Hi, my name is Jules Lin. I'm one of the thoracic surgeons, and thank you for joining us for today's talk on complex lung resections, sleeve lobectomy and pneumonectomy. The objectives of today's talk is to discuss the benefits of lung-sparing sleeve resection, review the indications for pneumonectomy, and describe possible complications after complex lung resections. After today's talk, we hope you'll be able to answer this question. A right upper lobe lung cancer with involvement of the right upper lobe orifice and the adjacent bronchus intermedius should be treated with, A, a pneumonectomy when possible. B, sleeve lobectomy when possible. C, definitive chemoradiation. Or D, neoadjuvant chemoradiation. The first successful pneumonectomy for lung cancer was performed by Evarts Graham in 1933. The patient was a gynecologist, and purchased a cemetery plot the day before surgery. This successful case led to the modern treatment of lung cancer. In fact, pneumonectomy was the treatment of choice until 1962, when results show that pneumonectomy increased complications but did not improve survival compared to a lobectomy. Most invasive lung cancers are now treated with a lobectomy. However, studies are being done to see if lesser resections like a segmentectomy are equivalent for smaller cancers, especially those that are partially solid. In this case, this a 65 year-old man with pneumonia. A chest x-ray showed atelectasis of the right lower lobe. And here, you can see on bronchoscopy there's an obstructing tumor of the right lower lobe bronchus. On chest CT, there's a 6.8 centimeter right lower lobe mass with no mediastinal lymphadenopathy. A biopsy was performed which showed squamous cell carcinoma. On PET scan, this mass is hypermetabolic, it measures 5.8 by 4.2 centimeters and has an SUV of 8.8. There is postobstructive atelectasis, and again, there's no mediastinal lymphadenopathy. On pulmonary function testing, FVC was 95% predicted. The FEV1 was 80% predicted, with a DLCO of 85% predicted. The patient is physically fit and is able to walk two miles, and has a Zubrod score of zero. So lung-sparing resections like sleeve lobectomy are preferred over pneumonectomy when possible. A sleeve resection removes a portion of the airway or pulmonary artery which are then reanastomosed. Here you can see in the illustration, here's a right upper lobe bronchus. Here's the bronchus intermedius leading to the right middle lobe and the right lower lobe. The cancer involving the right upper lobe bronchus can be resected with a sleeve lobectomy. And then the airway is reanastomosed. So a sleeve lobectomy preserves lung function, and it allows resection in patients that would not tolerate a pneumonectomy. It can be used in central tumors that involve a segment of the proximal airway. A sleeve resection of the airway alone is sometimes performed if there's no involvement of the lung parenchyma, for example a carcinoid tumor just involving the upper lobe bronchus. More extensive resection may require pericardial release to reduce tension. We can also perform a sleeve resection of the pulmonary artery if there is pulmonary arterial invasion. Or a pulmonary artery patch arterioplasty with a pericardial patch if there's focal involvement by tumor. And here you can see in the photograph that a pericardial patch has been used to repair the pulmonary artery. For a sleeve resection the work up includes a PET scan and a chest CT scan to exclude any metastatic disease. A bronchoscopy is performed to evaluate the extent of the airway involvement. And it's important to confirm that there's adequate cardiopulmonary function, so cardiopulmonary function testing, an echo or stress test if indicated, and you should always be prepared to perform a pneumonectomy if necessary. If the patient is not an operative candidate, then definitive chemoradiation or a palliative stent can be performed. There are potential complications from a sleeve resection, airway dehiscence if the anastomosis does not heal, anastomotic stenosis requiring dilations, and bronchoarterial fistula. To help prevent this, we usually interpose a muscle flap in between the airway and the pulmonary artery to prevent this. Andersson, et al., looked at major complications after sleeve lobectomy, and found no difference with pneumonectomy in five year survival. Okada, et al., found that increased long-term survival after sleeve lobectomy versus pneumonectomy, and this was independent of nodal status. So a meta-analysis was performed by the Ferguson group looking at all sleeve lobectomies and pneumonectomies between 1990 and 2003. And they found that models favored a sleeve lobectomy with a 3.5% 5-year survival advantage. Sleeve lobectomy was strongly favored, with 1.53 quality-adjusted life years. And was more cost effective, with $1,300 per quality-adjusted life year. Pneumonectomy is still useful, and is performed when excessive airway or vessel involvement Is found that is not amenable to sleeve resection. Here on CT scan you can see involvement of both the airway and the pulmonary artery, and if there's an involvement of several proximal airway or vascular structures a pnuemonectomy is preferred. The work-up is similar, and includes a PET scan and and chest CT to exclude any metastatic disease. Again, a bronchoscopy is performed to evaluate for the extent of airway involvement. And you need to confirm adequate cardiopulmonary function. Again, pulmonary function tasks, echo or stress test. And a quantitative ventilation-perfusion scan is useful to determine how much lung function is present from each lung. If the patient is not an operative candidate, then definitive chemoradiation or palliative stent can be performed. A pneumonectomy is relatively contraindicated when the FEV1 is less than 80% predicted, if there is significant pulmonary hypertension, hypercarbia, severe cardiac disease or mediastinal invasion or persistent N2 nodal disease. Complications associated with a pneumonectomy, the operative mortality is approximately 3 to 12%. A bronchopleural fistula can occur in 2 to 16% of patients and has a 30 to 50% mortality. It is more common on the right with neoadjuvent chemoradiation, a long bronchial stump or postoperative positive-pressure ventilation. Again, it is important to extubate these patients when possible early. We reinforce the bronchial stump with an intercostal muscle or pericardial fat flap to help prevent some of these complications, especially a bronchopleural fistula. A bronchopleural fistula is suspected when there is a hydropneumothorax, which you can see here on the chest x-ray. Especially if the chest was completely filled on a previous x-ray, with fluid. A chest tube should be placed immediately to decrease aspiration and to drain the post pneumonectomy space. And then an Eloesser flap is performed. This is a musculocutaneous flap with removal of several ribs to allow packing of the open chest cavity for long-term drainage. If the bronchpleural fistula heals, then the chest can be closed with a Clagett procedure. This is filling the chest with antibiotic solution and then closing the chest wound. The bronchopleural fistula can be repaired or re-stapled if there's a long bronchial stump. But if there's no residual stump, then you may need to consider closure with omentum or a muscle flap. So a right upper lobe lung cancer with involvement of the right upper lobe orifice and the adjacent bronchus intermedius should be treated with, A, a pneumonectomy when possible. B, Sleeve lobectomy when possible. C, definitive chemoradiation. Or D, neoadjuvant chemoradiation. The answer is sleeve lobectomy when possible. The take home points, a pneumonectomy has higher morbidity and mortality. A lung-sparing sleeve resection is preferred when possible, and complex lung resection are associated with potentially severe complications, and should be performed only in experienced centers. Thank you for your attention and listening to today's talk. And hopefully you learned something about complex lung resections, including sleeve lobectomy and pneumonectomy. Thank you.