Mainstem Bronchial Sleeve Resection With Pulmonary Preservation

Mainstem Bronchial Sleeve Resection With Pulmonary Preservation Robert J. Cerfolio, MD, Claude Deschamps, MD, Mark S. Allen, MD, Victor F. Trastek, MD, and Peter C. Pairolero, MD Section of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota Background. Resection of a mainstem bronchus with pulmonary preservation is a therapeutic option when disease is limited to the mainstem bronchus. We reviewed our experience with this procedure to determine the operative morbidity, mortality, and long-term out- come. Methods. From January 1965 through January 1995, 22 patients (13 male, 9 female) underwent circumferential mainstem bronchial sleeve resection without removal of pulmonary parenchyma. Median age was 37 years (range, 12 to 70 years). The right mainstem bronchus was involved in 12 patients and the left, in 10. Nineteen patients (86%) were symptomatic; symptoms included cough in 5, dyspnea in 5, wheeze in 3, hemoptysis in 3, and a combination of these in 3. Conventional tomography was done in 8 patients and identified every lesion. Bronchoscopy was diagnostic in all patients. Resection was for cancer in 15 patients (68%), benign stricture in 5 (23%), and an impacted broncholith in 2 (9%). The cancer was a carcinoid in 9 patients, a mucoepidermoid carcinoma in 3, squamous cell carcinoma in 2, and adenoid cystic carcinoma in 1. Fourteen patients were postsurgically classified as stage IliA (T3 NO M0) and 1 patient as stage IIIB (T4 N2 M0). The median length of the resected bronchus was 2.0 cm (range, 1.0 to 4.0 cm). Two patients required hilar release maneuvers. The bronchial anastomosis was reinforced with pleura in 10 patients, pericardium in 2, and serratus anterior muscle in 1. Results. There were no operative deaths. Three patients (14%) had postoperative complications. Follow-up was complete and ranged from 6 months to 25.7 years (median follow-up, 10.2 years). Twenty-one patients are currently alive. All patients are asymptomatic except 1 patient, who required a stent for an anastomotic stricture. No patient has had recurrence of cancer. Conclusions. In properly selected patients, mainstem bronchial sleeve resection with lung preservation can be performed safely and provides excellent relief of symptoms with good long-term survival. (Ann Thorac Surg 1996;61:1458-63) M ainstem bronchial sleeve resection is defined as circumferential resection of either mainstem bronchus. The procedure was first performed by Sir Clement Price Thomas in 1947 at the Westminster Hospital in London [1]. Resection of a mainstem bronchus is often performed with sleeve lobectomy; rarely, however, is it done without resecting any pulmonary parenchyma. This review examines our experience with this procedure. Patients and Methods Between January 1965 and January 1995, 17,213 pulmonary resections were performed at our institution. An additional 22 patients underwent mainstem bronchial resection with pulmonary preservation. Patients who had other bronchoplasty procedures, tracheal resection, bronchus intermedius resection, or any pulmonary resection were excluded. The records of these 22 patients were reviewed. Follow-up data were obtained from records of the patients' most recent clinic visits, correspondence Presented at the Forty-second Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9-11, 1995. Address reprint requests to Dr Deschamps, Mayo Clinic, 200 First St, SW, Rochester, MN 55905. from home health care providers, patient follow-up surveys, and telephone interviews. All patients with carcinoma were postsurgically staged by the TNM classification system of the American Joint Committee for Cancer Staging and End-Results Reporting [2]. Operative mortality included all deaths occurring within 30 days of operation or during the same hospitalization. Late mortality was defined as any subsequent death. Clinical Findings The median age at the time of mainstem bronchial sleeve resection for the 22 patients (13 male, 9 female) was 37 years (range, 12 to 70 years). The mainstem resection was on the right side in 12 and the left in 10. Indications for resection included an endobronchial malignancy in 15 patients (68%), a benign stricture in 5 (23%), and an impacted broncholith in 2 (9%). The 5 patients with a benign stricture all sustained blunt chest trauma prior to resection. The trauma occurred less than 2 months before resection in 3 patients, 25 years previously in 1 patient, and 30 years previously in 1. The cause of the trauma was a deceleration injury from a motor vehicle accident in 3 patients and a crush injury from heavy farm equipment in 2. Nineteen patients were symptomatic at the time of 1996 by The Society of Thoracic Surgeons 0003-4975/96/$15.00 Published by Elsevier Science Inc PII S0003-4975(96)00078-1

Ann Thorac Surg CERFOLIO ET AL 1459 1996;61:1458-63 MAINSTEM BRONCHIAL SLEEVE RESECTION MAyO 199~ Fig 1. Conventional tomogram of a 37-year-old man who sustained a crush injury to the chest at the age of 12 years demonstrates a 2.5-cm benign left mainstem bronchial stricture (arrow). Fig 3. (A) The patient is positioned in a standard lateral decubitus position, and a posterolateral thoracotomy is performed. (B) The carina and both mainstem bronchi as viewed from a right posterolateral thoracotomy. A 1-cm tumor is depicted in the right mainstem bronchus. diagnosis. Symptoms included cough in 5 patients, dyspnea in 5, audible wheeze in 3, hemoptysis in 3, and a combination of these in 3. The 3 asymptomatic patients were found to have bronchial narrowing after an abnormal chest roentgenogram. Chest roentgenography was done for all 22 patients, and the result was abnormal in 10 (45%). The roentgenograms demonstrated an infiltrate in 4 patients, complete lung collapse in 3, and lobar atelectasis in 3. Conventional tomography was performed in 8 patients and demonstrated the lesion in all of them (Fig 1). Chest computed tomography was performed in 7 patients and detected an endobronchial abnormality in 6 (86%) (Fig 2). Bronchoscopy was performed in all patients. A biopsy was done in 17 patients, and the specimens demonstrated malignancy in 15 of them. Preoperative pulmonary function testing was performed in 11 patients. The median functional vital capacity was 79% and ranged from 43% to 91% of predicted normal. The median forced Fig 2. Computed tomogram of a 48-year-old man shows a right mainstem bronchial carcinoid. expiratory volume in 1 second was 2.5 L (83% of predicted normal) and ranged from 47% to 97% of predicted normal. Anesthesia and Surgical Techniques The anesthesia techniques evolved over the 30 years of this study. At first, single-lumen endotracheal tubes were used. Currently, either a double-lumen tube or a long single-lumen tube with selective intubation of the contralateral mainstem bronchus is employed. Bronchoscopy was used to verify the position of the tube. The ipsilateral lung was ventilated across the operative field in 5 patients, and a jet ventilator was used in 3. Mediastinoscopy was performed in 2 patients, and the results were negative in both. The operative approach was through an ipsilateral posterolateral thoracotomy in all patients (Fig 3). The distal trachea and ipsilateral mainstem bronchus were mobilized. An opening was made distal to the lesion through the posterior membrane to assess resectability before the distal mainstem bronchus was transected (Fig 4). The proximal mainstem bronchus was subsequently transected and the sleeve removed. Circumferential histologic examination of the proximal and distal margins was done. In patients with a benign stricture, the resection was extended to healthy mucosa whenever possible. On the left side, adequate exposure was usually possible by gently retracting laterally the distal portion of the aortic arch. The bronchial anastomosis was performed with interrupted sutures with the knots placed outside the lumen (Fig 5). Nonabsorbable monofilament material was used in 18 patients and absorbable material in 4. The anastomosis was reinforced circumferentially with a pleural flap in 10 patients, pericardium in 2, and serratus anterior muscle in 1. Division of the inferior pulmonary ligament was performed in all patients. Pretracheal mobilization was used to decrease anastomotic tension in 21 patients,

1460 CERFOLIO ET AL Ann Thorac Surg MAINSTEM BRONCHIAL SLEEVE RESECTION 1996;61:1458-63 the main bronchus invading the distal trachea and one pretracheal node involved with carcinoma. Resection was complete in all patients except 1, who had microscopic evidence of adenoid cystic carcinoma at the margin. This patient received postoperative irradiation.... ~o Fig 4. The right mainstem distal bronchotomy is performed first, and the endobronchial lesion is assessed. A double-lumen endotracheal tube is positioned in the left mainstem bronchus. and intrapericardial release was added in 2. All patients had intraoperative bronchoscopy to assess patency of the lumen at completion of the anastomosis. All patients were extubated in the operating room or recovery room. The median length of resected mainstem bronchus was 2.0 cm (range, 1.0 to 4.0 cm). The cell type for the 15 patients with malignancy was carcinoid in 9, mucoepidermoid in 3, squamous cell in 2, and adenoid cystic in 1. Fourteen patients were postsurgically classified as stage IIIA (T3 NO M0), and 1 patient was staged IIIB (T4 N2 M0). This last patient had a squamous cell carcinoma of MAYO lgcas Fig 5. After removal of the right mainstem bronchial lesion and histologic examination of the margins, the anastomosis is performed with interrupted nonabsorbable monofilament sutures with knots placed outside the lumen. Results Hospitalization ranged from 4 to 14 days (median duration, 7.5 days). There were no operative deaths. Postoperative complications occurred in 3 patients (14%) and included reoperation for bleeding in 1, left vocal cord paralysis in 1, and an anastomotic stricture in I (2 months after resection). Follow-up was complete for all patients and ranged from 6 months to 25.7 years (median duration, 10.2 years). One patient died 24 years after resection of a myocardial infarction without any complications from the mainstem bronchial resection. The remaining 21 patients are currently alive. Twenty of the survivors are asymptomatic; 1 patient required multiple endobronchial laser treatments and stent placement for an anastomotic stricture. Seven other patients have had bronchoscopy after resection; none had any evidence of stricture formation or cancer recurrence. The single patient who received postoperative irradiation because of a positive proximal margin is alive and well without evidence of recurrent cancer 12 years after resection. Comment The goal of mainstem bronchial sleeve resection often is to preserve lung function without compromising survival. In 1955, Paulson and Shaw [3] presented the cases of 4 patients with traumatic bronchial disruption. All patients were treated with stricture resection, bronchial anastomosis, and pulmonary preservation. Later, in 1970, Paulson and associates [4] reported the results of 54 bronchoplasty procedures with lobectomy for carcinoma; 39 of the patients had circumferential excision of a mainstem bronchus. The feasibility and the success of bronchial sleeve resection for bronchopulmonary carcinoid tumor were further described by Wilkins and coworkers [5] in 1984. In their series of 111 patients seen over a 50-year period, operative mortality was 3.6%, and the 10-year survival rate was 82%. In that report, however, only 7 patients had resection with pulmonary preservation; two were mainstem bronchial resections. In 1987, Frist and associates [6] described the results for 15 patients who underwent mainstem bronchial resection with complete pulmonary preservation; only 1 patient, however, had a carcinoma. An updated report from the same institution by Newton and colleagues [7] comprised 27 patients, 15 of whom had carcinoma and 12, a variety of benign conditions. There were no operative deaths in the latter series, but 2 patients with benign disease required repeated dilations, and 1 subsequently died. In patients with benign disease, one of the concerns is whether the chronically atelectatic lung will resume acceptable function after airway reconstruction. Webb

Ann Thorac Surg CERFOLIO ET AL 1461 1996;61:1458-63 MAINSTEM BRONCHIAL SLEEVE RESECTION demonstrated in a canine model in 1953 that mainstern stricture caused by transection could later be treated by excision and bronchial reanastomosis [8]. In that model, the nonventilated lung reexpanded and resumed function after 9 months of complete atelectasis. Since then, several clinical reports [9, 10] have outlined the surgical techniques and the results of this type of procedure in patients with posttraumatic stricture. Mainstem bronchial resection has been shown to restore both airway patency and lung function after atelectasis lasting up to 9 years [11]. In our series, 2 patients had complete collapse of one lung 4 weeks and 6 weeks after trauma, and both lungs were reexpanded successfully. Careful patient selection is crucial. Bronchoscopy is mandatory in all candidates for the procedure. In patients with benign disease, bronchoscopy defines the proximal extent of the stricture and provides useful information regarding the remaining airway. Biopsy should be done of any suspicious area. None of our 15 patients with malignancy had bleeding complications after biopsy. In selected patients, the preoperative use of a laser or stent may allow drainage of pulmonary sepsis as a temporizing measure prior to surgical intervention [7]. Likewise, patients with diffuse airway disease, granulomatous disease, advanced malignancy, or bronchial collapse may better be treated with stent placement, laser, dilation, or irradiation rather than resection [12-16]. Select patients with broncholithiasis may also be treated nonsurgically [17]. Preoperative evaluation should include a chest roentgenogram to assess both the affected lung and the contralateral lung. Conventional tomography is an underused modality that provides excellent visualization of the trachea and rnainstem bronchus and is of greatest value in defining the distal extent of the stricture when bronchoscopy fails to traverse the lesion. Computed tomography is especially helpful in patients with endobronchial malignancy because it evaluates the pulmonary parenchyma, mediastinum, liver, and adrenal glands for metastatic disease. Recently helical computed tomography, which uses multiplanar reconstruction, has been shown to be highly accurate in diagnosing tracheal and mainstern bronchial stenoses [18]. Preoperative pulmonary function tests are of limited value. If the ipsilateral lung ventilates poorly preoperatively, pulmonary function often improves after resection. The decision to resect the mainstem bronchus should, therefore, be based on the patient's overall cardiopulmonary status. Careful anesthesia planning should precede the operation. A double-lumen endotracheal tube is preferable, but a long, straight tube placed in the contralateral bronchus or a bronchial blocker positioned in the ipsilateral bronchus are alternative options [19]. Across-thefield ventilation or jet ventilation can be used to ventilate both lungs if single-lung ventilation is poorly tolerated. Although we did not find it necessary in this series, the pulmonary artery may need to be occluded in select patients who become hypoxic after occlusion of the mainstem bronchus because of shunting. The surgical approach is through a posterolateral tho- racotomy in all patients because it allows access to the trachea, the mainstem bronchi, and the lung. Mediastinal lymph nodes are sampled for staging in all patients with malignancy prior to resection. The initial bronchotomy is placed distal to the lesion, and the airway is inspected. After circumferential transection distally, the mainstem bronchus is divided proximally, and both margins are histologically examined prior to the anastomosis. We favor complete resection of malignancy. If the distal margin has microscopic involvement by cancer, an upper lobectomy should be performed. If the proximal margin is microscopically involved with cancer, postoperative irradiation is warranted, especially for radiosensitive tumors. In select patients, sleeve pneumonectomy is also an option [20]. In patients with benign stricture, resection of all diseased mucosa is preferable. Anastomotic tension must be eliminated [7]. We favor interrupted sutures tied with knots outside the lumen. Inferior pulmonary ligament division was used routinely in our patients, and both hilar release and pretracheal mobilization were used selectively. Postoperative care should include early extubation to decrease pressure on the bronchial anastomosis and epidural anesthesia for pain management. Early ambulation, incentive spirometry, and chest physical therapy are part of the routine postoperative care to decrease respiratory complications. Bronchoscopy prior to dismissal provides a baseline view of the anastomosis. Lifelong follow-up is mandatory because patients have had local anastomotic recurrence of cancer as long as 17 years after resection [21]. In conclusion, mainstem bronchial resection is a safe and effective procedure in select patients. The indications include localized tumors, strictures, impacted broncholiths, and traumatic damage to the mainstem bronchus. When patients are properly selected and when careful anesthesia and surgical techniques are used, this procedure offers pulmonary preservation with excellent longterm function and survival. References 1. Thomas CP. Conservative resection of the bronchial tree. J R Coll Surg Edinb 1956;3:168-86. 2. Beahrs OH, Myers MH. American Joint Commission on Cancer: manual for staging of cancer. 2nd ed. Philadelphia: Lippincott, 1983:178. 3. Paulson DL, Shaw RR. Bronchial anastomosis and bronchoplastic procedures in the interest of preservation of lung tissue. J Thorac Surg 1955;29:238-59. 4. Paulson DL, Urschel HC, McNamara JJ, Shaw RR. Bronchoplastic procedures for bronchogenic carcinoma. J Thorac Cardiovasc Surg 1970;59:38-48. 5. Wilkins EWJr, Grillo HC, Moncure AC, Scannell JG. Changing times in surgical management of bronchopulmonary carcinoid tumor. Ann Thorac Surg 1984;38:339-44. 6. Frist WH, Mathisen DJ, Hilgenberg AD, Grillo HC. Bronchial sleeve resection with and without pulmonary resection. J Thorac Cardiovasc Surg 1987;93:350-7. 7. Newton JR Jr, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation. Ann Thorac Surg 1991;52:1272-80. 8. Webb WR. Studies of the re-expanded lung after prolonged atelectasis. Arch Surg 1953;66:801-9.

1462 CERFOLIO ET AL Ann Thorac Surg MAINSTEM BRONCHIAL SLEEVE RESECTION 1996;61:1458-63 9. Lin MY, Wu MH, Chan CS, Lai WW, Chou NS, Tseng YL. Bronchial rupture caused by blunt chest injury. Ann Emerg Med 1995;25:412-5. 10. Kinsella TJ, Johnsrud LW. Traumatic rupture of the bronchus. J Thorac Surg 1947;16:571-83. 11. Nonoyama A, Masuda A, Kasahara K, Mogi T, Kagawa T. Total rupture of the left main bronchus successfully repaired nine years after injury. Ann Thorac Surg 1976;21:445-8. 12. O'Donnell AE, Tsou E, Awh C, Fallat ME, Patterson K. Endobronchial eosinophilic granuloma: a rare cause of total lung atelectasis. Am Rev Respir Dis 1987;136:1478-80. 13. Edeli ES, Cortese DA, McDougall JC. Ancillary therapies in the management of lung cancer: photodynamic therapy, laser therapy, and endobronchial prosthetic devices. Mayo Clin Proc 1993;68:685-90. 14. Daum TE, Specks U, Colby TV, et al. Tracheobronchial involvement in Wegener's granulomatosis. Am J Respir Crit Care Med 1995;151:522-6. 15. Nakamura K, Terada N, Ohi M, Matsushita T, Kato N, Nakagawa T. Tuberculous bronchial stenosis: treatment with balloon bronchoplasty. AJR 1991;157:1187-8. 16. Nienhius DM, Prakash UB, Edell ES. Tracheobronchopathia osteochondroplastica. Ann Otol Rhinol Laryngol 1990;99: 689-94. 17. Trastek VF, Pairolero PC, Ceithaml EL, Piehler JM, Payne WS, Bernatz PE. Surgical management of broncholithiasis. J Thorac Cardiovasc Surg 1985;90:842-8. 18. Whyte RI, Quint LE, Kazerooni EA, Cascade PN, Iannettoni MD, Orringer MB. Helical computed tomography for the evaluation of tracheal stenosis. Ann Thorac Surg 1995;60: 27-31. 19. Ginsberg RJ. New technique for one-lung anesthesia using endobronchial blocker. J Thorac Cardiovasc Surg 1981;82: 542-6. 20. Jensik RJ, Faber LP, Kittle CF, Miley RW, Thatcher WC, El-Baz N. Survival in patients undergoing tracheal sleeve pneumonectomy for bronchogenic carcinoma. J Thorac Cardiovasc Surg 1982;84:489-96. 21. Grillo HC, Mathisen DJ. Primary tracheal tumors: treatment and results. Ann Thorac Surg 1990;49:69-77. DISCUSSION DR HAROLD C. URSCHEL, JR, (Dallas, TX): I compliment Dr Cerfolio on an excellent presentation that brings to our attention an important aspect of bronchoplasty. I had not planned to discuss this, but Dr Deschamps gave me the manuscript, and I will emphasize two points that are in it. Sir Clement Price Thomas published the first account of bronchoplasty resection. Actually, Gerbauer performed the first bronchoplasty for benign disease and I think Dr Robert Shaw did the first for malignant disease. Sir Clement Price Thomas was in the United States, saw them do it, went home, did one, and reported it earlier. The first one for cancer was done in Dallas, to the best of my knowledge. That group reported its results in 1955, and we did it again in 1970. The important thing is that the morbidity and mortality for pneumonectomy are high. Therefore, lung tissue should be spared whenever possible. Bronchoplasty is very difficult, particularly in the left mainstem bronchus. I think this presentation by Dr Cerfolio is very well done. I did not have a chance to review our data, but I think we have done more than 300 bronchoplasties. Dr. Cerfolio, how many bronchoplasties does this series of 22 represent, not total pulmonary resections but bronchoplasty procedures? We have roughly 40 for just mainstem bronchi. Broncholiths located near the carina can become adherent to both the right and left mainstem bronchi. They can be devastating problems causing bleeding and infection and require careful management. The most interesting group was in this report. Doctor Harrell, a pulmonologist in San Diego, does a lot of laser and stent work for bronchoplasty. Seven or 8 years ago, he referred to us a patient who was pregnant and had a totally obstructed left mainstem bronchus. Because of the distal infection, he had to use a laser to open the obstructing mucoepidermoid carcinoma. He then placed a stent to hold it open. This cleaned out the patient's lungs, and she delivered the baby. We resected that lesion at an interval stage with only bronchosplasty. The patient is alive and doing well. Since that time, we have had approximately 10 patients who have had some sort of acute obstruction with distal infection. One effective form of treatment of these patients is to open up the bronchus, place a stent, and then drain the lung. At a later time, perform the resection, whether it be for a carcinoid or any other type of tumor. DR CERFOLIO: Thank you for your comments, Dr Urschel. You raise several points. I do not have the exact number of bronchoplasties performed over this 30-year interval. However, similar to your data, this series is a mere fraction of the patients who underwent bronchoplasty. We had a very strict definition and equally strict entry criteria for this study. Only patients who had complete circumferential resection were included in this series. Only 2 of the 22 patients had impacted broncholiths. A bronchoplasty procedure was initially tried, and because the broncholith and the tissue around it were so inflamed, a circumferential resection had to be performed. The other topic concerned draining a septic lung. We agree that in select patients, either a stent or laser can be used successfully to drain a lung that has been atelectatic, septic, or both. If indicated, resection of the bronchus can then be performed subsequently. DR JOSEPH I. MILLER, JR, (Atlanta, GA): I congratulate Dr Cerfolio and associates on an exceedingly well done report and thank them for the opportunity to briefly review it before presentation. I, too, emphasize the extremely rare incidence of this. As pointed out, the incidence in this study was 22 cases in about 17,200 resections, or 0.1%, in a 30-year period at the Mayo Clinic. I have a couple of questions. First, in this group of patients, 15 had bronchial adenomas, only two of which were squamous cell carcinomas; so 13 of the 15 patients with tumor had bronchial adenomas. In this subgroup, was the reason for circumferential resection the extent of involvement on the circumferential wall? A lot of bronchial adenomas arise on the posterior wall and could be excised by bronchotomy with reconstruction and reinforcement. Second, my colleagues and I see a large number of patients with a mainstem bronchial adenoma, and frequently they are not surgical candidates. They are elderly. I submit that yttriumaluminum garnet laser therapy combined with endobronchial

Ann Thorac Surg CERFOLIO ET AL 1463 1996;61:1458-63 MAINSTEM BRONCHIAL SLEEVE RESECTION brachytherapy leads to almost total control of the adenomas when the patients are not candidates for surgical intervention. We have had at least 5 needing major resection, and they could not tolerate even a thoracotomy physiologically. Laser therapy plus brachytherapy was used. My final comment concerns your stricture group. I realize this study covers a 30-year period and that stents were not readily available until 1993. However, in the stricture group, maybe rather than resection, dilation and stenting might prove helpful. DR CERFOLIO: Thank you, Dr Miller, I appreciate your comments. You had three points. The first one concerns 13 of the 15 patients who had primary endobronchial tumors, excluding the 2 patients with squamous cell carcinoma. This series does not represent all patients who had endobronchial malignancies in the mainstem bronchus. Bronchotomy was initially attempted in some instances, but full circumferential resection was necessary to remove all tumor and achieve negative margins. The second point concerns yttrium-aluminum garnet laser treatment and brachytherapy in patients who are either too old or too sick to undergo resection. We agree that in selected patients, this is a viable option. The last point concerns patients with strictures. We think that in a young person with a posttraumatic stricture, the best chance for long-term function without having to return for stent removal or replacement is to proceed with stricture resection and primary anastomosis. We favor this option in patients who are good surgical candidates. However, in selected patients, stenting can be an option. DR MARK J. KRASNA (Baltimore, MD): I have a brief technical comment. With our experience now with lung transplantation, my associates and I have found that a telescoping anastomosis with a figure-of-8 suture is very good when we are resecting the main bronchus distally or at the bronchus intermedius. I think that when a true main bronchus resection that is flush with the carina, as you described, is done, one usually does not have the option to telescope. Therefore, we generally use an intercostal muscle flap and simply wrap it circumferentially. DR CERFOLIO: We agree. None of the patients in this series had the telescoping method, and as described, we favor wrapping the bronchial anastomosis with vascularized tissue in select patients.