Overview of Pulmonary Sleeve Resection
Pneumonectomy is a surgery that removes an entire half of a person’s lung, typically performed to remove lung tumors. However, this can increase the risk of serious illness and even death. The act of removing parts of the lung is known as pulmonary resection and it comes in different methods depending on how much of the lung needs to be removed.
Pulmonary Sleeve Resection (PSR) is a specific type of surgery involving the removal of a section of the bronchus (airways to your lungs) and/or pulmonary vessels (blood vessels in your lungs), while leaving the unscathed parts of the lung intact. This surgery will often involve bronchoplasty or vascular reconstructions. These are medical terms for the methods used to rejoin the separated pieces of bronchus or blood vessels. The main reason for this surgery is to treat lung neoplasm, which is a growth or tumor in the lung.
When only one lobe of the lung is involved in the surgery, it’s often labelled as “sleeve lobectomy” (SL). Some doctors also use the term “extended” when describing a sleeve resection that involves removing more than one lobe of the lung.
PSR was first carried out to remove a harmless mass from the lung around the late 1940s. The goal was to preserve as much lung function as possible. By the 1950s, it was established that PSR could also be used to treat lung cancer. The 1980s saw an increase in the use of SL as a method to treat less aggressive types of lung cancer.
The benefits of SL in terms of cancer control and preserving lung function are frequently researched, mainly in patients with non-small cell lung cancer, a type of lung cancer that starts in the cells lining the lungs. Analysis of several studies has shown that people with early-stage locally advanced lung cancer, who have undergone PSR, have better survival rates and quality of life than those who have undergone the traditional pneumonectomy. Now, thanks to improvements in lung-sparing surgeries and better care before, during, and after surgery, PSR techniques are now the favored approach for many forms of lung cancer, even in those with healthy lungs before surgery.
Improvements in specific types of surgery, such as video-assisted thoracic surgery (VATS) and robotic surgery, have made complex lung resections like SL possible through minimally invasive methods. Minimally invasive means that smaller cuts are used, which can lead to less pain and faster healing time. While more doctors are using minimally invasive techniques, not all hospitals have the necessary expertise for these methods. This is particularly true for PSR, which is a complex procedure.
However, when compared to pneumonectomy, PSR has been associated with longer survival, better quality of life, better lung function, and lower mortality rates. Although initially it was performed on those patients who could not tolerate pneumonectomy, PSR is now the preferred approach when the growths are positioned in a way that makes this type of surgery possible.
Anatomy and Physiology of Pulmonary Sleeve Resection
The bronchial tree and pulmonary vasculature, which are the airways and blood vessels in our lungs, have a particular arrangement that’s important for performing lung surgeries. The right lung has three sections, called lobes, while the left lung has two. On the right side, the airway first branches into the right upper lobe, before branching into two other lobes – the right middle and the right lower lobe. On the left side, the airway splits into an upper and a lower lobe.
A type of lung surgery, known as a pulmonary sleeve resection, is often performed in the right upper lobe. This is because it has an advantage of having a longer branch for reconstruction after surgery. However, it can also occasionally be performed in the left upper or left lower lobe.
In a standard pulmonary sleeve resection, a portion of one lobe and a part of the airway (or bronchus) are removed. The cut ends of the airway are then joined back together. If more than one lobe is removed, it’s known as an extended sleeve resection. Contrastingly, a pneumonectomy is a surgery where one entire lung is removed, without reconstructing the airway. Another type of surgery combines removing sections (segmentectomy) and whole lobes (lobectomy) of the lung.
Depending on the surgery, additional procedures on the arteries or veins may be required. Sometimes, surgeons may refer to a “double sleeve” surgery. This is a surgery where both the blood vessels and airways of the lung are operated on.
Why do People Need Pulmonary Sleeve Resection
If a patient has an advanced stage of lung cancer, the cancerous growth or lesion might stretch into a part of the main windpipe, or bronchus. When this part of the bronchus is surgically removed, it’s essential to leave enough healthy bronchus tissue to maintain lung function on the affected side. A specific surgical procedure called pulmonary sleeve resection (PSR) is useful for treating central tumors, whether they’re benign (noncancerous) or low-grade (slow-growing).
The way that doctors classify lung cancer has changed over time. The most recent system was published in 2017 by the American Joint Committee on Cancer (AJCC) and Union Internationale Contre le Cancer (UICC). It’s known as the TNM classification and it ranks lung tumors based on their location (T for tumor), whether they have spread to nearby lymph nodes (N for node), and if they have metastasized or spread to other parts of the body (M for metastasis).
PSR is generally considered for patients with Stage I to IIb lung cancer and those who have either no lymph node involvement (N0) or only hilar (near the windpipe) nodal disease (N1). As treatments improve, we’re finding that certain patients with very small amounts of cancer spread to a single lymph node station (N2), might also benefit from PSR. Importantly, they would first need to respond well to initial treatment to decrease the size and extent of their cancer.
PSR can treat various types of lung diseases such as carcinoid tumors and non-small-cell lung cancer (NSCLC), which is a category of lung cancers that grow and spread slower than others. Other types that might also be suitable for PSR include squamous cell carcinoma, myofibroblastic tumor, adenoma, metastatic sarcoma, or granular cell tumors.
When a Person Should Avoid Pulmonary Sleeve Resection
Generally, for people with lung cancer that has spread to a late stage, surgery may not be an option. According to the latest guidelines by the American Joint Committee on Cancer (AJCC), lung cancers that have spread to the lymph nodes in the chest or to other parts of the chest itself, can’t be treated with surgery. Also, if the cancer has spread to other parts of the body (M1) or to the lymph nodes on the opposite side of the chest (N3), surgery isn’t typically recommended.
When doctors plan surgery for lung cancer, they might consider two major types of surgery: pulmonary sleeve resection (PSR) or pneumonectomy. PSR is a procedure to remove the part of the lung carrying the tumor, whereas pneumonectomy involves the removal of the entire lung. For a person to undergo PSR, it has to ensure that the whole tumor can be removed (R0). If there’s any tumor left after the surgery, the patient runs a higher risk of the cancer returning.
Next, the person’s overall health must be favorable for surgery. For instance, if they are living with heart disease or if tests show that their lungs are not functioning optimally, the doctor might decide that a major lung surgery may not be suitable. In that case, the surgery might be discouraged.
Equipment used for Pulmonary Sleeve Resection
The Pulmonary Sleeve Resection (PSR), which is a type of lung surgery, requires specific equipment and resources. This includes:
– An Operating Room: This is a clean, controlled environment where the surgery is performed.
– Flexible Bronchoscope: This is a medical device used to view the patient’s airways and lungs.
– Sterile Drapes, Gowns, and Supplies: These are used to maintain cleanliness and prevent infection during surgery.
– Thoracic/Rib Retractor: A tool used to hold the ribs apart and provide better access to the lungs.
– Surgical Knives and Clamps: These tools are used to cut and secure tissues during surgery.
– Absorbable and Non-absorbable Sutures: These are threads used to close wounds or surgical incisions. Absorbable sutures dissolve over time, whereas non-absorbable ones don’t and may need to be removed later.
– Surgical Staplers: They are specialized tools used to close skin wounds or to connect or remove parts of the organs such as the lungs.
– Chest Tubes/Drains: These are tubes inserted into the chest to drain fluids or air and facilitate healing after the surgery.
All these resources should be readily available in the operating room for a thoracic surgery (surgery involving the chest), along with trained medical staff.
Who is needed to perform Pulmonary Sleeve Resection?
To carry out a specific type of lung surgery known as pulmonary sleeve resection (PSR), several highly skilled professionals are required. This includes a special type of doctor known as a thoracic surgeon who is trained in chest-related surgeries. An anesthesiologist, a doctor who gives medicines to make you sleep during surgery, is also needed, and they should have experience working with chest surgeries. There are also some other crucial helpers in the surgery room, such as an assistant to the surgeon and a surgical technician, who have special training in assisting with operations. A surgical nurse is also required, who looks after the patient during and after the surgery.
After the surgery, it is ideally recommended for the patient to be transferred to a specific area in the hospital called a specialized intensive care unit. Here, doctors who specialize in care after serious surgeries (intensivists) and nurses will closely monitor and take care of the patient. These experts are particularly familiar with the special care needed by patients who have just had chest surgery.
Preparing for Pulmonary Sleeve Resection
Before undergoing certain surgeries, doctors need to look at the patient’s health in detail. This aims to make sure that the patient is fit enough for the operation. This includes a general health check (physical examination), lung function tests (pulmonary function testing), checking the airways and lungs with a small camera (bronchoscopy), body scanning (computed tomography, CT), and a special scan to see how cells in the body are working (18F-fluorodeoxyglucose PET scan).
If the patient has factors that could increase their risk during surgery, like a long history of smoking, then doctors should check the patient’s heart health. For instance, if doctors suspect that cancer has spread to the lymph nodes — tiny glands that help to fight infection — in the chest (nodal disease), they might use a small camera to inspect the area (endobronchial ultrasound, EBUS) or make a small cut in the neck to examine the lymph nodes (mediastinoscopy).
For patients with a lung tumor who are preparing for an operation to remove part of their lung (pulmonary sleeve resection, PSR), they might receive treatments to shrink the tumor before the surgery. This could include drugs to kill cancer cells (neoadjuvant chemotherapy) and possibly radiation treatment.
How is Pulmonary Sleeve Resection performed
Pulmonary sleeve resection, or PSR, is a procedure involving the lungs, which is thought to be quite complex compared to other lung surgeries, particularly because it requires rebuilding certain parts of the lung. This surgery is usually performed with the patient laying on their side and involves a larger cut (or incision) in the chest, a method known as an open thoracotomy approach.
Before the operation begins, patients are put to sleep with general anesthesia, a tube is inserted into their windpipe (intubation), and a urinary catheter is placed. Doctors also usually establish good intravenous access, meaning they create a pathway for fluids and medications to enter the bloodstream easily. It’s common for another line to be inserted into an artery to keep an eye on blood gases, which can provide helpful information about lung function during the procedure.
One of the tricky aspects of this surgery involves the separation of the lungs, achieved using a tube in the airway (either a single-lumen endotracheal tube with a special accessory called a bronchial blocker or a double-lumen endotracheal tube). This allows the surgeon to work on one lung at a time.
A few important objectives guide the doctors during this procedure:
* Firstly, the aim is to entirely remove the tumor, if this procedure is being done for lung cancer, while ensuring there is no leftover disease on the edges (margins) of the tissue removed.
* Secondly, the tissue that is cut during the surgery is stitched back together using a special kind of thread (an absorbable braided or monofilament suture).
* Finally, the stitched area is covered with a layer of tissue steeped in blood (vascularized tissue) to support healing.
After the sick part of the lung is removed, the edges of the remaining airway are examined to make sure no disease is left. The airway is then securely stitched back together, and it’s usually recommended to add an extra layer of vascularized tissue on top for better healing. This can be harvested from a few different areas like between the ribs (intercostal muscle flap), surrounding the heart (pericardial fat pad), or a gland in the chest called the thymus (thymic fat wrap).
Lymph nodes, which are small filters for harmful substances in the body, in the center of the chest (mediastinum) are also usually removed in the surgery. After everything is done, typically, a tube is left behind in the chest to drain any fluid, and a local anesthetic is added near the ribs (intercostal nerve block) to prevent post-surgery pain. At the end of the operation, a camera is introduced into the airway (bronchoscopy) to inspect the stitched area and clear out any unwanted secretions that gathered during the procedure.
Importantly, though, with the advancement of surgical techniques, minimally invasive methods, which involve smaller cuts and cause less damage, can now also be used for this kind of surgery. These include Video-assisted thoracoscopic surgery (VATS), performed through small holes in the chest using a special camera on a long, thin tube or even robot-assisted surgery, where robot arms do the surgery under the surgeon’s control. These procedures, however, are more complex and should be performed at centers where the doctors have ample experience in these techniques.
Possible Complications of Pulmonary Sleeve Resection
After surgery on the lungs, known as pulmonary sleeve resection (PSR), the risk of patients dying is around 3%. This is a small percentage compared to 6% of patients who undergo a different lung surgery called pneumonectomy.
After these surgeries, there may be complications which require examination including using medical imaging like a chest x-ray or a CT scan. In some cases, doctors might also need to look inside the airways and the food pipe using bronchoscopy and esophagoscopy, respectively.
One study examined two types of lung surgeries – pneumonectomy and a similar surgery known as sleeve lobectomy (SL). They found that the outcome of the surgery relates to the stage of the lung cancer. For patients without cancer in the lymph nodes (N0), a survival rate of 60% was reported. But for those with cancer discovered in the lymph nodes near the lungs (N1), this rate dropped to 30%.
After the surgery, patients can sometimes experience early complications like:
– Breakage of the surgical connection in the airway (bronchial anastomosis)
– Twisting of the lung or the airway
– Lung infection (pneumonia)
– Continuous leakage of air from the lungs
– Leakage of lymphatic fluid into the chest (chylothorax)
– Blood in the chest cavity (hemothorax)
– Infection of the surgical wound
– A pocket of pus in the chest (thoracic empyema)
– Blockage in lung arteries (pulmonary embolism)
– Paralysis due to damage to the nerve controlling the diaphragm (phrenic nerve palsy)
– Death of lung tissue (pulmonary infarction)
– Bulging out of lung tissue through the surgical cut (pulmonary hernia)
– Collapse of parts of the lung (atelectasis)
– Serious lung condition (ARDS)
– Need to use a ventilator for a long period
– Irregular heart rhythm (atrial fibrillation)
Further down the line, some patients may have late complications like:
– Return of lung cancer at the same spot
– Narrowing of the surgical connection in the airways (bronchial anastomotic stenosis)
– Abnormal connections forming between the food pipe and chest (esophagopleural fistula), or between the airway and chest (bronchopleural fistula)
After lung surgery, some patients may experience a problem called bronchial dehiscence (splitting of the stitched airway), which is an early complication happening in up to 6% of people. Using a CT scan, doctors can often see a defect in the bronchial wall and persistent air and fluid levels. These issues can be due to surgical problems like deficient blood supply (ischemia) or excessive strain.
Narrowing of the surgically created airway connection (bronchial anastomotic stenosis) can occur as a late complication in up to 18% of patients.
The chances of cancer returning at the same spot are 8% in sleeve lobectomy compared to 10% after pneumonectomy. However, this does not worsen long-term survival. In fact, patients undergoing sleeve lobectomy show improved 5-year survival rates.
For less invasive surgical techniques, older age, pre-existing health problems, and the surgeon’s skill level can increase the risk of complications after surgery.
What Else Should I Know About Pulmonary Sleeve Resection?
Pulmonary sleeve resection (PSR) is a surgical technique for patients with advanced lung cancer who otherwise might not be suitable for a more intense surgery called pneumonectomy. Essentially, it’s a more conservative operation that could benefit even those with normal lung function before the operation. Over time, it has been shown to potentially improve survival rates and the overall quality of life compared to pneumonectomy.
PSR is not without its challenges. While it may lead to better long-term survival rates and fewer recurrences of cancer, it might also result in some complications soon after the surgery. Yet many professionals consider it a preferred technique for handling advanced cases of lung cancer.
In fact, a large study pooled the results of several smaller studies and found that people who underwent PSR had a 50% survival rate five years after treatment. Comparatively, those who opted for pneumonectomy had a 30% survival rate. The rate of death related to the operation was also lower for PSR (3%) than pneumonectomy (6%). Plus, PSR resulted in fewer cases of cancer coming back in the same region (17%) compared to pneumonectomy (30%).
On the downside, PSR might make the surgery take longer and could lead to more bleeding than pneumonectomy.
Recent advancements in less invasive surgical procedures have made it possible to apply PSR at specific hospitals. There’s a technique known as VATS (Video-Assisted Thoracoscopic Surgery), which, although it tends to take longer, is as safe and effective as traditional open chest surgery. Even robotic versions of the sleeve resection surgery show promising results, with similar risks and survival rates to both open surgeries and VATS. However, more practice and knowledge are necessary before these innovative surgical techniques become widespread.
