Management of Anastomotic Complications After
Sleeve Lobectomy for Lung Cancer
Katsunobu Kawahara, MD, Sinji Akamine, MD, PhD, Takao Takahashi, MD,
Akihiro Nakamura, MD, Masashi Muraoka, MD, Hiroharu Tsuji, MD,
Shinsuke Hara, MD, Yutaka Tagawa, MD, Hiroyoshi Ayabe, MD, and
Masao Tomita, MD
First Department of Surgery, Nagasaki University School of Medicine, Nagasaki, Japan
One hundred twelve patients (102 male and 10 female)
underwent sleeve lobectomy for lung cancer from Janu-
ary 1969 to December 1991. Bronchopleural fistula oc-
curred in 6 (5.6%), bronchovascular fistula in 2 (1.8%),
pulmonary arterial occlusion in 2 (1.9%), anastomotic
stricture or stenosis in 7 (6.3%),and local recurrence in 7
patients (6.3%). Early repair of bronchopleural fistula
combined with an omentopexy achieved permanent clo-
sure of the fistula. Two patients who underwent a com-
pletion pneumonectomy for a pulmonary arterial occlusion
died of respiratory failure. Two patients experienced
A lthough bronchoplastic procedures generally are
safe, anastomotic complications are serious and
frequently fatal. Extended lymph node dissection for lung
cancer increases the risk of bronchial wall ischemia and
anastomotic dehiscence [l, 21. An extended resection also
may result in excessive tension on the bronchial suture
line, leading to anastomotic dehiscence or stricture. How-
ever, limited resection increases the chance of local recur-
rence. Our experience in the management of bronchial
anastomotic complications after sleeve lobectomy for lung
cancer is presented, and the relevant literature is re-
viewed.
Material and Methods
From January 1969 to December 1991, 132 patients under-
went sleeve lobectomy at Nagasaki University Hospital.
The operation was performed for lung cancer in 112
patients (102 male and 10 female; 77%), and this cohort
forms the basis for this study. Patient age ranged from 40
to 79 years (mean age, 63 years). The histologic type and
TNM stage are shown in Table 1.
Indications for a Sleeve Lobectomy for Lung Cancer
A sleeve lobectomy was performed when the lung cancer
involved the orifice of a lobar bronchus or extended
proximally into a main or intermediate bronchus. Sleeve
resection also was performed in patients who were not
Accepted for publication Sep 20, 1993.
Address reprint requests to Dr Kawahara, First Department of Surgery,
Nagasaki University School o f Medicine, Sakamoto I-Chome 7-1, #852,
Nagasaki, Japan.
0 1994 by The Society of Thoracic Surgeons
uncontrollable bleeding into the bronchial tree through a
bronchovascular fistula and sudden death. Completion
pneumonectomy is indicated for a stricture due to scar
formation. If pneumonectomy is precluded by poor pul-
monary reserve, endoscopic excision using biopsy for-
ceps is an alternative. Endoscopic resection is the treat-
ment of choice for suture granulomas. Complications
associated with bronchial or vascular anastomoses are
serious and frequently fatal.
(Ann Thorac Surg 1994;57:1529-33)
likely to tolerate a pneumonectomy for central tumors due
to poor pulmonary reserve or who suffered from suppu-
ration or bleeding caused by tumor with or without
mediastinal node involvement.
Surgical Techniques
Standard surgical technique was used [14]. As much
peribronchial vascular tissue at the site of resection as
possible was preserved, and a tumor free-margin was
verified by frozen-section examination of the proximal
and distal bronchial margins of the specimen. Bronchial
anastomoses were performed using interrupted 3-0 or 4-0
absorbable polyglycolic acid (Vicryl; Ethicon, Somerville,
NJ) sutures. Continuity of the bronchial tree was restored
by creating an end-to-end anastomosis. Luminal disparity
was corrected by tailoring the approximation of the mem-
branous portions. The suture line was covered circumfer-
entially with either a parietal pleural flap, pericardial fad
pad, or pericardial flap. Arterial anastomoses were per-
formed using continuous 5-0 or 6-0 polypropylene
(Prolene; Ethicon) sutures.
Results
Sleeve lobectomy combined with pulmonary angioplasty
was performed in 37 patients, and segmental resection of
the pulmonary artery was performed in 21 patients. Ten
patients underwent tangential resection of the pulmonary
arterial wall and direct suture closure. Patch repair was
performed in 6 other patients using a polytetrafluoroeth-
ylene (Gore-Tex; W.L. Gore & Assoc, Naperville, IL)
sheet. Twenty-four patients suffered bronchial anasto-
motic complications (21.4%), 2 of whom died within 30
0003-4975/94/$7.00
1530 KAWAHARA ET AL
COMPLICATIONS OF SLEEVE LOBECTOMY
Table 1. Histology and TNM Stage of Lung Cancer in 112
Patients Undergoing Sleeve Resection
No. of
Variable patients(%)
Histology
Squamous cell carcinoma 83 (74.2)
Adenocarcinoma 15 (13.4)
Large cell carcinoma 7 (6.3)
Small cell carcinoma 5 (4.5)
Adenosquamous cell carcinoma l(0.9)
Stage
I 29 (25.9)
I1 15 (13.4)
IIIA 57 (50.9)
IIIB 8 (7.1)
IV 3 (2.7)
days postoperatively. Surgical complications included
bronchopleural fistula in 6 patients (5.6%),bronchovascu-
lar fistula in 2 (1.8%), local recurrence in 8 (7.1%), and
pulmonary arterial occlusion in 2 patients (1.8%)(Table 2).
Bronchopleural Fistula
Bronchopleural fistula presented from 4 to 14 days post-
operatively and was heralded by hemoptysis, pyrexia,
and tachycardia. Five patients had stage IIIA disease and
1 had stage I. Two patients underwent pulmonary angio-
plasty, and 1 patient underwent pulmonary artery and
superior vena cava resection. Reanastomosis of the right
main bronchus in the presence of a bronchopleural fistula
was performed in 2 patients. The bronchial anastomosis
was covered circumferentially with an omental flap in
both these patients. These patients survived from 5 to 7
months but died of metastatic disease. In 1 patient, the
bronchial stump was tumor-free on examination of the
frozen-section specimens, but cancer was detected on
the permanent section. A completion pneumonectomy
was performed in 2 patients, who died of respiratory
failure 52 and 54 days after operation.
Closed thoracostomy tube drainage was performed in 1
patient, who died 47 days after operation. In another
patient, a minor endobronchial leak at the bronchial
anastomosis was sealed with fibrin glue. Unfortunately,
this patient died of local recurrence 13 months later.
Bronchovascular Fistula
Two patients died of uncontrollable bleeding into the
bronchial tree. In 1patient, a combined right upper sleeve
lobectomy and pulmonary arterial and superior vena cava
wedge resection had been performed. Massive hemopty-
sis occurred 3 days after operation. In another patient, a
right lower sleeve lobectomy, combined with an intratho-
racic esophagectomy and gastric pull-through reconstruc-
tion using the retrosternal route, was performed. Bleed-
ing occurred 10 days after the operation.
Pulmonay Arterial Occlusion
Pulmonary arterial occlusion occurred in 2 patients, each
of whom had undergone a sleeve lobectomy combined
Ann Thorac Surg
1994;57152933
with segmental resection of the pulmonary artery. Com-
pletion pneumonectomy was performed 4 days after the
initial operation. These patients died of respiratory failure
47 and 55 days later.
Stricture or Stenosis of the Bronchial Anastomosis
Stricture of the bronchial anastomosis secondary to scar
formation developed in 3 patients, and stenosis due to
granuloma formation in 4 additional patients. Two pa-
tients had stage I disease, l had stage 11, 3 had stage IIIA,
and 1 had stage IIIB disease. Completion pneumonec-
tomy was performed in 2 patients because of lobar atel-
ectasis due to a severe stricture at the right main bronchus.
One of these 2 patients is alive 10 years postoperatively, and
the other died of an unrelated cause 6 years after opera-
tion. Endoscopic laser therapy combined with balloon
dilation of a bronchial anastomotic stricture was per-
formed in 1 patient who had undergone right upper and
middle sleeve lobectomies. During a 4-year period, he
required endoscopic balloon dilation at 3- to 4-month
intervals to maintain a patent bronchial lumen. Endo-
scopic excision of bronchial suture granulomas was per-
formed in 4 patients, with satisfactory results. No patient
suffered recurrence of stenosis after excision of a suture
granuloma.
Local Recurrence
Local recurrence at the bronchial anastomosis or adjacent
proximal bronchus was detected by fiberoptic bronchos-
copy in 7 patients. All lesions were squamous cell carci-
noma. Six patients had stage IIIA disease, and 1 patient
had stage I disease. Two patients with stage IIIA disease
had undergone a sleeve lobectomy combined with a
pulmonary arterial segmentectomy. In all patients, the
bronchial stump was tumor-free on frozen section exam-
ination of the surgical specimen. However, 1 patient had
cancer at the bronchial margin on permanent section.
Adjunctive radiation therapy, 45 to 70 Gy, was admin-
istered to 5 patients, and a complete or partial response
was obtained in all patients. Four patients survived from
6 months to 3 years after operation but eventually died of
recurrent disease. One patient who survived 4 years after
operation, even though she suffered a local recurrence 2
years after sleeve lobectomy and received 70 Gy of radia-
tion therapy. However, the tumor had invaded the tra-
chea, requiring the insertion of a expandable metallic
stent to preserve tracheal patency. In another patient, a
completion sleeve pneumonectomy was performed fol-
lowing tumor recurrence after radiation therapy for a
tumor that had extended to the carina. This patient died
due to anastomotic leakage 6 days after carinal resection.
Two patients refused further therapy for local recurrence
and died of hematologic metastases.
Comment
Bronchopleural fistula results from ischemia of the bron-
chial anastomosis. The most common cause is disruption
of the vascular supply during extensive peribronchial
dissection, as can occur with dissection of the subcarinal,
Table 2. Complications of Bronchial Anastomosis After Sleeve Lobectomy for Lung Cancer
Patient Age
No. (y) Sex TNM Stage Histology Primary Procedure Complication Treatment for Complication Outcome
1 70 M T3NOMO IIIA Squamous cell carcinoma RUL-SL PA-seg Bronchopleural fistula Completion pneumonectomy 52 days" (respiratory
failure)
2 74 M T3N2MO IIIA Squamous cell carcinoma RLL-SL Bronchopleural fistula Reanastomosis with 7 moa (metastatic
omentopexy disease)
3 60 M T2NOMO I Squamous cell carcinoma RUL-SL Bronchopleural fistula Chest tube drainage 47 days" (renal
failure)
4 61 M T2NOMO I Squamous cell carcinoma RLL-SL Bronchopleural fistula Endoscopic sealing with 13 moa (metastatic
fibrin glue disease)
5 72 M T2N2MO IIIA Adenocarcinoma LUL-SL Bronchopleural fistula Completion pneumonectomy 54 days" (respiratory
failure)
6 67 M T3N2MO IIIA Squamous cell carcinoma RUL-SL Bronchopleural fistula Reanastomosis with 5 moa (metastatic
omentopexy disease)
7 66 M T4N2MO IIIB Adenocarcinoma RUL-SL PA-wedge Bronchovascular fistula .. 3 days" (suffocation
SVC repair due to bleeding)
8 66 M T4N2MO IIIB Squamous cell carcinoma RLL-SL Bronchovascular fistula ... 10 days" (suffocation
esophagectomy due to bleeding)
9 64 M T3NlMO IIIA Squamous cell carcinoma LUL-SL PA-seg Pulmonary arterial Completion pneumonectomy 2 mo" (respiratory
obstruction (day 4) failure)
10 54 M T3N2MO IIIA Adenocarcinoma LUL-SL PA-wedge Pulmonary arterial Completion pneumonectomy 2 moa (respiratory
obstruction (day 4) failure)
11 50 M T3N2MO IIIA Squamous cell carcinoma RUL-SL Stricture Completion pneumonectomy 10 Y
12 75 M T2NOMO I Squamous cell carcinoma RUL-SL Stricture Endoscopic excision of 6Y
suture granuloma
13 48 M T3NOMO IIIA Squamous cell carcinoma RUL-SL Stricture Completion pneumonectomy 6 p (unrelated)
14 69 M T3NOMO IIIA Squamous cell carcinoma RUL-SL Stricture Endoscopic excision of 3Y
suture granuloma
15 65 M T2NlMO Squamous cell carcinoma LUL-SL PA-wedge Stricture Endoscopic excision of 5Y
suture granuloma
16 64 M T4NlMO IIIB Squamous cell carcinoma LUL-SL PA-wedge Stricture Endoscopic excision of 2 moa (aortic
suture granuloma rupture)
17 68 M T2NOMO I Squamous cell carcinoma RM&UL-SL Stricture Endoscopic laser & balloon 4Y
dilation
18 51 M T3N2MO IIIA Squamous cell carcinoma RUL-SL PA-seg Local recurrence (refusal) 12 moa (recurrence)
19 75 M T3NOMO IIIA Squamous cell carcinoma RUL-SL Local recurrence Radiation 22 mo" (recurrence)
20 55 F T2N2MO IIIA Squamous cell carcinoma RUL-SL PA-wedge Local recurrence Radiation, expandable 51 mo" (recurrence)
metallic stents
21 77 M T2N2MO IIIA Squamous cell carcinoma RM&LL-SL Local recurrence Radiation 6 moa (recurrence)
22 72 M T3N2MO IIIA Squamous cell carcinoma LUL-SL Local recurrence (rehsal) 24 moa (recurrence)
23 61 M T2NOMO IIIA Squamous cell carcinoma RLL-SL Local recurrence Radiation, completion 12 moa (recurrence)
pneumonectomy
24 63 M T2N2MO IIIA Squamous cell carcinoma RUL-SL Local recurrence Radiation 30 moa (recurrence)
a Death.
LLL = left lower lobe; LUL = left upper lobe; PA-seg = pulmonary arterial segmentectomy; PA-wedge = pulmonary arterial wedge resection; RLL = right lower lobe; RM&LL = right middle
and lower lobe; RM&UL = right middle and upper lobe; RUL = right upper lobe; SL = sleeve lobectomy.
1532 KAWAHARA ET AL
COMPLICATIONS OF SLEEVE LOBECTOMY
hilar, and interlobar lymph nodes. Once a bronchopleural
fistula has been diagnosed, repair should be undertaken
immediately. The leak should be closed primarily and the
anastomosis wrapped circumferentially with an omental
flap, which enhances revascularization of the bronchial
wall [5]. In patients who are not likely to tolerate a
pneumonectomy, an attempt should be made to seal the
leak endoscopically with fibrin glue [6]. This is most likely
to be successful when the fistula is small. Chest tube
drainage alone is unlikely to be successful and may result
in the formation of an empyema and aspiration through
the fistula.
Patients in whom bronchovascular fistula develops may
die precipitously due to massive hemoptysis. Although a
pleural flap does not promote revascularization of the
bronchial anastomosis [7], most surgeons cover bronchial
anastomoses with tissue as a physical barrier to prevent
fistula formation [14, 81.
Severe anastomotic strictures must be excised and re-
anastomosis performed. If this is impossible, a completion
pneumonectomy is indicated if atelectasis or obstructive
pneumonia has developed in the lung remnant. An en-
dobronchial stent, such as the silicone tube stent [9] or an
expandable metallic stent [lo, 111, can be inserted through
the stricture after endoscopic dilation using a balloon,
bougie, or laser photocoagulation in patients who are not
likely to tolerate a completion pneumonectomy. Membra-
nous scars in the larger airways can be treated success-
fully with laser photocoagulation [ E l . Because strictures
are due to the loss of cartilaginous support and the
formation of thick scar tissue, stenosis will recur in most
cases. Photocoagulation therefore provides only tempo-
rary relief [13]. In this series, stenosis recurred 2 weeks
after laser photocoagulation. Completion pneumonec-
tomy was performed in 1patient and repeated endoscopic
balloon dilation in the other. Suture granulomas can be
excised easily with endoscopic biopsy forceps or ablated
by laser photocoagulation. We did not encounter suture
granulomas when an absorbable suture material, such as
Vicryl, Dexon, or polydioxanone was used.
The incidence of local recurrence has been reported to
be 10.3% after pulmonary resection and bronchoplastic
procedures [14]. Unless metastatic lesions are detected, a
completion pneumonectomy is indicated. Radiation ther-
apy is an alternative in patients for whom pneumonec-
tomy is contraindication or who refuse additional opera-
tion. Recently, endobronchial irradiation for malignant
airway obstruction, with and without tumor ablation
INVITED COMMENTARY
It would have been helpful if Kawahara and associates
had listed their bronchial complications in 7- or 8-year
successive time frames as there is a learning curve asso-
ciated with the performance of a successful and compli-
cation-free sleeve lobectomy. My early experience had a
Ann Thorac Surg
1994;571529-33
using a neodymium:yttrium-aluminum garnet laser, has
been reported to be successful [15, 161.
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higher incidence of bronchial complications, but as en-
hanced techniques learned through experience were ap-
plied to sleeve lobectomy, my anastomotic complication
rate has been significantly minimized. Kawahara and
associates are carrying out sleeve lobectomy in many