Bronchoplasty for pulmonary preservation: A novel technique

摘要

Central MessagePreservation of uninvolved tissue during resection of low-grade airway tumors can allow for novel reconstruction techniques that preserve pulmonary function. Preservation of uninvolved tissue during resection of low-grade airway tumors can allow for novel reconstruction techniques that preserve pulmonary function. Bronchoplasty is a technique used to preserve pulmonary function in patients with central airway tumors. This typically incorporates a “sleeve” technique or circumferential resection of the airway with primary reconstruction of the remaining uninvolved bronchus and lung. This technique was an advance in thoracic surgery for the management of central airway tumors allowing preservation of pulmonary function and avoidance of a pneumonectomy. More recently, minimally invasive techniques, both video-assisted thoracic surgery and robotics, have been increasingly utilized when performing these major operations.1Li J. Wang W. Jiang L. Yin W. Liu J. Shao W. et al.Video-assisted thoracic surgery resection and reconstruction of carina and trachea for malignant or benign disease in 12 patients: three centers' experience in China.Ann Thorac Surg. 2016; 102: 295-303https://doi.org/10.1016/j.athoracsur.2016.01.080Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar In particular, the robotic technology allows for improved visualization through a binocular camera with greater magnification. The wristed instrumentation allows greater precision for cutting and sewing when using a minimally invasive technique. Because of these improvements, the options for resection and reconstruction with minimally invasive techniques has grown.2Caso R. Watson T.J. Khaitan P.G. Marshall M.B. Outcomes of minimally invasive sleeve resection.J Thorac Dis. 2018; 10: 6653-6659https://doi.org/10.21037/jtd.2018.10.97Crossref PubMed Scopus (20) Google Scholar Endoscopic bronchoscopic techniques have also evolved; however, without complete resection, local recurrence can occur.3Yang H.M. Yin J. Li G. Liu X.C. Zhonghua Er Ke Za Zhi. 2021; 59: 27-32https://doi.org/10.3760/cma.j.cn112140-20200904-00849Crossref PubMed Google Scholar The surgical management of low-grade tumors requires local resection with negative margins and a creative approach to bronchoplasty may be of use. For these patients, an atypical approach to resection and reconstruction may be more appropriate. We present a case where a novel approach allowed for preservation of pulmonary function. A 58-year-old healthy avid cyclist with a carcinoid tumor of the right lower lobe presented initially at age 50 years (Figure 1, A). He underwent endoscopic bronchoscopic treatment, including laser. Over time, the extrabronchial component of the tumor continued to grow (Video 1). He ultimately sought our opinion. He underwent robotic resection of the posterior membranous portion of the right lower lobe bronchus (Figure 1, B and C). The superior segmental bronchus was then used as a flap for reconstruction avoiding a middle and lower lobectomy (Video 2). The superior segmentectomy was completed with a pericardial fat pad-thymic flap. He was discharged without complications on postoperative day 2. Pathology revealed typical carcinoid; margins and nodes were negative. He is well without recurrence at 2.5 years’ follow-up (Video 3). A comprehensive video demonstrating the entire case may be viewed here (Video 4). This case demonstrates a novel approach to bronchoplasty. When performed open or minimally invasively, it can allow for maximization of pulmonary preservation in appropriate patients. When contemplating management of airway tumors multiple factors need to be taken into consideration. The ideal management strategy may include a variety of types of resection and reconstruction that are very much specific to each case. However, maximization of pulmonary function should be taken into consideration when devising a reconstructive strategy. When circumferential sleeve resection is