Avoiding pneumonectomy in chronic complete lung atelectasis: sleeve right upper lobectomy for right main bronchus obstruction—case report

Introduction

Main bronchus obstruction may arise from both benign and malignant conditions, including post-inflammatory stenosis and endobronchial tumors. These lesions often affect young patients and may lead to prolonged complete lung atelectasis due to delayed diagnosis, as clinical symptoms can remain limited and non-specific. Despite radiological evidence of total lung collapse, the obstructive process is frequently limited to the main bronchus or extends only a short distance distally (not beyond the upper lobe bronchus), preserving the potential for anatomically conservative resection.

In current surgical practice, sleeve lobectomy has progressively replaced pneumonectomy as the preferred treatment for centrally located airway lesions whenever complete resection is feasible. Multiple series have demonstrated that sleeve resection provides equivalent oncological outcomes while significantly reducing perioperative morbidity and preserving postoperative pulmonary function (1-3).

However, the indication for sleeve resection in the setting of long-standing complete atelectasis remains controversial. Chronic airway obstruction is intuitively associated with concerns of irreversible parenchymal damage, fibrosis, and impaired re-expansion, as well as potential risks related to reperfusion injury and bronchial anastomotic healing. Consequently, pneumonectomy is still frequently considered in such cases, reflecting uncertainty regarding the limits of lung viability after prolonged collapse.

Here, we present two cases of long-term complete atelectasis due to main bronchus obstruction successfully managed by sleeve lobectomy. This report aims to advance current practice by illustrating: (I) the potential for functional recovery of chronically atelectatic lung parenchyma after restoration of airway continuity; and (II) the long-term safety and durability of the bronchial anastomosis, supported by extended follow-up of up to eight years in one patient. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0026/rc).

Cases presentation

All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Case 1

A 30-year-old female was referred to the Institute of Pneumonology “Marius Nasta”, Bucharest, in May 2018, presenting with progressive dyspnea over a 9-month period. Her medical history was notable for pulmonary tuberculosis, successfully treated in 2016, with complete clinical recovery until the onset of current symptoms. Her physical examination was marked by dyspnea and absent breath sounds on the right side.

Chest computed tomography (CT) demonstrated complete right lung atelectasis, associated with ipsilateral mediastinal shift and elevation of the right hemidiaphragm. The right main bronchus appeared completely obstructed (Figure 1). Flexible bronchoscopy confirmed severe stenosis of the right main bronchus with complete luminal occlusion and a diverticular appearance (Figure 1). The pulmonary function was [forced vital capacity (FVC) =46.2%, forced expiratory volume in 1 second (FEV₁) =43.8%, diffusing capacity of the lungs for carbon monoxide (DLCO): 41.2%, maximal oxygen consumption (VO_2max): 14.51 mL/min/kg].

Figure 1 Preoperative axial chest CT (A) and flexible bronchoscopy at the level of the carina (B). CT, computed tomography.

A right lateral thoracotomy was performed. Intraoperatively, dense pleuropulmonary adhesions were encountered and carefully lysed, allowing mobilization of the collapsed lung. The right main bronchus was dissected and opened longitudinally from the carina toward the right upper lobe bronchus and bronchus intermedius. Direct inspection revealed a patent bronchus intermedius and preserved distal bronchial tree, which was confirmed by intraoperative cross-table bronchoscopy.

A right upper sleeve lobectomy was performed by end-to-end bronchial anastomosis between the carina and bronchus intermedius. The intermedius bronchus was obliquely cut in order to ensure an equal diameter of the anastomosis partner. The anastomosis was performed by two 4.0 polydioxanone (PDS) running sutures, one for the posterior aspect of the anastomosis and the other one anteriorly. Once the anastomosis was made the remaining lung re-expanded very easily and completely filled the diminished right thoracic cavity.

The postoperative course was uneventful. The chest tube was removed on postoperative Day 3, and the patient was discharged on Day 6. Follow-up imaging demonstrated satisfactory re-expansion of the remaining right lung (Figure 2), with significant improvement in respiratory function. Three-month post-operative pulmonary function was FVC =55.7%. FEV₁ =54.4%, DLCO: 54.4%, VO_2max=18.7%, increase in effort tolerance. At follow-up, the patient was asymptomatic and had resumed normal daily activities.

Figure 2 Day 1 postoperative chest X-ray (A), 6 months postoperative flexible bronchoscopy at the level of the carina (B), and 8 years postoperative X-ray (C).

Case 2

A 34-year-old male presented to the Centre Hospitalier Monkole, Kinshasa, in November 2025 with progressive dyspnea of three months’ duration and absent breath sounds on the right side at physical examination. Chest CT revealed complete atelectasis of the right lung associated with ipsilateral mediastinal shift and diaphragmatic elevation suggestive of a long-standing process. A centrally located endobronchial lesion obstructing the right main bronchus was identified (Figure 3). Flexible bronchoscopy confirmed complete obstruction by an endobronchial tumor (Figure 3). The pulmonary function was: FVC =42.6%, FEV₁ =37.4%, he could climb only one stair. Laboratory investigations showed polycythemia [hemoglobin (Hb) =17.7 g/dL, hematocrit (Ht): 52%], likely secondary to chronic hypoxia.

Figure 3 Preoperative axial chest CT and flexible bronchoscopy. (A) Chest CT. (B) Flexible bronchoscopy at the level of the carina, centered at the right obstructed main bronchus. CT, computed tomography.

Transbronchial biopsy was inconclusive and did not demonstrate any malignancy. Surgical resection was indicated, with a planned right upper sleeve lobectomy and possible conversion to pneumonectomy if distal lung viability proved inadequate.

A right lateral thoracotomy (8 cm) was performed. After adhesiolysis and mobilization of the lung, intraoperative assessment by inspection and palpation revealed a macroscopically viable lung parenchyma and a patent bronchial tree distal to the upper lobe bronchus.

Systematic lymph node dissection was performed, including stations 7, 11, 10, 2, and 4. The pulmonary vessels for the upper lobe were individually divided using staplers. Following completion of the fissures, the bronchial tree was transected distally just below the origin of the upper lobe bronchus (Figure 4) and proximally one cartilage ring from the carina. The specimen was removed, and the azygos vein was divided using a vascular stapler to facilitate exposure. Frozen section was not performed.

Figure 4 First section of bronchial tree just under the upper bronchus.

A bronchial sleeve resection was completed with end-to-end anastomosis between the right main bronchus and the bronchus intermedius using two running 3-0 PDS sutures (Figure 5). Air leak testing confirmed an airtight anastomosis. The azygos vein stump was used to cover and protect the anastomosis.

Figure 5 Bronchial anastomosis before closing.

The postoperative course was uneventful (Figure 6). The chest drain (24 Fr) was removed on postoperative Day 4, and the patient was discharged on Day 6. Despite a recommended convalescence period of one month, the patient resumed work two weeks after surgery. The laboratory test with was normal from Day 1 (Hb =13.7 g/dL, Ht =41%). The patient could climb stairs (up to the third with no limitation) from Day 4. One-month post-operative pulmonary function was FVC =57.6%, FEV₁ =55.2%.

Figure 6 Day 1 postoperative chest X-ray (A) and one month postoperative flexible bronchoscopy at the level of the carina (B).

Definitive histopathological examination revealed a 1.8 cm × 4 cm typical carcinoid tumor [pT2aN0, tumor-node-metastasis (TNM) 9th edition], with invasion limited to the submucosal layer and negative resection margins.

Patients’ perspective

In Case 1, the patient is from Suceava, Romania: “I am very happy, I have no complaints after the intervention, I have kids since then and I am enjoying my live, many thanks…”

In Case 2, the patient is from Democratic Republic of Congo, in Lubumbashi: “Thank you very much for all, may God bless you, I have resumed my professional and personal life, I was supposed to have my marriage ceremonies in December 2025, I canceled all because of the disease, and I am going to get married on May 16th…Please, receive the gratitude from my fiancée and my aunt…”

Discussion

Our findings suggest that chronic complete lung atelectasis secondary to main bronchus obstruction can be managed by sparing lung resection without increased perioperative morbidity. This observation is consistent with prior studies demonstrating that sleeve resections provide outcomes comparable to pneumonectomy while preserving pulmonary function and reducing short and long-term complications (1-3).

Compared to some reported series (4), our perioperative management was simplified. We did not use three-dimensional (3D) reconstruction, postoperative positive end-expiratory pressure, or prolonged ventilatory support, and both patients were extubated in the operating room. Despite this, length of stay was shorter than in comparable reports, suggesting that extensive perioperative adjuncts may not be mandatory when careful patient selection and meticulous surgical technique are applied.

Endobronchial interventions represent an alternative in selected cases of airway obstruction. However, in our series, the lesions were not amenable to bronchoscopic management. In addition, main bronchus complete obstruction carries a potential risk of contralateral lung flooding during endoscopic procedures, supporting a surgical approach in such settings.

A key technical concern, particularly on the right side, is the availability of proximal cartilage to suture afterward. This can be reliably assessed preoperatively using coronal imaging (Figure 7). In most tumor-related obstructions, the surface is concave. When obstruction involves the origin of the main bronchus, the anastomosis can be performed at the carina (as it has been reported in the first case).

Figure 7 Coronal view of the tumor obstruction in the main bronchus, showing concavity surface of the tumor and the cartilage to be used after the resection.

The viability of the chronically atelectatic lung and the recovery of diaphragmatic function are additional concerns. In our experience, lung viability should be assessed intraoperatively after complete mobilization and bronchial dissection, the ultimate viability is confirmed after the bronchial anastomosis. All patients demonstrated rapid postoperative functional recovery, indicating that prolonged atelectasis does not necessarily preclude functional restoration.

Re-expansion pulmonary edema (RPE) is a recognized complication after prolonged lung collapse, particularly beyond 72 hours (5), with reported mortality rates up to 20% (6). Its pathophysiology involves both microvascular alterations due to chronic collapse and mechanical stress during re-expansion. Preventive strategies such as gradual re-expansion and corticosteroid therapy are not easily applicable in sleeve resections. Notably, no cases of RPE were observed in our series, suggesting that controlled habitual re-expansion following bronchial reconstruction may reduce this risk.

We observed reduced caliber of pulmonary vessels intraoperatively, likely reflecting chronic hypoperfusion. The inferior pulmonary ligament was preserved in all cases. Available evidence indicates that its division is not essential for lung re-expansion (7) and the ligament may contribute to anastomotic stability by limiting excessive mobility, in case of sleeve upper lobectomy (8).

Overall, our experience supports that right sleeve upper lobectomy is a feasible and safe alternative to pneumonectomy in patients with chronic complete lung atelectasis due to main bronchus obstruction. Importantly, this procedure can be performed using standard surgical techniques, without the need for advanced technological platforms.

This study is limited by its case report design and small sample size. Further studies with larger cohorts are required to validate these findings and define optimal patient selection criteria.

Conclusions

Sleeve upper lobectomy is a safe and feasible surgical option for patients with chronic complete lung atelectasis secondary to main bronchus obstruction. By preserving lung parenchyma while maintaining adequate radicality, it may represent a preferable alternative to pneumonectomy.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0026/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0026/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0026/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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