Sleeve Resection & Sleeve Lobectomy
Lung-Sparing Surgery for Central Tumours

The airways branch like a tree. The trachea divides into the left and right main bronchi, and each main bronchus divides again into the bronchi supplying each lobe. A tumour that arises at one of those junctions, at the origin of a lobar bronchus or in the main bronchus itself, sits at the point where the airway to the whole lung passes. The traditional answer to that problem was to remove the entire lung, because removing the lobe alone would leave tumour behind at the cut edge of the bronchus.

A sleeve resection answers it differently. Instead of removing everything beyond the tumour, the surgeon removes a complete ring (a sleeve) of bronchus containing the tumour, with a clear margin above and below it, and then joins the two cut ends of the airway together. The join is a hand-sewn anastomosis. Once it has healed, air passes through it into the lung beyond exactly as it did before.

The first operation of this kind was performed in London in 1947, by Sir Clement Price Thomas at the Brompton Hospital, for a tumour of the bronchus. It has been standard practice for central airway tumours for decades since. It accounts for a small share of lung cancer operations, in the region of 6 to 8 per cent of resections, so it is reasonable to ask specifically whether it has been considered.

A tumour in the middle of the chest sits next to the main airways, the pulmonary artery and the heart. Being told it is too close to these structures usually means that a lobectomy alone would leave tumour at the cut edge, or that the operation would have to remove the whole lung. It does not always mean that no operation is possible.

Where the tumour involves the main bronchus, a sleeve resection removes that segment of airway and rejoins the ends. Where it involves the pulmonary artery, an arterial sleeve or double sleeve resection reconstructs the artery as well. Where it has grown into the pericardium, the sac around the heart, a section of it can sometimes be removed and repaired in the same operation. Chemotherapy and immunotherapy given first can also shrink a central tumour away from these structures.

Some tumours cannot be removed with a clear margin by any operation, for example where they extend along the airway beyond what can be rebuilt or involve every lobar airway on that side. Dr Okiror does not perform carinal resection or sleeve pneumonectomy. The assessment uses the CT, PET-CT and bronchoscopy to define exactly where the tumour reaches.

If you have been given this or another reason why surgery is not possible, the reasons and which of them can change are set out on the page told surgery is not an option. The wider treatment of tumours involving the lymph nodes or central structures is covered on the stage 3 lung cancer page.

The qualification that applies to all four. None of these comparisons is randomised, and patients selected for pneumonectomy tend to have larger, more central and more node-positive tumours than those selected for sleeve resection. Part of the survival difference reflects the disease rather than the operation. A sleeve resection is chosen because a complete resection can be achieved with a sound reconstruction. Preserving lung is the benefit; a complete resection is the condition for choosing it. Where the airway cannot be cleared and rebuilt, removing the whole lung is the correct operation and the evidence above does not argue against it.

This is the operation most patients do not know exists. Where a tumour grows within the wall of the bronchus and does not extend outward into the surrounding lung, the whole problem is a segment of airway. That segment is removed and the airway rebuilt. The lung beyond it is untouched, re-expands after the operation, and continues to work.

The tumours that behave this way are, most commonly, bronchial carcinoid tumours. These are slow-growing neuroendocrine tumours which often arise in a main or lobar bronchus, frequently in younger patients, and which are commonly mistaken for asthma for months or years because they cause wheeze, cough and repeated infection in the same part of the lung. Typical carcinoid tumours are cured by complete surgical removal in the great majority of cases. Removing an entire lung from a young patient to treat a tumour sitting inside a centimetre of bronchus is a poor trade where a sleeve resection can clear it.

The same principle applies to some rarer airway tumours: low-grade mucoepidermoid carcinoma, and adenoid cystic carcinoma, which spreads along the inside of the airway wall and therefore needs generous margins along its length. These are discussed further on the rare chest tumours page.

Dr Okiror has performed bronchial sleeve resection without lung resection at the left main bronchus and at the bronchus intermedius, the segment of airway between the right upper lobe and the lower part of the right lung, which is the commonest site for a carcinoid tumour that can be treated this way.

Where the tumour involves both the lobar bronchus and the lobe it supplies, the lobe is removed, as in a standard lobectomy, together with a circumferential segment of the adjacent main bronchus. The two remaining cut ends of the airway are then joined, reconnecting the rest of that lung to the trachea. The commonest version is a right upper lobe sleeve lobectomy, where the right upper lobe and a sleeve of the right main bronchus are removed and the bronchus intermedius is sewn to the main bronchus.

The comparison to hold in mind is what the alternative costs. A right pneumonectomy removes around 55 per cent of the lung tissue and the corresponding share of the pulmonary vascular bed. A right upper lobe sleeve lobectomy removes the upper lobe and keeps the rest. For a patient with limited breathing reserve, that difference decides whether surgery is possible at all, which is why borderline lung function is one of the strongest indications to attempt a sleeve reconstruction.

A sleeve lobectomy is also indicated where bulky lymph nodes at the origin of a lobar bronchus make a standard lobectomy impossible: the node involvement extends into the bronchial wall, so the bronchus must be resected further back than a lobectomy allows.

The pulmonary artery runs alongside the bronchus, and a central tumour frequently involves both. Involvement of the interlobar pulmonary artery has historically been one of the standard reasons to proceed to pneumonectomy: if the artery to the remaining lobes cannot be preserved, the lobes cannot be preserved either.

The artery can also be reconstructed. Where tumour involves a segment of the pulmonary artery, that segment is resected and the artery repaired or reconstructed: a pulmonary artery sleeve, also called an arterial sleeve. Where the bronchus and the artery are both involved, both are resected and both reconstructed in the same operation. That is a double sleeve, or bronchovascular sleeve resection.

It is a longer and more demanding operation than a bronchial sleeve alone, it requires control of the pulmonary artery above and below the resected segment, and it is performed in a minority of units. Its value is that it moves the boundary of what can be preserved. Patients whose tumour involves both structures, and who would otherwise be offered a pneumonectomy, may keep the rest of that lung.

Dr Okiror performs pulmonary artery sleeve and double sleeve resection. As with bronchial sleeve resection, the operation is undertaken only where a complete resection can be achieved; where the artery cannot be reconstructed with a clear margin, the correct operation is a pneumonectomy.

In Dr Okiror’s practice a sleeve resection includes bronchoscopy at three separate points, all under the same anaesthetic on the day of surgery. This is how he conducts the operation; it is not a separate procedure or an extra admission.

Diagnostic bronchoscopy before admission is a separate matter and is usually already part of the work-up by the time a patient reaches a surgical opinion. Airway assessment and intervention outside the context of resection is covered on the central airway interventions page.

Most of Dr Okiror’s lung cancer operations are performed robotically or by keyhole technique. Sleeve resection is the exception. Open thoracotomy remains his most common approach to a sleeve resection, and it remains the standard for complex airway reconstruction generally.

He does perform sleeve resection robotically in selected cases. What decides the approach is the reconstruction: the extent of airway to be resected, the position of the anastomosis and how accessible it is, the quality of the bronchial tissue to be joined, whether the pulmonary artery is involved as well, and whether previous treatment has scarred the tissue planes. Where all of those favour it, the operation can be completed robotically to the same standard. Where they do not, an open approach gives the control the reconstruction needs.

Patients who have read about minimally invasive surgery sometimes hear an open approach as a step backwards. The access is chosen to fit the operation: a lobectomy is done robotically because that suits it, and a complex airway reconstruction is done openly for the same reason. An anastomosis that leaks or narrows is the most serious complication of this operation, and nothing is traded against getting it right.

Everyone considered for a sleeve resection is assessed as though a pneumonectomy might be necessary. Occasionally the disease at operation proves more extensive than the imaging suggested, and completing the resection means removing the whole lung. Fitness is therefore assessed against the larger operation, with lung function testing and, where reserve is limited, cardiopulmonary exercise testing, set out on the lung function and fitness pages. Consent for a sleeve resection includes that possibility, and it is discussed before the day.

The early recovery follows the pattern of the approach used. Where the operation has been performed openly, the hospital stay is longer than after a keyhole lobectomy and pain control is planned in advance. The approaches used are described on the pain relief after thoracic surgery page. General guidance on the weeks afterwards is on the recovery after lung surgery page.

What is specific to a sleeve resection is the anastomosis. It needs to heal, and healing depends on a good blood supply to the bronchial ends and on the lung beyond it inflating properly. Clearing secretions in the first days is more important than after a standard lobectomy, and physiotherapy starts early for that reason.

Follow-up is clinical and by CT. Bronchoscopy afterwards is arranged where something raises a question about the join: a cough that persists, a wheeze localised to one side, breathlessness that does not settle in the expected way, or an infection recurring in the same part of the lung. Narrowing at the anastomosis is uncommon and is treatable when it is found early, so those symptoms should be reported promptly.

Where the pathology shows nodal involvement, adjuvant treatment is discussed at the multidisciplinary team meeting in the usual way. Having had a sleeve resection rather than a pneumonectomy generally makes systemic treatment easier to tolerate, because more lung has been kept.