The importance of parenchymal preservation during pulmonary surgery was realized over 50 years ago when descriptions of bronchial resection and reconstruction were first published.1–3 Since then, considerable technical refinement and anatomic insight have expanded indications for lung-sparing operations. Bronchoplastic resections form one category of these procedures with a unique set of indications. These operations are technically more demanding than standard anatomic pulmonary resections, although, the additional time spent performing these procedures is justly rewarded in considerable functional lung preservation.
The terms bronchoplasty and bronchoplastic resection have been applied to a wide variety of operations of main or lobar bronchi. The operations usually involve a concomitant parenchymal resection; resection and reconstruction of the bronchus alone is quite rare. Bronchoplasty refers to resection and reconstruction of a lobar bronchial orifice (e.g., right upper lobe) without removing a segment of main bronchus. This is in contradistinction to a “sleeve” resection in which a circumferential portion (or sleeve) of a central bronchus is included as part of the operation. Because of the gaps that sleeve resections create in the target airways, release maneuvers (to reduce tension on the anastomosis) are usually necessary.
The standard indication for bronchoplastic resection is an endobronchial lesion emanating from either the main bronchus itself or a lobar bronchus with main bronchus encroachment. The extent of the diseased area must allow for safe reconstruction when margins are considered. Etiology is often a low-grade neoplasm such as typical carcinoid or mucoepidermoid cancer4 or, rarely, isolated bronchial stenosis secondary to granulomatous disease, trauma, caustic injury, foreign body, or benign neoplasm.5,6 Bronchoplastic resections can be applied to more invasive cancers, that is, non–small-cell lung cancer (NSCLC) or metastases, when trying to spare lung parenchyma in a patient with marginal pulmonary function. While lung is preserved, oncologic principles, namely, achieving a complete resection (including a negative margin), must not be compromised.7 Positive margins are not an acceptable alternative to complete resection.
The issue of N1/N2 lymph node involvement clearly complicates the decision to proceed with a lung-sparing bronchoplastic resection versus pneumonectomy or bilobectomy. To date, there are no data to suggest that larger parenchymal resections provide a higher cure rate for stage II or stage III lung cancer. Therefore, bronchoplasty can be performed for stage II or stage III lung cancer as long as a complete resection can be obtained. In addition, data from several European studies of neoadjuvant chemotherapy and/or radiation therapy suggest that a bronchoplastic resection can be performed without additional morbidity. Of note, radiation therapy completed more than 3 months before the resection considerably increases the technical difficulty and should be considered high risk. Few definitive contraindications exist for bronchoplastic or sleeve resection techniques as long as the patient's performance status allows. One should know in advance whether pneumonectomy is an option in case the sleeve is technically not feasible.