Sleeve Lobectomy vs. Pneumonectomy
The sleeve lobectomy has significant advantages compared to pneumonectomy
- Reduction of mortality and improvement of quality of life (1)
- Preservation of functional lung parenchyma (2)
- In case of a second malignancy in the course (e.g., on the opposite side), there is the possibility of a renewed anatomical resection (3)
The most common sleeve resection is the upper sleeve resection on the right. Performing a pneumonectomy is increasingly less justified in the context of sleeve resection, as sleeve resection shows significantly better quality of life and lower morbidity and mortality with equivalent oncological results. Therefore, in the current guideline, sleeve resection was recommended not only for patients with limited lung function but for all patients where technically feasible instead of the otherwise necessary pneumonectomy. A ratio of pneumonectomy to sleeve resections lower than 1:1.5 can serve as a quality benchmark for indication. (2)
Anastomotic Healing
Anastomotic healing is inherently at risk due to the preceding lymphadenectomy with devascularized bronchus. Predisposing factors such as diabetes mellitus, nicotine, preoperative chemo- or radiotherapy further increase the risk.
Suture Material: All suture techniques described in the literature (1 to 3 continuous sutures, single button sutures) can be safely applied without significant differences. However, the suture material should always be a monofilament, absorbable material, such as Maxon, PDS, or Biosyn. (4)
Lumen Incongruence: The problem of incongruent lumina of the bronchial stumps to be anastomosed can usually be solved by adjusting the stitch distances. Alternatively, the smaller bronchus can be cut obliquely for a larger suture surface or the larger bronchus can be pleated at the membranous part. (5)
Tension-Free: To achieve a tension-free anastomosis, the recommended mobilization of the lung by preparation at the pulmonary ligament should be performed. Additionally, a U-shaped incision of the pericardium below the lower pulmonary vein (pericardial release) or mobilization of the main bronchi while preserving the vascular supply can be helpful.
Blood Supply of the Bronchial Anastomosis and Coverage with Pedicled Flap
After transection, the distal bronchus loses its antegrade blood supply and lymphatic drainage. In the short term, a shunt formation with retrograde blood flow between the pulmonary and systemic arteries can occur. After about 2 weeks, the blood supply is restored. In pneumonectomy, devascularization plays an even greater role, as there is complete blood loss, and thus the rates of healing disorders of the bronchial stump after pneumonectomy are higher than those of the anastomoses.
The most common cause of anastomotic insufficiency is reduced blood supply. The secondary vascularization described above can be accelerated by contact with vital tissue, which also minimizes the formation of a stenosis. (6) Options include pedicled flaps of the serratus anterior muscle, intercostal musculature, pericardial fat tissue, or thymic fat pad.
Despite better blood supply, the benefit in terms of a lower insufficiency rate through such coverage is not clearly proven. (7)