92: Bronchoplasty for Benign Lung Lesions

Although bronchoplasty for malignant lung lesions is common, bronchoplasty for benign lung lesions is relatively rare. In most instances, these lesions are published as individual case reports, and various approaches and procedures have been performed. In this chapter, selected case reports of bronchoplasty for benign lung lesions are used to illustrate each disease entity. Specific entities discussed in this chapter include bronchoplasty for tracheobronchomalacia, tuberculous bronchial lesions, endobronchial benign tumors, endobronchial inflammatory polyps, bronchial stenosis after bronchial anastomosis, and bronchial disruption.

Tracheobronchomalacia is characterized by weakness of the tracheobronchial wall and supporting cartilage. Collapsing airways due to tracheobronchomalacia have been stabilized with a variety of external splints; for example, autologous rib or various types of prostheses. A new technique has been reported in which a ringed polytetrafluoroethylene (PTFE) graft splint was placed for a serious case of tracheobronchomalacia.¹ The patient was a 55-year-old man with grade 3 tracheobronchomalacia (Johnson's classification) (Table 92-1).² Chest CT scan showed a crescent deformity of the trachea (Fig. 92-1A). Bronchoscopy revealed crescent-type stenosis (Fig. 92-1B). Matsuoka et al.¹ cut the 12-mm diameter ringed PTFE graft to a length of 2.5 cm (Fig. 92-2A). The prosthesis was divided longitudinally and spread. The rings were cut at various points to fit the membranous portion of the trachea and bronchi (Fig. 92-2B), after which the prosthesis was sutured to the cartilage and membranous portion with 4-0 PDS-II sutures (Fig. 92-2C). This process was repeated from the trachea to the bilateral bronchi. The patient's symptoms were markedly improved after surgery. Postoperative chest CT scan showed that the caliber of the trachea was well preserved (Fig. 92-3).

Endobronchial tuberculosis is often associated with significant tracheobronchial stenosis. The incidence of strictures in females is remarkably higher than in males.^3,4 The left main bronchus is affected most often.^3,4 If the stricture is an active tuberculous lesion and the patient has symptoms due to the stenosis, antituberculosis medication should be given, and laser ablation, balloon dilation, and/or stenting should be performed.^3–5 Surgical bronchoplasty is indicated for nonactive tuberculous lesions with symptoms and/or repeated infections.^3–5 Case reports of sleeve resection of the left main bronchus, sleeve left upper lobectomy, balloon dilation, and Dumon stent placement have been published.^6–8

Sleeve Resection of Left Main Bronchus

A 31-year-old woman came to the hospital with left chest pain and dyspnea after medical therapy for pulmonary tuberculosis.⁶ Chest x-ray showed atelectasis of the left lower lobe and mediastinal deviation to the left (Fig. 92-4A). Bronchoscopy revealed a cicatricial obstruction of the left main bronchial orifice (Fig. 92-4B). By MRI, it was concluded that the left upper lobe and lower lobe bronchi were patent. Sleeve resection of the left mainstem bronchus was performed from the carina to the left second carina. The anastomosis was done by interrupted 4-0 absorbable suture, and it was reinforced by two mattress stitches of 4-0 nonabsorbable suture. Virtual CT endoscopy showed no anastomotic stenosis 1 year and 9 months after the operation (Fig. 92-5).

Sleeve Left Upper Lobectomy

A 33-year-old man presented with a past medical history of pulmonary tuberculosis.⁷ He developed left pneumonia, and chest x-ray showed left atelectasis. Stenosis of the left mainstem bronchus could be seen at bronchoscopy, and balloon dilation was performed twice. However, stenosis and pneumonia recurred frequently. Therefore, he was admitted for surgery. Chest x-ray showed patchy and granular shadows due to the repeated pneumonia (Fig. 92-6). Chest tomogram showed a 15-mm obstruction of the left mainstem bronchus, and the left upper lobe bronchus was not seen. Stenosis of the left mainstem bronchus was clearly observed by three-dimensional CT scan (Fig. 92-7A). Bronchoscopy revealed occlusion of the left mainstem bronchus two rings from the carina (Fig. 92-7B). At thoracotomy, via the fourth intercostal space, the left upper lobe was found to be damaged by tuberculosis. Therefore, a left upper sleeve lobectomy was performed. The total left mainstem bronchus was resected, and the carina and the left lower lobe bronchus were anastomosed with 4-0 PDS interrupted sutures. Postoperative bronchoscopy revealed an excellent anastomosis (Fig. 92-7C).

Balloon Dilation and Dumon Stent

Kobayashi et al.⁸ reported that balloon dilation alone for tuberculous bronchial stenosis resulted in dilation failure and recommended implantation of a Dumon stent instead. Figure 92-8A illustrates severe stenosis of the left mainstem bronchus before balloon dilation. Nine months after the seventh balloon dilation, the stenosis still remained (Fig. 92-8B). Figure 92-8C shows the condition of the left mainstem bronchus 6 months after the placement of a 10-mm diameter Dumon stent (Novatech, Grasse, France). Because granulation formation was seen at the distal edge of the stent, it was removed. Nineteen months after stent removal, the granulation disappeared completely (Fig. 92-8D), and the lumen was reestablished without further need for dilations.

Benign tumors of the airways are much less common than those with malignant potential. In particular, benign endobronchial tumors are extremely rare. Benign neoplasms may cause serious or fatal conditions as a consequence of airway obstruction and therefore cannot be left untreated. However, the least invasive treatment modalities should be chosen, and these tumors generally are removed by bronchoscopy or by bronchoplasty. Resection of the lung parenchyma usually can be avoided. In this section, cases of endobronchial mucous gland adenoma, lipoma, and hamartoma are reported.

Endobronchial Mucous Gland Adenoma

Bronchial mucous gland adenoma is a rare disease that arises from bronchial glands of the mucous type. A 77-year-old man presented with bloody sputum and cough.⁹ CT scan (Fig. 92-9A) showed a tumor in the left mainstem bronchus. Bronchoscopy revealed a polypoid tumor in the left mainstem bronchus. The diagnosis of mucous gland adenoma was made by biopsy. Circumferential resection of the left mainstem bronchus was performed, and the tumor was removed (Fig. 92-9B). The anastomosis was made by interrupted 3-0 absorbable suture. The tumor was diagnosed histologically as bronchial mucous gland adenoma (Fig. 92-9C).

Endobronchial Lipoma

Bronchial lipoma is rare and makes up approximately 0.1% of all pulmonary tumors.¹⁰ A 72-year-old man was found by bronchoscopy to have an endobronchial lipoma in the bronchus of the lingula accompanied by squamous cell carcinoma (SCC) in the lower lobe bronchus.¹¹ Figure 92-10A shows a yellowish polypoid tumor with smooth surface at the orifice of the bronchus of the lingula. A left lower lobectomy was done for the SCC. Sleeve resection of the bronchus of the lingula with telescoping bronchial anastomosis was performed for the lipoma. The length of the resected bronchus was 10 mm from the bifurcation of the upper and lingual division. Histologic examination showed mature adipose tissue diagnosed as a benign endobronchial lipoma (Fig. 92-10B).

Endobronchial Hamartoma

Although hamartoma is the most common form of benign lung tumor, endobronchial hamartoma is rare, and only 1.4% of hamartomas are located in the bronchus.¹² A 46-year-old man was admitted to the hospital with fever and productive cough.¹³ Chest x-ray and CT scan (Fig. 92-11A) showed partial atelectasis of the left lung. A 20 × 17 mm mass in the left mainstem bronchus was observed by CT scan. Bronchoscopy demonstrated complete obstruction of the left mainstem bronchus by a hard tumor with a smooth surface (Fig. 92-11B). The tumor was too hard to get a good biopsy specimen for definitive diagnosis. By thoracotomy and bronchotomy, the tumor, which obstructed the left upper lobe bronchus and left mainstem bronchus, was removed partially to preserve the left upper lobe (Fig. 92-11C). The remainder was resected completely by transbronchial electrosurgery snare and neodymium: yttrium-aluminum-garnet (Nd:YAG) laser 2 weeks after the thoracotomy. The tumor was 35 × 15 × 15 mm in diameter and was diagnosed as a hamartoma. No finding of recurrence was seen by bronchoscopy at follow-up 3 years after the resection.

Inflammatory bronchial polyp is a rare, benign, and nontumorous lesion similar to inflammatory polyps of the nasal cavities. It is composed of inflammatory granulation tissue. It can be treated bronchoscopically and/or surgically. Resection with a forceps, hot snare, and Nd:YAG laser is available using a bronchoscope. A case of sleeve bronchial resection for an inflammatory polyp is reported here.¹⁴ A 60-year-old man was referred because cancer was suspected by sputum cytology. Chest CT scan (Fig. 92-12A) revealed a polypoid lesion in the bronchus of the lingula. Bronchoscopy (Fig. 92-12B) revealed a smooth-surfaced polypoid lesion at the lingular orifice. The biopsy revealed squamous metaplasia with moderate atypia histologically. Sleeve resection of the bronchus of the lingula was performed, and the lesion was resected (Fig. 92-12C). The superior bronchus and inferior bronchus of the lingular division were anastomosed, respectively, to the upper lobe bronchus by interrupted 5-0 absorbable sutures. The pathologic diagnosis of the resected specimen was inflammatory bronchial polyp (Fig. 92-12D).

Bronchial stenosis may occur after bronchial wedge resections, sleeve resection, or lung transplantation. Treatments include surgical resection and reanastomosis, debridement by forceps, laser resection, balloon dilation, and stent placement. As an example, a case of debridement by forceps, laser resection, and stent placement for anastomotic stenosis after right upper wedge lobectomy is reported here.¹⁵ A 71-year-old man underwent right lobectomy with bronchial wedge resection for squamous cell lung cancer. The bronchial anastomosis was performed with interrupted 3-0 absorbable sutures, and it was wrapped with an intercostal muscle flap. A few weeks after the surgery, bronchoscopy revealed local infection at the anastomotic site. Necrotic tissue at the anastomotic site was removed by biopsy forceps. Methicillin-resistant Staphylococcus aureus was detected in the bronchial lavage fluid, and vancomycin was given. Six months after surgery, bronchoscopy was done because of increased breathing difficulty, and severe anastomotic stricture was found. Figure 92-13A shows the stenosis of 2 mm and inflammatory granulation tissue. Three-dimensional CT scan revealed a serious anastomotic stenosis (Fig. 92-13B). Therefore, Nd:YAG laser resection for the inflammatory granulation was performed, and a self-expanding metallic stent (Ultraflex stent, Boston Scientific, Natick, MA) was placed successfully. Figures 92-13C and D show the placed stent and widely opened anastomosis.

Bronchial disruption secondary to blunt trauma is unusual. The prognosis is poor, and greater than half the patients die before arriving at a hospital.¹⁶ It is important to suspect the condition by clinical and radiographic findings. Early bronchoscopy is strongly recommended to get a definitive diagnosis. More than 80% of tracheobronchial disruptions are within 2.5 cm of the carina.¹⁶ If bronchial disruption is found, immediate surgical repair should be performed. A case of complete transection of the left mainstem bronchus due to blunt chest trauma has been reported.¹⁷ A 62-year-old man was hit by a car and brought to an emergency center. Severe subcutaneous emphysema was present in the neck and chest. Breath sounds were reduced in the left chest. Chest x-ray (Fig. 92-14A) after bilateral chest tube placements showed bilateral pneumothoraces, subcutaneous emphysema, pneumomediastinum, multiple rib fractures, and tracheal shift to the right. Chest CT scan (Fig. 92-14B) revealed bilateral lung contusion in addition to the chest x-ray findings. Because of a massive air leak from the left chest tube, bronchoscopy was done. It demonstrated complete transection of the left mainstem bronchus at two rings from the carina. Emergency thoracotomy was performed, and an end-to-end anastomosis was carried out with interrupted 4-0 absorbable sutures. The anastomosis was wrapped with a fifth intercostal muscle flap.

Although bronchoplasty for benign disease is not commonly performed, the importance of maintaining bronchial patency with minimal loss of lung parenchyma is paramount. As such, these cases are particularly challenging and understanding the full range of therapeutic options, as presented in this chapter, is important for all thoracic surgeons.