Lung cancer remains the most fatal malignancy globally, responsible for more than 1.8 million deaths each year [1]. Centrally located tumors often necessitate complex surgical interventions. Although pneumonectomy was once considered the standard approach for centrally located tumors, sleeve resection has emerged as a less invasive, lung-conserving alternative with comparable outcomes [2,3]. First described in the 1950s, bronchoplastic procedures are now well-established for both malignant and selected benign lesions [4]. Sleeve lobectomy involves circumferential resection of a bronchus and reanastomosis of the airway, preserving pulmonary parenchyma. Its benefits include better postoperative pulmonary function and reduced morbidity [5]. However, most data originate from high-volume thoracic centers. There is limited literature from low-volume centers, especially in the Indian context. We present a case series of patients undergoing sleeve resections at our tertiary care institution in Northwest India, highlighting clinical characteristics, operative outcomes, and short-term follow-up.

This is a retrospective observational study conducted at SMS Medical College, Jaipur, from February 2023 to March 2025. All patients who underwent bronchial sleeve resection during this period were included. Preoperative evaluation included imaging (CT, PET-CT), bronchoscopy, and histopathological confirmation. Data collected included age, sex, ASA score, histology, operative time, complications, hospital stay, margin status, and lymph node yield. Follow-up was assessed at 1 and 3 months postoperatively. Descriptive analysis was performed using Microsoft Excel.

A total of 8 patients underwent sleeve resection for bronchial lesions at our institution between February 2023 and March 2025. The mean age was 46 years, with a male-to-femaleratio of 3:1 (6 males, 2 females). Three patients had a history of smoking.Demographic details, disease characteristics, complications, and follow-up outcomes are summarized in Table 1. The right lungwas more commonly involved (6 cases, 75%), and the most frequently performed resections were right upper, middle, lower, or intermediate sleeve resections. Left-sided resections were performed in 2 patients. The predominant histological diagnosis was Neuroendocrinetumor (4/8), followed by squamous cell carcinoma (2/8), mucoepidermoid carcinomaandadenocarcinoma. The mean operative timewas282.5 minutes, and the average number of lymph nodes removed was 13.5. Negative surgical margins were achieved in all cases. A single patient (12.5%) developed a prolonged air leak lasting more than 7 days, which was managed conservatively.The mean hospital stay was 6.25 days. At 1-month follow-up, all patients had uneventful recovery with no evidence of complications. At3 months, 7 out of 8 patients remained clinically stable without signs of recurrence. Table 1 : Sleeve Resection Case Summary Case Age/Sex Lesion Site Type of Resection Histology Complications Hospital Stay Margin Lymph Nodes Removed Follow Up 1 30/F Right Right lower sleeve lobectomy well differentiated neuroendocrine tumor Yes 11 negative 15 no evenfull 2 53/M Right Right upper and middle sleeve lobectomy Mucoepidermoid carcinoma No 5 negative 23 no evenfull 3 58/F Left left lower sleeve lobectomy well differentiated neuroendocrine tumor No 5 negative 16 no evenfull 4 29/M Right Right Intermediate bronchus resection well differentiated neuroendocrine tumor No 4 negative 11 no evenfull 5 37/M Right Right middle sleeve lobectomy Neuroendocrine tumor- Grade 2 No 5 negative 12 no evenfull 6 52/M Left left lower sleeve lobectomy adenocarcinoma no 8 negative 12 no evenfull 7 61/M Right Right lower sleeve lobectomy SCC no 5 negative 11 recurrence 8 48/M Right Right upper sleeve lobectomy SCC no 7 negative 8 no evenfull Case2Summary The patient presented with a tumor involving both the right upper and middle lobes, with extension into the intermediate bronchus. In order to achieve negative surgical margins, a combined right upper and middle lobectomy was performed, including resection of the intermediate bronchus. Bronchoplastic reconstruction was then carried out by anastomosing the right lower lobe bronchus to the right main bronchus. Post-operative recovery was uneventful. A follow-up chest X-ray at three months demonstrated full expansion of the right lower lobe, which had re-expanded to occupy the entire right pleural cavity, indicating good functional and anatomical outcome (Figure 1). Case 4 Summary The patient was diagnosed with a neuroendocrine tumor involving the right intermediate bronchus. Due to the prolonged course of the disease, there was associated atelectasis of the right middle and lower lobes. A bronchoplastic procedure in the form of sleeve resection of the intermediate bronchus was performed to preserve lung parenchyma. Postoperatively, the patient was managed with an intensive pulmonary rehabilitation program, including regular use of an incentive spirometer. At 6-month follow-up, imaging revealed satisfactory re-expansion of both the right middle and lower lobes, with significant improvement in pulmonary function (Figure 2). Case 5 Summary This patient was diagnosed with a neuroendocrine tumor originating from the right middle lobe, with extension into the intermediate bronchus. A middle lobectomy was performed along with resection of the involved portion of the intermediate bronchus. Bronchoplastic reconstruction was achieved by anastomosing the right lower lobe bronchus to the remaining segment of the intermediate bronchus. The procedure was aimed at preserving the functional capacity of the right lower lobe. Postoperative recovery was uneventful (Figure 3). Case 7 Summary The patient was diagnosed with squamous cell carcinoma localized to the right lower lobe, with preoperative bronchoscopy and imaging confirming limited disease. A right lower lobe sleeve resection was performed to achieve oncologic clearance while preserving lung function. The initial postoperative course was uneventful. However, at 3-month follow-up, imaging revealed disease recurrence, indicating early local relapse despite complete resection .

Sleeve resections enable effective tumor clearance while conserving lung tissue in central airway lesions. Its success hinges on surgical expertise and careful patient selection. Our series, though small, aligns with global reports demonstrating its safety and efficacy [6,7]. The absence of nodal metastasis in our cohort likely reflects the predominance of neuroendocrine and low-grade histologies. Similar findings were reported by Grillo and Gaissert, who emphasized sleeve resection's role in treating carcinoid tumors [8]. Notably, none of the patients in our series died postoperatively, a finding that aligns well with reported mortality rates of 1–4% in existing literature[9]. While larger series from high-volume centers have reported longer operative times and higher complication rates, our results suggest that with adequate training and support, sleeve resections can be safely performed in low-volume settings [10,11]. Case 2 demonstrated a classic indication for bronchoplastic resection, where a tumor involving both the upper and middle lobes extended to the intermediate bronchus. Resection of both lobes followed by re-anastomosis of the lower lobe bronchus to the right main bronchus preserved pulmonary function and allowed full re-expansion of the right lower lobe, as confirmed radiologically at 3 months. Such reconstruction avoids the morbidity associated with pneumonectomy and has shown comparable oncologic outcomes in multiple studies[5,12]. Neuroendocrine tumors, often considered low-grade malignancies with slow progression, may still lead to significant functional compromise due to prolonged bronchial obstruction. This was evident in Cases 4 and 5. In Case 4, the chronicity of disease resulted in complete atelectasis of the right middle and lower lobes. However, post-sleeve resection and pulmonary rehabilitation, re-expansion of the lung was achieved, demonstrating the functional reversibility following timely intervention. Case 5 involved a middle lobe neuroendocrine tumor extending into the intermediate bronchus, managed with a middle lobectomy and partial bronchial resection, followed by a successful bronchial anastomosis preserving the lower lobe. These findings emphasize that sleeve resections offer benefits beyond tumor removal, including the potential to restore lung function in selected low-grade tumors[13,14]. Case 7 presented a more aggressive histology—squamous cell carcinoma of the right lower lobe—with limited disease on preoperative imaging. Despite performing a right lower lobe sleeve resection with curative intent, the patient experienced disease recurrence within 3 months. This underscores the need for careful patient selection and the consideration of adjuvant therapy in high-grade malignancies. While sleeve resections are feasible in squamous cell carcinoma, early recurrence, as observed here, has been reported in literature and may be influenced by microscopic tumor spread beyond imaging resolution[6,15,16]. Overall, all patients in our series remained clinically stable at 3-month follow-up, with satisfactory lung expansion achieved postoperatively in bronchoplasty cases. Only one case showed recurrence, consistent with the known behavior of aggressive histologies like squamous cell carcinoma. Numerous studies advocate for sleeve resections as a preferable alternative to pneumonectomy, citing reduced complications and similar long-term outcomes [17,18]. Our findings are in line with published studies that support the safety and efficacy of sleeve resections even in a low-volume center, provided there is adherence to oncologic principles and postoperative surveillance. Limitations include small sample size, short follow-up duration, and lack of pulmonary function data postoperatively. However, this study adds to the growing body of evidence supporting lung-sparing strategies in thoracic surgery.

This case series underscores the efficacy and safety of sleeve lung resection as a parenchyma-preserving surgical option for central bronchial lesions, even within the setting of a low-volume thoracic unit. With meticulous patient selection, comprehensive preoperative evaluation, and skilled surgical technique, excellent short-term outcomes can be achieved, as demonstrated by minimal complications and high rates of postoperative lung re-expansion. Notably, limited intermediate bronchial resections with preservation of both lobes highlight the evolving scope of bronchoplastic procedures beyond conventional lobectomies. These findings advocate for broader adoption of lung-sparing techniques, especially in selected low-grade malignancies. Future prospective studies with larger cohorts and long-term follow-up are warranted to validate these observations and refine surgical indications.

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