accepted for publication May 17, 2006.

* Address for reprints: Shinichiro Miyoshi, MD, PhD, Department of Cardiothoracic Surgery, Dokkyo University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan. (Email: miyoshi{at}dokkyomed.ac.jp).


Figure 1
Dr Miyoshi


An extended sleeve lobectomy is rarely attempted to avoid a pneumonectomy for patients with primary lung cancer.1Go This atypical bronchoplasty procedure is technically demanding because there is a large size discrepancy between the 2 bronchial stumps. Herein we report successful implementation of an extended sleeve lobectomy with a telescoping anastomosis.

Clinical Summary

A 76-year-old man was referred to our hospital for additional investigation of an abnormal shadow on chest roentgenographic images obtained during a screening examination. A computed tomographic scan demonstrated a large mass shadow, 4 x 5 cm in size, that originated in the posterior segment of the right upper lobe (S2; Figure 1, A and B). Flexible fiberoptic bronchoscopy revealed a tumor that had completely occluded the posterior segmental bronchus of the right upper lobe (B2). A biopsy specimen was diagnosed as squamous cell carcinoma of the lung. Magnetic resonance imaging of the brain, computed tomographic scanning of the abdomen, and a bone scintigram demonstrated no evidence of distant metastases. Thus his clinical stage was classified as T2 N0 M0, stage IB disease.


Figure 1
View larger version (53K):
[in this window]
[in a new window]

  		Figure 1. Appearance of tumor on computed tomographic scan and operative findings. A and B, Computed tomographic images show a large mass shadow, 4 x 5 cm in size, in the posterior segment of the upper lobe (S2) extending down to the lower lobe. C, A tumor originating in S2 is shown invading the outer wall of the intermediate bronchus. D, A recurrent branch of the pulmonary artery to the posterior segment of the upper lobe (A2b) and a branch of the pulmonary artery to the superior segment of the lower lobe (A6) show tumor invasion. Heavy solid lines in C and D demonstrate divided sites. ULB, Upper lobe bronchus; MLB, middle lobe bronchus; B6, superior segmental bronchus of the lower lobe; BB, basal bronchus of the lower lobe; LAPA, large anterior pulmonary arterial branch of the upper lobe; A2b, recurrent pulmonary arterial branch to the posterior segment of the upper lobe; A6, pulmonary arterial branch to the superior segment of the lower lobe; A3, pulmonary arterial branch to the anterior segment of the upper lobe; MLPA, middle lobe pulmonary artery; BPA, basal segmental pulmonary arterial branch.

 
The chest was opened through the fifth intercostal space with a posterolateral thoracotomy after achievement of general anesthesia by using a double-lumen endotracheal tube. The tumor originating in S2 had invaded the outer wall of the intermediate bronchus (Figure 1, C). A recurrent branch of the pulmonary artery to the posterior segment of the upper lobe (A2b) and a branch of the pulmonary artery to the superior segment of the lower lobe (A6) were not isolated because of tumor invasion (Figure 1, D). The pulmonary artery branches of the upper lobe and middle lobe, except for A2b, as well as the superior pulmonary vein, were double ligated and divided. After administration of heparin, the main and basal pulmonary arteries were clamped and divided at the inner side of each clamp. The tumor was extirpated with division of the main and basal bronchi and a segmentectomy of S6.

There was a large size discrepancy between the bronchial stumps, and thus 2 adjusting stitches were placed in the membranous part of the main bronchial stump and tied as shown in Figure 2, A and B. A telescoping bronchial anastomosis was then performed with interrupted sutures2Go by using 4-0 monofilament absorbable materials. The cartilage sutures were tied so that the basal bronchus was inserted into the main bronchus at a depth equal to the circumference of the cartilage. A pericardial incision was performed around the inferior pulmonary vein to decrease tension on the bronchial anastomosis. A pulmonary artery anastomosis was also performed, after placing an adjusting running suture onto the proximal stump. The anastomoses of the bronchus and pulmonary artery were completed as shown in Figure 2, C. Finally, the pericardial fat pad was inserted between the bronchial and pulmonary artery anastomoses.


Figure 2
View larger version (73K):
[in this window]
[in a new window]

  		Figure 2. Appearance of bronchial anastomosis. A and B, Two stitches were used in the membranous part of the main bronchial stump, and then a telescoping bronchial anastomosis was performed with interrupted sutures. C, Completed anastomoses of the bronchus and pulmonary artery are shown. D, Flexible fiberoptic bronchoscopic image shows the anastomotic site 10 months after the operation.

 
The postoperative course was uneventful. Flexible fiberoptic bronchoscopy was performed 10 months after the operation, which showed no stenosis at the anastomotic site (Figure 2, D). The patient was doing well without recurrence 3 years and 7 months after the operation.

Discussion

Recently, Okada and colleagues1Go reported the results of extended sleeve lobectomy procedures for 15 patients who were classified into 3 groups on the basis of the mode of reconstruction: group A, anastomosis between the right main and lower bronchi or basal segmental bronchi with resection of the upper and middle lobes or those and S6; group B, anastomosis between the left main and basal segmental bronchi with resection of the upper lobe and S6; and group C, anastomosis between the left main and upper division bronchi with resection of the lingular segment and lower lobe.

There are 3 techniques used for size matching between the proximal and distal bronchial stumps. One is to use 2 adjusting stitches in the membranous part of the larger stump.1Go The second technique is to make a cuff on the smaller stump by trimming the carina. We have applied the second technique to patients in group C according to the above classification. The third technique is a telescoping anastomosis. Our experience has shown that the largest difference in size between the 2 bronchial stumps occurs in patients classified as group A, as in the present case, probably because the diameter of the right main bronchus is generally larger than that of the left main bronchus. The distal stump is also quite thin and frail. Despite these disadvantages for a bronchial anastomosis with an extended sleeve lobectomy, a telescoping-type anastomosis might reduce anastomosis-related complications. This technique is also useful for single-lung transplantation3Go or bronchoplasty procedures in patients with lung cancer after induction therapy2Go for the same purpose.

References

  1. Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Matsuoka H, Satake S, et al. Extended sleeve lobectomy for lung cancer: the avoidance of pneumonectomy. J Thorac Cardiovasc Surg 1999;118:710-714.[Abstract/Free Full Text]
  2. Ohta M, Sawabata N, Maeda H, Matsuda H. Efficacy and safety of tracheobronchoplasty after induction therapy for locally advanced lung cancer. J Thorac Cardiovasc Surg 2003;125:96-100.[Abstract/Free Full Text]
  3. Calhoon JH, Grover FL, Gibbons WJ, Bryan CL, Levine SM, Bailey SR, et al. Single lung transplantation: alternative indications and technique. J Thorac Cardiovasc Surg 1991;101:816-825.[Abstract]



This article has been cited by other articles:


Home page
 Asian Cardiovasc. Thorac. Ann.Home page
H. Tanaka, M. Ohta, A. Matsumura, N. Ikeda, N. Kitahara, and K. Iuchi
Carinoplasty With Telescope Anastomosis for Tuberculous Bronchial Stenosis
Asian Cardiovasc Thorac Ann, June 1, 2009; 17(3): 307 - 309.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. Chida, M. Minowa, S. Miyoshi, and T. Kondo
Extended sleeve lobectomy for locally advanced lung cancer.
Ann. Thorac. Surg., March 1, 2009; 87(3): 900 - 905.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Shinichiro Miyoshi
Noriyoshi Sawabata
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Miyoshi, S.
Right arrow Articles by Sawabata, N.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Miyoshi, S.
Right arrow Articles by Sawabata, N.
Related Collections
Right arrow Trachea and bronchi

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS