Thoracoscopic Extended Right Middle Plus Lower Sleeve Lobectomy for Non-Small-Cell Lung Cancer

Summary

Here we present thoracoscopic extended sleeve lobectomy, an applicable procedure for patients with centrally located non-small-cell lung cancer that exceeds an anatomic lobe and improves the probability of complete resection while preserving respiratory capacity.

Abstract

Complete surgical resection is essential for resectable non-small-cell lung cancer. In selected patients who have received induction therapy, extended sleeve lobectomy (ESL) can obviate pneumonectomy while achieving R0 margins when central tumors cross inter-lobar boundaries. This study demonstrates the procedure of extended right middle plus lower lobe sleeve resection.

Following three cycles of pembrolizumab plus platinum-doublet chemotherapy, a 57-year-old man with cT3N2M0 (IIIB) squamous cell carcinoma demonstrated radiological stability and persistent endobronchial invasion of the right secondary carina. A thoracoscopic extended right middle plus lower sleeve lobectomy was performed. First, the inferior and middle-lobe veins were stapled intra- and extra-pericardially. Subcarinal and ipsilateral paratracheal lymph nodes were dissected systematically. Radical removal of the middle and lower lobes was then achieved after temporary blockade of the right pulmonary artery and the superior pulmonary vein; hence, a safe dissection of the secondary carina can be performed. A "U"-shape portion of the right main bronchus was trimmed to adjust the appropriate size for bronchial anastomosis with the upper lobe bronchus, which was performed with a continuous suture. After leak-testing, the anastomotic site was covered by a free thymic fat flap.

The duration of the surgery was 200 min with approximately 50 mL of blood loss. Bronchoscopy on postoperative day 6 confirmed an intact anastomosis. Histopathology revealed a 4 cm moderately differentiated squamous carcinoma with 1/31 positive nodes. Adjuvant PD-1 inhibitor monotherapy was given, and the patient remains under surveillance.

Introduction

Complete resection is crucial for oncological control of non-small-cell lung cancer (NSCLC). For patients with resectable NSCLCs, preoperative programmed death-1 (PD-1) inhibitor with chemotherapy can achieve a pathological complete response rate of 24% with a 5-year overall survival rate of 65.4%^1,2. Though the perioperative immunotherapy that significantly changes the treatment paradigm of resectable NSCLC, nearly 10% of patients who received induction immunochemotherapy eventually required pneumonectomy to remove their tumors across phase III trials^1,3,4,5.

For centrally located locally advanced NSCLC, sleeve lobectomy has been proven to be an efficient way to avoid pneumonectomy while achieving R0 resection. The extended sleeve lobectomy (ESL) technique, as described by Okada et al. in 1999, aims to provide a solution for tumors that require removal of parenchyma greater than an anatomic lobe⁶. The original report classifies such procedure into three subtypes; Namely, type A: anastomosis between right main and lower bronchi with resection of the upper plus middle lobes, type B: anastomosis between left main and basal segmental bronchi with resection of the upper lobe and superior segment of the lower lobe, and type C: anastomosis between left main and upper division bronchi with resection of the lingular segment and lower lobe. In 2013, an additional type D ESL, namely, anastomosis of the right main and upper lobe bronchi with resection of the middle plus lower lobes, was described⁷. As indicated by a recent study, ESL in patients with NSCLC who undergo neoadjuvant immunochemotherapy is feasible and has a superior event-free survival compared with those who received pneumonectomy⁸.

This paper aims to describe the detailed steps for conducting extended right middle plus lower lobe sleeve resection in patients with locally advanced NSCLC who received induction therapy.

Protocol

Written informed consent was obtained from the patient for publication. The procedure was performed in accordance with the ethical guidelines; however, institutional review board approval was exempted for this study.

1. Patient selection

1. Select patients with upfront or post-induction resectable centrally located NSCLC in the ostium of bronchus intermedius on a recent contrast-enhanced CT scan and bronchoscopy (maximum of 4 weeks old).
2. Exclude patients with metastatic disease, invading upper lung bronchi greater than 5 mm, or who are physically unable to tolerate one-lung ventilation.
3. During training, exclude patients with previous major thoracic surgery or radiotherapy.

2. Surgical technique

1. Operative setting
   1. Place the anesthetized patient in the left decubitus position.
   2. Place sterile drapes to expose the region from the anterior axillary line to the mid-scapular line.
   3. Create a 4 cm utility port with diathermy in the fourth intercostal space and a 1 cm thoracoscope incision in the seventh intercostal space.
   4. Perform a routine thoracoscopic exploration from the costodiaphragmatic recess to the apex of the chest to exclude pleural metastases.
      NOTE: Use of bronchoscopy via endotracheal intubation is advisable for localizing the tumor to determine the extent of resection.
2. Hilar exploration
   1. Exposure
      1. Use the ultrasonic scalpel to divide the inferior pulmonary ligament, open the posterior mediastinal pleura up to the inferior border of the azygos arch.
      2. Preserve the vagus nerve, dissect the posterior aspect of the subcarinal lymph nodes with an ultrasonic scalpel.
   2. Dissection of the pulmonary vein
      1. Open the pericardium in a "U-shape" with a scalpel alongside the inferior pulmonary vein.
      2. Dissect the inferior pulmonary vein with a double-hinged dissector, then divide the vein intrapericardially with an endoscopic linear stapler.
      3. Dissect the middle lobe pulmonary vein extrapericardially and similarly divide the vein.
3. Lymph node dissection
   1. Subcarinal lymph nodes
      1. Given that the subcarinal lymph nodes are attached firmly to the bronchus intermedius, leave these nodes for dissection after dividing the bronchus.
   2. Paratracheal lymph nodes
      1. Following the removal of the anterior hilar nodes, begin the dissection with the sub-azygos arch region. Use the ultrasonic scalpel to seal the lymphatic vessels under direct vision.
      2. Open the mediastinal pleura alongside the superior vena cava up to the inferior border of the subclavian artery with a scalpel. Remove the superior and inferior paratracheal lymph nodes in a whole package. Care should be taken not to injure the underneath innominate artery.
4. Proximal vessels control and bi-lobectomy
   1. Proximal hilar control
      1. Use the endoscopic Harken clamp to encircle the entire right pulmonary artery and the remaining superior pulmonary vein together.
      2. Achieve temporary blocking of the vessels by the Rumel-Belmont tourniquet, placed in the upper chest cavity.
   2. Dissection of the secondary carina
      1. Identify the interlobar node between the upper lobe bronchus and the bronchus intermedius. Use an electrocautery hook to open a landmark point to facilitate the upper lobe bronchus division with a scissor.
      2. Similarly, divide the right main bronchus. Obtain direct visualization of the tumor invading the secondary carina after complete division.
   3. Resection of the middle and lower lobes
      1. Dissect the interlobar nodes with their surrounding tissues to the bronchus intermedius with an electrocautery hook to guarantee a safe margin.
      2. Remove the subcarinal lymph nodes.
      3. Divide the remaining pulmonary artery as well as the horizontal fissure by an endoscopic linear stapler. Retrieve the middle and lower lobes in a specimen bag through the utility port.
      4. Send bronchial edges from both proximal (right main bronchus) and distal (right upper lobe bronchus) for frozen section to exclude any tumor residue.
5. Azygos vein suspension and bronchial stump adaptation
   1. Use a part of the urine tube (8 Fr) to encircle the azygos arch, and stitch it to the posterior chest wall to help expose the right main bronchus by retracting the azygos arch.
   2. Remove a part of the right main bronchus in a "U" shape in the cartilage-membrane joint section by endoscopic scissors.
   3. Approximate the defect by two interrupted sutures to adapt the size of the right main bronchus with 3-0 absorbable sutures.
6. Bronchial anastomosis
   1. Perform a continuous running suture with 4-0 Polydioxanone for bronchial anastomosis. Hang the thread for suturing the posterior wall in the parietal pleura to avoid thread kinking.
   2. Tie the knot by a knot pusher extracorporeally. Then, perform the saline irrigation test with 30 cm H₂O airway pressure.
7. Thymic flap coverage
   1. Harvest a thymic fat flap, either pedicle or free, by the ultrasonic scalpel to cover the anastomotic site. Leave the pericardial defect open. Place a 24 Fr chest tube, and close the incisions using absorbable sutures.

Results

A 57-year-old man presented with mild hemoptysis at the outpatient clinic. On CT scan, a 4.6 cm hilar mass was found; a subsequent bronchoscopy confirmed squamous cell carcinoma with PD-L1 expression of 2% in the bronchus intermedius. The patient was diagnosed with cT3N2M0 IIIB lung cancer following PET and brain MRI scans. Three cycles of pembrolizumab plus platinum-based doublet chemotherapy were administered as induction therapy uneventfully. Stable disease (3.7 cm) was confirmed by the CT scan, and the bronchoscopy i...

Discussion

ESL is a feasible procedure to avoid pneumonectomy in selected patients with centrally located NSCLCs. Thoracoscope can provide high-resolution visualization, hence may increase the chance of R0 resection by experienced surgeons. A previous study had suggested that ESL could be more valuable in patients with right-sided tumors. In a recent report by Chen et al., ESL offers a chance of complete resection for patients with poorer predicted postoperative respiratory function following neoadjuvant immunochemotherapy

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Echelon Flex Endopath 60 mm Stapler	Ethicon	GST60T	Powered surgical stapler with gripping surface technology
Echelon Flex Vascular stapler	Ethicon	PVE35A	35 mm standard articulating endoscopic vascular linear cutter
Gold reload for Echelon 60	Ethicon	GST60D	Regular/thick tissue thickness, open staple height 3.8 mm, closed staple height 1.8 mm
Harmonic Advanced Hemostasis 45 cm	Ethicon	HAR745	Curved tip, energy sealing and dissecting, diameter 5 mm, length 45 cm
Hem-o-Lok Clips MLX	Weck Surgical Instruments, Teleflex Medical, Durham, NC	544230	Vascular clip 3-10 mm Size Range
Hem-o-Lok Polymer Ligation System	Weck Surgical Instruments, Teleflex Medical, Durham, NC	544965	non-absorbable polymer composition and flexible hinge
White reload for PVE35A	Ethicon	VASECR35	Vascular/thin tissue thickness, open staple height 2.5 mm, closed staple height 1.0 mm