Chapter 66

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 greatly expanded indications for lung-sparing operations. Bronchoplastic resections form one category of these procedures and have a unique set of indications. There is no question that these operations are technically more demanding than standard anatomic pulmonary resections, yet, by appreciating their benefits, the additional time spent performing these procedures is justly rewarded.

The terms bronchoplasty and bronchoplastic resection have been applied to a wide variety of operations of either main or lobar bronchi. The operations usually involve concomitant parenchymal resection. Indications for resection and reconstruction of the bronchus alone are rare. Although some thoracic surgeons have interchanged right upper lobe bronchoplasty with right upper lobe sleeve resection, a lobar bronchial orifice (e.g., right upper lobe) occasionally can be reconstructed without resecting a sleeve of main bronchus.

The standard indication for bronchoplastic resection is an intrabronchial 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 reconstruction after the resection. Etiology is often a low-grade neoplasm such as typical carcinoid or mucoepidermoid4 or, rarely, isolated bronchial stenosis secondary to granulomatous disease, trauma, foreign body, or benign neoplasm.5,6 Bronchoplastic resections can be applied to more invasive cancers (non-small cell lung cancer (NSCLC) or metastases), but oncologic principles, namely, achieving a complete resection (including a negative margin), must be followed.7 The naive mind-set that a positive margin simply can be radiated postoperatively must be avoided. Regardless of operation, if an incomplete resection could be predicted preoperatively, the patient likely would benefit greater from chemoradiation therapy as definitive therapy or, at least, as induction therapy (i.e., administered preoperatively).

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. In fact, pneumonectomy appears to be a risk for mortality after induction therapy for resectable stage IIIA lung cancer.8 Consequently, there is no compelling reason to avoid bronchoplasty for stage II or stage III lung cancer as long as a complete resection can be obtained. In addition, data from several European studies using neoadjuvant chemotherapy or radiation have permitted a bronchoplasty to be performed without additional morbidity.

Few definitive contraindications exist to bronchoplasty aside from those just discussed or the general fitness of any patient undergoing pulmonary resection of any type. Although bronchoplastic resections appear to be safe when performed after induction chemoradiation therapy (at least up to 4500 cGy), radiation therapy delivered more than 3 months before the resection should be considered a risk.

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