Is a sleeve lobectomy significantly better than a pneumonectomy?

Abstract

A best evidence topic was written according to a structured protocol. The question addressed was 'whether a sleeve lobectomy results in a better survival rate than a pneumonectomy in suitable patients?' Altogether, more than 327 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude in the biggest meta-analysis of nearly 3000 patients, the five-year survival was 50% for sleeve lobectomy compared to 30% for pneumonectomy. Operative mortality was 3% vs. 6% for pneumonectomy, and locoregional recurrence was 17% vs. 30%. These results are broadly consistent across all the 13 cohort studies presented here many of which document a 20-year single centre experience or more. There are significant issues in all cohort studies on this subject as, due to their non-randomized nature, the reason for not performing a sleeve resection may well have been more advanced disease, which would necessarily mean that the pneumonectomy patients would have a lower expected survival and higher local recurrence. In addition, there have been many large cohort studies to date and thus no more are required, as future studies are unlikely to resolve this issue. Thus, the only study that would adequately correct for this issue would be a randomized trial, but to prove a 10% increase in five-year survival a 300 patient study would be needed. This is bigger than any study ever done in this area and as some centres took 30 years to collect these numbers of potential sleeve patients an RCT is not a realistic possibility. Therefore, we conclude that no more cohort studies should be performed, as the results will be consistent with the meta-analyses and an RCT to eliminate their bias is unattainable, and thus no more research should be done on this topic and surgeons should use the figures presented above and in more detail in this best evidence topic to govern their management in the future.

Parenchymal-Sparing Lung Resections: Technique of Sleeve Resections

“…The benefits of sleeve resection over pneumonectomy in terms of postoperative morbidity and mortality are now well established. [1][2][3] Parenchymal-sparing resections are preferred as long as an R0 resection can be achieved, even in those patients predicted to tolerate pneumonectomy based on preoperative pulmonary function tests. A thorough N1 nodal dissection is critical to minimize recurrence.…”

“…1,2 Moreover, several recent studies favor sleeve resection over pneumonectomy in terms of long-term survival, quality of life, and postoperative functional status. [1][2][3][4] Still somewhat controversial is the use of sleeve resection in patients with N1 disease. However, a recent study suggests that pneumonectomy provides no survival advantage over sleeve resection in the setting of N1 disease.…”

Die chirurgische Therapie des Lungenkarzinoms – Konsensusfähige Empfehlungen anhand der aktuellen Leitlinien

“…Diese Alternative zur Pneumektomie ist sowohl mit einer geringeren Mortalität als auch mit besseren funktionellen Ergebnissen und einem besseren Überleben verbunden. Die onkologischen Ergebnisse sind gleichwertig oder sogar besser, die 5-Jahres-Überlebensrate beträgt 50 % -im Vergleich zu 30 % bei der Pneumektomie [9]. Da eine Manschettenresektion jedoch technisch deutlich anspruchsvoller ist als eine Pneumektomie, wird dieses Verfahren leider nicht so häufig eingesetzt, wie es mög-lich wäre.…”

Single-port video-assisted thoracoscopic surgery (VATS) right pneumonectomy: a case report

“…In marginal cases where VATS sleeve or double sleeve lobectomy cannot be performed a conversion to open sleeve lobectomy is always preferred over a VATS pneumonectomy (1)(2)(3). Since indications for a VATS pneumonectomy are very limited, only a few reports of single-port VATS pneumonectomy exist (4,5).…”