Overview
Definition:
Sleeve segmentectomy is a lung-preserving surgical technique that involves the resection of a lung segment along with a portion of a major bronchus, which is then reconstructed by reanastomosing the remaining bronchus to the remaining lung parenchyma
It is an alternative to lobectomy or pneumonectomy when a tumor is located near the bronchial carina or involves a segmental bronchus, aiming to maintain lung function.
Epidemiology:
Sleeve segmentectomy is indicated in a small percentage of lung resections, typically for centrally located lung cancers that are amenable to lung-sparing surgery
The incidence is higher in younger patients or those with compromised pulmonary function where lobectomy would lead to significant morbidity.
Clinical Significance:
This technique is crucial for managing lung malignancies near the bronchial tree while maximizing lung function preservation
It offers a oncologically sound alternative to more extensive resections, improving quality of life and reducing postoperative respiratory compromise in carefully selected patients, making it a vital skill for thoracic surgeons preparing for DNB and NEET SS exams.
Indications
Oncologic Indications:
Primary non-small cell lung cancer (NSCLC) involving a segmental bronchus or carina with clear margins
Recurrent lung cancer after previous surgery
Bronchial adenomas or other benign tumors causing airway obstruction
Limited metastatic disease to a single segment with bronchial involvement.
Functional Indications:
Patients with limited pulmonary reserve (e.g., COPD, prior pneumonectomy) who cannot tolerate lobectomy or pneumonectomy
Elderly patients with significant comorbidities where lung function preservation is paramount
Bilateral lung disease where preserving lung parenchyma is essential.
Radiological Criteria:
Tumor size typically less than 3 cm
Tumor located within 2 cm of the carina or involving a segmental bronchus
No evidence of extraluminal extension beyond the segmental bronchus or involvement of the contralateral main bronchus
No mediastinal lymph node involvement (N2 disease) for curative intent, though it can be considered in specific palliative settings.
Contraindications:
Extensive nodal involvement (N2 or N3 disease)
Distant metastasis
Tumors involving the main stem bronchus of the contralateral lung
Inability to achieve adequate bronchial margins
Severe comorbidities precluding major surgery or reconstruction.
Preoperative Preparation
Patient Evaluation:
Comprehensive cardiopulmonary assessment including pulmonary function tests (PFTs), arterial blood gas (ABG) analysis, and high-resolution CT (HRCT) chest
Cardiac evaluation (ECG, echocardiogram) as needed
Assessment of nutritional status.
Imaging Studies:
Contrast-enhanced CT scan for staging, assessing tumor extent, and identifying lymph node involvement
PET-CT scan for metabolic staging
Bronchoscopy with biopsy for histological confirmation and assessment of airway involvement
MRI may be useful for assessing chest wall invasion.
Surgical Planning:
Detailed surgical plan outlining the extent of bronchial and parenchymal resection, the planned reconstruction technique (e.g., simple end-to-end anastomosis, use of interposition grafts), and lymph node dissection strategy
Multidisciplinary team discussion (MDT) is essential.
Anesthetic Considerations:
General anesthesia with double-lumen endotracheal tube for single-lung ventilation
Careful fluid management and hemodynamic monitoring
Postoperative ventilation strategy planning.
Surgical Techniques
Approach:
Can be performed via thoracotomy (open surgery) or video-assisted thoracoscopic surgery (VATS)
VATS offers advantages of smaller incisions, less pain, and faster recovery, but may be technically challenging for complex sleeve resections.
Bronchial Resection And Reconstruction:
The affected lung segment and the involved portion of the bronchus are resected
The remaining proximal bronchus is then meticulously anastomosed to the distal bronchus or the remaining lung parenchyma
Techniques include simple end-to-end anastomosis, or occasionally, bronchoplasty
Staples or absorbable sutures are commonly used.
Parenchymal Resection:
The lung parenchyma distal to the resected bronchus is removed, typically as a wedge resection or segmentectomy
The remaining lung is then inflated to ensure air-tightness of the bronchial anastomosis.
Lymph Node Dissection:
Systematic mediastinal lymph node dissection (e.g., stations 2R/L, 4R/L, 7, 10, 11) is performed to ensure oncological clearance and staging
Accurate nodal assessment is critical for prognosis and adjuvant therapy decisions.
Postoperative Care
Monitoring:
Close monitoring of respiratory status, vital signs, and oxygenation
Chest X-rays to assess lung expansion and fluid status
Bronchoscopy may be performed early postoperatively to check the anastomosis.
Pain Management:
Effective pain control is crucial, often involving epidural analgesia or patient-controlled analgesia (PCA) with opioids
Multimodal analgesia strategies are preferred.
Respiratory Support:
Early mobilization and pulmonary physiotherapy are essential
Chest drains are managed appropriately
Non-invasive ventilation (NIV) or mechanical ventilation may be required in select cases.
Nutritional Support:
Adequate nutritional intake is important for wound healing and recovery
Consultation with a dietitian may be beneficial.
Complications
Early Complications:
Bronchial stump dehiscence or fistula formation
Air leak
Hemorrhage
Infection (pneumonia, empyema)
Atelectasis
Anastomotic stenosis
Bronchospasm.
Late Complications:
Late bronchial stenosis or fibrosis
Bronchiectasis distal to the anastomosis
Recurrent tumor
Chronic air leak
Persistent cough.
Prevention Strategies:
Meticulous surgical technique with adequate bronchial margins
Careful handling of bronchial tissues
Tension-free anastomosis
Appropriate suture material
Prophylactic antibiotics
Aggressive pulmonary physiotherapy
Early postoperative bronchoscopy for assessment and intervention if needed.
Prognosis
Factors Affecting Prognosis:
Histological type and grade of tumor
Stage of disease (TNM staging)
Completeness of surgical resection (R0 resection)
Lymph node status
Patient comorbidities
Quality of bronchial and vascular reconstruction
Presence of adjuvant therapy.
Outcomes:
When performed in carefully selected patients with early-stage disease and achieved R0 resection, sleeve segmentectomy can offer long-term survival comparable to lobectomy for selected lung cancers
Lung function preservation is a significant advantage.
Follow Up:
Regular clinical and radiological follow-up is mandatory
This typically includes serial chest X-rays and CT scans to monitor for recurrence or complications
Periodic bronchoscopies may be indicated based on individual risk factors and clinical findings.
Key Points
Exam Focus:
Understand indications for sleeve segmentectomy vs
lobectomy/pneumonectomy
Differentiate between different types of sleeve resections (e.g., carinal, lobar)
Know the complications of bronchial anastomosis and their management
Recognize imaging findings suggestive of carcinoid tumors or early central NSCLC amenable to sleeve resection.
Clinical Pearls:
Achieving adequate bronchial margins is paramount for oncologic safety
A tension-free anastomosis is critical for preventing dehiscence
Consider VATS for experienced surgeons to minimize invasiveness
Early bronchoscopy is crucial for assessing anastomosis integrity postoperatively.
Common Mistakes:
Underestimating the extent of bronchial involvement
Inadequate lymph node dissection
Creating a tension-filled anastomosis
Failing to achieve clear surgical margins
Overly aggressive resection in patients with poor pulmonary reserve
Delaying diagnosis and treatment for centrally located tumors.