Sleeve pneumonectomy is extremely uncommon with 0.027–0.045% of primary lung cancer cases undergoing surgical treatment in 2014 and 2016.2−4 Although the 30-day mortality rate ranged from 0–5.9%, its hospital mortality ranged from 6.7–29.4%, and it is a highly invasive technique with high risk of complications and mortality.2−4 Sleeve pneumonectomy is rarely experienced even in a high-volume center, so re-operative cases and reports after sleeve lobectomy are also rare. Recently, salvage surgery is performed more frequently if strict indications are met for treatment-refractory cases or recurrence after treatment.1
Surgical approach (safe vascular treatment), anastomosis technique (preserving blood supply to the anastomotic site and anastomosis method), and perioperative management (prevention and management for complications) are important aspects of surgery.
In addition to sleeve lobectomy, previous induction/adjuvant chemotherapy may cause severe inflammation and adhesion around the tracheal bifurcation. Since the main tumor was in contact with the azygos vein stump immediately after branching from the SVC, a lateral approach from the thoracic cavity was possible and safe, considering the need for SVC reconstruction.
Sleeve pneumonectomy is mostly right-sided and approached by posterolateral thoracotomy.5 In this case, it was difficult to mobilize and divide the pulmonary artery more proximally via the lateral approach; therefore, median and posterolateral incision or hemi-clamshell incision was considered optimal. Although this surgical approach took a longer time including postural change, complicated blood vessel treatment could be performed under a good visual field without stress.
Maximal blood supply preservation and avoiding excessive tension are important for successful anastomosis. Tracheal blood flow is mainly supplied from the esophagus side, so the detachment of the dorsal side of the distal trachea was minimized in this case. Anastomosis from both sides is necessary for effective visualization of the anastomosis site due to the thickened tracheal wall and surrounding tissues and decreased mobility associated with adhesion. We used preferentially interrupted suture for cases with marked caliber mismatch or thickened bronchial wall. In this case, there was no caliber mismatch; therefore, the anastomosis was performed with an interrupted suture without adjusting the anastomosis. Telescope anastomosis easily corrects massive caliber mismatch by intussusception of the left main bronchus into the distal trachea and prevents kinking and excessive tension.6 In the present case, no obvious anastomosis-related complications were noted during follow-up.
Postoperative anastomotic complications occur in up to 14% of sleeve pneumonectomy cases, with mortality rate up to approximately 50% with a poor prognosis.7 Although anastomotic procedures are associated with anastomotic complications, preoperative treatment is important. In preoperative radiation therapy, high-dose irradiation increases the risk of bronchopulmonary fistula, and sleeve pneumonectomy has been reported as a relative-absolute contraindication for dose > 45 Gy.5 The irradiation dose in our case was 36 Gy, and no anastomotic complication occurred.
In conclusion, salvage surgery is performed more frequently if strict indications are met for treatment of refractory or recurrent cases. For airway reconstruction surgery on the proximal side, the difficulty of securing the airway and vessels more centrally and the effect of prior treatment, such as radiotherapy and/or chemotherapy, make the operation more difficult. The two-stage approach provides a good field of view and operative field and can be safely performed even in difficult operations.