Bronchial Stump Research Articles

Непосредственные результаты органосохранных анатомических резекций и пневмонэктомий у больных раком легкого пожилого и старческого возраста

The aim of the research. The aim of the study was to conduct a comparative analysis of the immediate results of organ-preserving anatomical resections and pneumonectomy in elderly and senile patients with lung cancer. Material and methods. The study included 126 patients over 60 years of age, who were divided into 2 groups depending on the extent of the surgical intervention performed. Group A was represented by 63 patients who underwent organ-preserving anatomical resections and group B enrolled 63 patients after pneumonectomy. The groups were formed through retrospective analysis of prospective data obtained from the electronic registry. In all cases, the comorbid background was assessed, as well as options for preoperative correction of the concomitant pathology. In the postoperative period, the number and severity of complications were assessed using the TMM (Thoracic Morbidity and Mortality) System, and an intergroup comparative statistical analysis was performed. Results. According to the results of the study, postoperative complications among patients in group A were recorded in 22 (34.9%) cases, mortality was established in 4 (6.35%) patients. In group B, the number of complications and mortality were registered in 18 (28.6%) and 6 (9.52%) cases, respectively. Among the complications registered in group A, the most common were prolonged air discharge through the drainage and cardiac arrhythmias. In the group after pneumonectomy, complications associated with arrhythmia also prevailed, while the complication occurred statistically more often. Among the lethal outcomes in both groups, the main cause was progressive cardiovascular insufficiency against the background of arrhythmia, as well as failure of the bronchus stump and suture. Conclusion. Despite the absence of reliable differences in the total number of complications and mortality in the groups, there is a clear trend towards a higher frequency of fatal complications in the group after pneumonectomy. A feature was noted in the continuing risk of mortality, regardless of the severity of the complication. Among patients after organ-preserving anatomical resections, reversible deviations from the normal course in the postoperative period prevail. In addition, this extent of surgical intervention provides for better functionality and quality of life to elderly and senile patients.

ANALYSIS OF COMPLICATIONS OF SURGICAL TREATMENT IN PATIENTS WITH LUNG TUMORS

The aim of the study was to identify factors that are associated with complications after surgery for lung cancer.
 Materials and Methods. Retrospective analysis of the surgical treatment results in patients with lung cancer who were operated on in 2010-2014 at the department of thoracic surgery of the Lviv Oncological Regional Treatment and Diagnostic Center. The study included 461 patients. The data of each patient were divided into the following groups: general characteristics, tumor characteristics, treatment characteristics, and complications. The whole cohort of patients was analyzed and their separate subgroups were compared by age, type of complications, and type of surgery.
 Results and Discussion. Elderly patients have three times higher levels of postoperative dyspnea and much higher levels of cardiac arrhythmias. Pulmonary complications are more common in men, after more aggressive surgeries with longer time of operative pulmonary ventilation; increase with age. This subgroup is also characterized by longer postoperative period and a higher in-hospital mortality rate. Postoperative complications such as dyspnea, fistula of the bronchial stump, and pleural empyema, higher levels of pleural punctures, and postoperative bed-day were more common in the group of patients who underwent pneumonectomy. A higher level of postoperative pneumonia and a longer drainage period were observed in the group of other operations. It is noteworthy that the level of dyspnea in elderly patients who underwent pneumonectomy is three times higher.
 Conclusions. There are age-related features connected to the onset of postoperative complications in patients with lung tumors who have undergone surgery. Complications typical for the patients after different types of operations were found. It is established that the age of patients and the type of surgical treatment significantly change the palette of postoperative complications. An improved method for predicting complications is required.

Preventive esophagomyobronchoplasty as a method to prevent the failure of the bronchial stump in pneumonectomy for lung cancer

Aim. Comparative analysis of insufficiency rate of bronchial stump sutures in pneumonectomy for lung cancer, depending on suturing techniques.
 Methods. A patented technique for bronchial stump suturing has been introduced into the practice of the GOBUZ clinic Novgorod Regional Clinical Hospital based on the Department of thoracic surgery since 2015 for pneumonectomy for lung cancer. Before the introduction of the developed technique, various generally accepted methods of bronchial stump forming were used (mechanical suture, manual suture, their combination, bronchial stump coverage with mediastinal pleura, pericardial flap). A retrospective analysis of 173 case histories and operational protocols of patients with lung cancer who underwent pneumonectomy was carried out for the failure of bronchial stump sutures when using conventional suturing techniques between 2010 and 2014 (the first group of patients). We also performed a retrospective and prospective analysis of 204 case histories and operational protocols of patients in a similar clinical group when using a patented suturing technique between 2015 and 2020 (the second group of patients). Statistical analysis was carried out by using Statistica 10.0 software (StatSoft, Inc. 2011). The qualitative and quantitative indicators were analyzed by using the Pearsons 2-test with Yatess correction.
 Results. A retrospective analysis shows that the failure rate in the use of generally accepted bronchial stump suturing techniques for 20102014 was 10.4%. After the implementation of the method of preventive esophagobronchomyoplasty, complications as bronchial stump suture failure were not detected in any case between 2015 and 2020.
 Conclusion. The study shows high efficiency, a decrease in the incidence of complications as the failure of bronchial stump sutures in the use of the developed method of preventive esophagomyobronchoplasty in pneumonectomy for lung cancer.

Congenital partial pericardial defect discovered incidentally during surgery for lung cancer: a case report and literature review

BackgroundCongenital pericardial defects are rare congenital anomalies, often asymptomatic and incidentally detected during thoracic surgery.Case presentationA 74-year-old man with primary lung cancer (cT1cN0M0, Stage IA3) underwent thoracoscopic radical lobectomy. At the time of thoracotomy, a pericardial defect was found on the ventral side of the hilar region, and the left atrial appendage was exposed. Due to concern that contact between the bronchial stump and the left atrial appendage may lead to postoperative bleeding and heart hernia, the pericardial defect was closed with an expanded polytetrafluoroethylene GoreTex® membrane. Preoperative computed tomography was reanalyzed with a 1 mm slice, congenital pericardial defect was detected as the pericardium had penetrated under the left atrial appendage.ConclusionsIn congenital partial pericardial defect, contact between the left atrial appendage and bronchial stump, due to movement of the lung or heart, increases the risk of bleeding after lung resection. Therefore, closure of the defect should be considered. Although it is difficult to diagnose congenital partial pericardial defect preoperatively, computed tomography taken with a slice thickness of 1 mm is useful for diagnosis.

Division of the intersegmental planes, including the arterial, venous and bronchial stumps. Retrieval of the specimen, negative underwater test for air leak and Tisseel® application.

Division of the intersegmental planes, including the arterial, venous and bronchial stumps. Retrieval of the specimen, negative underwater test for air leak and Tisseel® application.

Low Cardiopulmonary Toxicity With Use of IMRT When Delivering Postoperative Radiation Therapy (PORT) in Patients With NSCLC

The role of PORT for patients with resected stage IIIA (N2) NSCLC is controversial. Recently, the Phase III LungART trial reported a significant improvement in mediastinal control with PORT but failed to show an overall survival (OS) benefit, due in part to cardiopulmonary (CP) toxicity (7% early and 20% late grade (G) 3-5). However, LungART employed 3D conformal radiotherapy (3D-CRT) in 90% of patients as well as elective treatment of mediastinal nodal stations. We evaluated the risk of CP toxicity associated with use of postoperative IMRT for this population.We conducted a retrospective study of consecutive patients with NSCLC treated with postoperative IMRT between 2008 and 2019. Patients were eligible if they were found to have incidental pN2 or an R1/2 resection. Targets of PORT for pN2 were bronchial stump, ipsilateral hilum, and involved mediastinal station(s). The primary objective was incidence of CTCAE (v4) G3+ CP toxicities. Secondary objectives were major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction, coronary revascularization or hospitalization due to heart failure; disease-free survival (DFS); and OS. Cumulative incidence and Kaplan-Meier method were used as appropriate.73 patients received PORT with IMRT. Median follow-up was 54 months. Median age at diagnosis was 65 years (range 36 - 81); 33 patients (45%) had pre-existing cardiovascular disease and 48 (65.8%) were current/former smokers. 50 patients had pN2 disease and 23 patients had R1/R2 resection. Among patients with pN2, the median number of involved mediastinal nodes was 1 (range 1 - 12). All patients with pN2 and 70% of patients with R1/R2 resection received chemotherapy, the majority of which was sequential (n = 52, 71.2%). Median RT dose was 54 Gy (range 45 - 66 Gy) in 27 fractions for patients with pN2 and 59.4 Gy (range 45 - 66 Gy) in 30 fractions for patients with R1/R2 resection. 3-year cumulative incidence of G3+ CP toxicity was 2.7%, with an overall incidence of 6.8% (5 events in 73 patients). The rate of G3+ CP toxicity in patients with pN2 was 8%. Three patients developed ≥1 MACE: one died of a cardiac arrest and two underwent coronary revascularization. Two of these patients had a history of coronary artery disease. Two episodes of G3+ toxicity involved valve replacements in patients with pre-existing valvular disease. 3-year DFS was 51.4% (95% CL 46.9 - 55.1%). Two patients with pN2 developed mediastinal failures. 3-year OS was 62.3% (95% CL 50.2 - 74.4%).PORT for pN2 NSCLC using IMRT and no elective nodal irradiation is associated with a low rate of G3+ CP toxicity in patients with pN2, comparable to the chemotherapy only arm of the LungART trial. Our data suggest that highly conformal radiation techniques should be prospectively assessed for their potential to translate the known local control benefit of PORT into a survival advantage.

NECROTIZING PNEUMONIA AND MASSIVE AIR LEAK IN A PATIENT WITH COVID-19

TOPIC: Cardiothoracic Surgery TYPE: Global Case Reports INTRODUCTION: To observe the pathological characteristics and the clinical significance of COVID 19 infected pneumonia causing degeneration and necrosis of parenchymal cells, thrombus in small and medium vessels. Pulmonary pathological changes of fatal COVID-19 are diffuse alveolar damage that is presents in the acute exudative stage and the organic proliferative stage. There is alveolar cavity formation, fibrinous exudate, fibroblastic proliferation in alveolar septum, and alveolar epithelial cell injuries. A large number of neutrophils and monocytes infiltration is present in most cases and bacteria and fungi are detected in some cases, suggesting a serious combination to generate lung necrosis and huge air leak. CASE PRESENTATION: The case of a 50 years old female with severe COVID 19 pneumonia, requiring admission to the ICU during her hospitalization present bilateral pneumothorax that was solved with bilateral chest tube, one week later present persistent right pneumothorax and a continuous air leak that prevented ventilation, surgical intervention was decided as a result of the ventilatory, hemodynamic deterioration and state of sepsis finding in the right lower lung focal hemorrhage, organization of exudates in various cavities in the lung, and pulmonary fibrosis generating degeneration and necrosis of parenchymal cells, formation of thrombus in small vessels, and pathological changes of chronic diseases were observed with fibrous tissue, firm adhesions DISCUSSION: Infectious disease by COVID 19 pneumonia can generate cavitary lung process, necrotizing pneumonia, lung abscess and septic pulmonary embolism. Being able to aggregate infections that include cavitating fungal and superinfection of preexisting spaces. Accompanied by infarction from thromboembolic disease. In these cases, we found an extensive lung necrosis with a grade 4 air leak, accompanied by intraparenchymal purulent fibrin, infected cavities with fluid and bronchial necrosis as well as blood vessel thrombosis CONCLUSIONS: The management of this pathology include treatment as any lung necrosis with major resection and reinforcement of the bronchial stump with the considerations of the aerosol that are generated by bronchial necrosis and parenchyma, the initial approach includes immediate obturation of the bronchus and subsequently continue with vascular dissection. Which indicates that COVID pneumonia can present in a short time all the changes of acute and chronic disease. Generally, an acute or subacute process suggests bacterial and fungal causes of pulmonary abscesses, necrotizing pneumonias, and septic emboli. And a chronic process suggests mycobacterial, fungal, viral, or parasitic infections;malignancy or autoimmune disorders REFERENCE #1: Anaesthesia. 2020 Nov;75(11):1509-1516. doi: 10.1111/anae.15112. Epub 2020 Jun 2. Management of the airway and lung isolation for thoracic surgery during the COVID-19 pandemic: Recommendations for clinical practice endorsed by the Association for Cardiothoracic Anaesthesia and Critical Care and the Society for Cardiothoracic Surgery in Great Britain and IrelandM Thornton 1, D Reid 1, B Shelley 2 3, M Steven 1 REFERENCE #2: Anaesthesia. 2020 Nov;75(11):1509-1516. doi: 10.1111/anae.15112. Epub 2020 Jun 2.Management of the airway and lung isolation for thoracic surgery during the COVID-19 pandemic: Recommendations for clinical practice endorsed by the Association for Cardiothoracic Anaesthesia and Critical Care and the Society for Cardiothoracic Surgery in Great Britain and IrelandM Thornton 1, D Reid 1, B Shelley 2 3, M Steven 1 REFERENCE #3: Am Fam Physician. 1991 Nov;44(5):1719-21.Necrotizing aspiration pneumoniaD Disler 1, S A Deluca DISCLOSURES: No relevant relationships by Gabriela Alejandra Buerba Romero Valdes, source=Web Response No relevant relationships by Gabriela Del Angel Millan, source=Web Response No relevant relationships by EMMANUEL PENA GOMEZ PORTUGAL, source=Web Response No relevant relationships by ALMA SOLANO NIETO, source= eb Response

Preserving the eponym: Klinkenbergh technique for bronchial stump suturing

The technique for bronchial stump suturing following lung resection which is currently applied in the Department of Thoracic Surgery at the University Hospitals Leuven, Belgium owes its name to the Dutch surgeon Dr. Klinkenbergh (1891–1985). A true pioneer of cardiothoracic surgery in Europe, Dr. Klinkenbergh dedicated himself to the surgical treatment of pulmonary tuberculosis. His work was praised by his peers for his precision and the reasoning behind every gesture. The Klinkenbergh technique consists in performing two running sutures which cross each other ‘in the same manner as the laces of a shoe’ to close the bronchus, limiting the occurrence of broncho-pleural fistulas. In our experience with more than 100 patients in the last 5 years (2016–2020) who underwent open pneumonectomy for benign or malignant disease, less than 2% developed post-operative broncho-pleural fistulas.

Stapling of an endobronchial suction tube with the bronchus during robot-assisted right lower lobectomy: a case report

BackgroundTroubleshooting intraoperative complications requires careful management, and the safest technique should be chosen. We recently experienced a unique intraoperative bronchial complication during pulmonary lobectomy in robot-assisted thoracic surgery (RATS). There is no consensus on whether to continue RATS or convert to a more familiar technique, such as video-assisted thoracic surgery (VATS) or thoracotomy, for intraoperative complications that occur during RATS, and the decision should be determined individually.Case presentationA 74-year-old woman with primary lung adenocarcinoma (clinical stage IA2) underwent robot-assisted right lower lobectomy under one-lung ventilation and CO2 insufflation. Intraoperatively, the anesthesiologist placed the endobronchial suction tube in the right bronchus with intention of maintaining the right lung collapse, which was simultaneously stapled with the right lower bronchus during the right lower lobe bronchial closure using a robotic stapler. During robot-assisted manipulation, we removed the staples involved with the suction tube, one by one, using robotic-arm forceps and sutured the partially opened stump. Subsequently, the bronchial stump was covered with a pedicled pericardial fat pad. The postoperative course was uneventful, and the patient developed no complications when followed up 8 months after discharge. Hence, we could rectify this intraoperative bronchial complication using a robot-assisted technique and avoid conversion to VATS or thoracotomy.ConclusionThe precise manipulation techniques in RATS contributed to facilitate the successful execution of surgical procedures, such as staple removal and re-suturing of the bronchial stump and may be a useful as a method for such troubleshooting such intraoperative complications.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Transpleural Сontralateral Occlusion of the Left Main Bronchus Stump 
 in a Patient with Bronchopleural Fistula and Chronic Pleural Empyema

Bronchopleural fistula (BPF) is a pathological communication between the bronchial tree and the pleural cavity, the most common complication of anatomical lung resection.BPF rarely closes spontaneously and almost always requires surgical or bronchoscopic interventions.The main methods of treatment are sanitation of the pleural cavity with the development of empyema and re-occlusion of the bronchial stump. The development of this complication in the postoperative period is accompanied by an increase in hospitalization time, a high risk of chronic pleural empyema, exacerbation of chronic diseases and death. The mortality rate ranges from 18 to 67%. Most often, BPF is manifested after removal of the right lung (8-13%), compared with the left side (1-5%), which is due to the anatomical features of the main bronchus.The presented clinical case describes a non-standard surgical approach in the treatment of bronchopleural fistula and chronic empyema of the residual pleural cavity in a young patient.

"Tissue Handling" in Thoracic Surgery - Results of a Delphi Expert Consensus Conference of the German Society for Thoracic Surgery

The aim of this working group of the German Society for Thoracic Surgery (DGT) was to develop an expert consensus based on the Delphi method to define "tissue handling" and depict intraoperative handling of specific anatomical structures during thoracic surgery. Invited experts (thoracic surgery specialists; n = 93) completed two consecutive rounds of electronic Delphi questions on four main topics: transection of lung parenchyma, dissection/separation of pulmonary vessels, angioplasty/vascular anastomoses, and bronchus settling closure/plasty/anastomosis. Consensus was set at ≥ 75% agreement. At the subsequent expert conference, the results of the Delphi surveys were discussed and TED voting was used to try to reach consensus. In each case, 66 (71%) answers were given in the first round of questions and 33 (35%) in the second round. Disputed questions were evaluated again by a final vote at the expert conference (54 participants; average participation 55%). The term "tissue handling" includes all procedures for dissection, transection, sealing, and reconstruction of various autologous tissues in the context of thoracic surgery (100% consensus). Similarly, the term "angioplasty expansion" was defined with a 97% consensus. Consensus was reached mainly for the technique of transecting the lung parenchyma using stapling suture devices, the recommendation of covering anastomoses as well as bronchial stump after pretreatment (> 75%). This expert consensus describes for the first time the concept of tissue handling in thoracic surgery. Furthermore, this Delphi process led to a comprehensive current inventory of different intraoperative procedures in German thoracic surgery with derived consensual recommendations for tissue handling of lung parenchyma, vessels and bronchial structures.

Surgical ligation level of the bronchial artery influences tissue oxygen saturation of the bronchus and the incidence of postoperative bronchofistula after pulmonary lobectomy

Lobectomy, or the removal of a lobe of the lung, is the most commonly performed lung cancer surgery. One of the most severe postoperative complications is a bronchial stump fistula, which often occurs following a right lower lobectomy. During lymph node dissection, the bronchial arteries, which supply blood to the bronchus, are cut. Subsequently, reduced blood supply to the bronchus may result in bronchofistula. We investigated the relationship between the level of the surgical ligation of the bronchial arteries and the decrease in blood flow at the bronchial stump during a right lower lobectomy. This study aimed to clarify the relationship between the anatomical amputation level of the bronchial artery and the decrease in tissue oxygen saturation at the bronchial stump, allowing us to identify a surgical procedure that reduces the risk of a bronchopleural fistula following pulmonary lobectomy and an appropriate bronchial artery amputation site that could be used in future lobectomies. We developed a new system (micro-tissue oxygen saturation) that enabled the semi-quantification of the oxygen saturation of thin tissues in pinpoint during video-assisted thoracic surgery. Changes in the blood flow at the bronchial stump were examined during lymph node dissection and bronchial artery amputation using a biological pig lobectomy model. The regional oxygen saturation level at the bronchial wall was 95.5%±1.0% in normal conditions. A gradual decrease in regional oxygen saturation was observed, as the cutting point of the bronchial artery was moved higher. When the bronchial artery coursing into the middle lobe bronchus was preserved, the blood flow in the bronchus was preserved at 82.8%±1.3%. When the branches of the bronchial arteries running both inside and outside of the intermediate bronchial trunk were cut at high positions, regional oxygen saturation level decreased to 55.7%±1.2%. The preservation of at least one bronchial artery at the level of the middle lobe bronchus minimizes the reduction of tissue oxygen saturation at the lower lobe bronchial stump. The ligation of bronchial arteries at a higher position results in desaturation <60%, which may increase the risk of bronchial stump fistula.

Unilateral thoracoscopic view of the left pneumonectomy. In sequence it is possible to appreciate the isolation and division, by means of a mechanical stapler, of the left main pulmonary artery and of the superior and inferior left pulmonary veins. Finally, the stump of the left main bronchus, previously divided, is extracted from the mediastinum

Unilateral thoracoscopic view of the left pneumonectomy. In sequence it is possible to appreciate the isolation and division, by means of a mechanical stapler, of the left main pulmonary artery and of the superior and inferior left pulmonary veins. Finally, the stump of the left main bronchus, previously divided, is extracted from the mediastinum

Treatment of Chylothorax complicating pulmonary resection with hypertonic glucose Pleurodesis

BackgroundTo retrospectively assess the efficacy of hypertonic glucose pleurodesis for treatment of chylothorax after pulmonary resection.MethodsOut of a total of 8252 patients who underwent pulmonary resection (at least lobectomy) at department of thoracic surgery, between June 2008 and December 2015, 58 patients (0.7%) developed postoperative chylothorax. All patients received conservative treatment, including thoracic closed drainage, oral fasting, and total parenteral nutrition.ResultsConservative treatment was successful in 50 (86.2%) patients, while eight patients [mean age: 58.0 years (range, 45–75)] were treated with hypertonic glucose pleurodesis. All eight patients had undergone operation for lung cancer (four squamous cell carcinomas and four adenocarcinomas). The bronchial stump was covered by pleural flap in three patients. After pleurodesis, three patients developed fever but without empyema; thoracentesis was performed in two patients. The mean time interval between pleurodesis and operation was 4.3 days (range,3–5) days. The average length of stay was 23.1 days (range, 18–31). No recurrent pleural effusion was observed over a mean follow-up duration of 28 months.ConclusionHypertonic glucose pleurodesis performed via the chest drainage tube is a viable treatment option for chylothorax after lung resection, prior to resorting to a thoracoscopic or thoracotomic ductus thoracicus ligation of the thoracic duct leak. It is a simple, safe and efficient modality associated with rapid recovery and less pain.

Single-port thoracoscopic anatomic resection for chronic inflammatory lung disease

BackgroundIt is challenging to proceed thoracoscopic anatomic resection when encountering severe pleural adhesion or calcified peribronchial lymphadenopathy. Compared with multiple-port video-assisted thoracoscopic surgery (MP-VATS), how to overcome these challenges in single-port (SP-) VATS is still an intractable problem. In the present study, we reported the surgical results of chronic inflammatory lung disease and shared some useful SP-VATS techniques.MethodsWe retrospectively assessed the surgical results of chronic inflammatory lung disease, primarily bronchiectasis, and mycobacterial infection, at our institution between 2010 and 2018. The patients who underwent SP-VATS anatomic resection were compared with those who underwent MP-VATS procedures. We analyzed the baseline characteristics, perioperative data, and postoperative outcomes, and illustrated four special techniques depending on the situation: flexible hook electrocautery, hilum-first technique, application of Satinsky vascular clamp, and staged closure of bronchial stump method.ResultsWe classified 170 consecutive patients undergoing thoracoscopic anatomic resection into SP and MP groups, which had significant between-group differences in operation time and overall complication rate (P = 0.037 and 0.018, respectively). Compared to the MP-VATS group, the operation time of SP-VATS was shorter, and the conversion rate of SP-VATS was relatively lower (3.1% vs. 10.5%, P = 0.135). The most common complication was prolonged air leakage (SP-VATS, 10.8%; MP-VATS, 2.9%, P = 0.045).ConclusionsFor chronic inflammatory lung disease, certain surgical techniques render SP-VATS anatomic resection feasible and safe with a lower conversion rate.

Novel thoracoscopic lymph node dissection techniques for left upper lobectomy with a fused fissure

: Currently, lobectomy with systematic lymph node dissection (LND) is the standard surgical procedure for early stage, non-small cell lung cancer (NSCLC). Several issues may arise when performing a lobectomy such as a fused fissure, especially during thoracoscopic surgery. In this case, performing hilar LND in a conventional manner may be difficult. Since both hilar and mediastinal LND are essential procedures during surgery for NSCLC, it is crucial to achieve both safe lobectomy and precise systematic LND in fused fissure cases. To address this difficult situation, we have developed the following three novel thoracoscopic techniques that focus on LND: (I) the “anterior fissure first technique”, (II) the “#4L-posterior first technique”, and (III) the “anterior #7 dissection technique”. First, the anterior fissure first technique enables the operator to view the entire hilar lymph node, similar to a situation with a complete fissure, and allows the hilar LND to proceed in a conventional manner. Second, when using the #4L-posterior first technique, the left lower paratracheal (#4L) LND is straightforward since the left recurrent laryngeal nerve (RLN) has already been dissected, and only the anterior area of #4L remains to be dissected. Finally, during the anterior #7 dissection technique, when performing the subcarinal (#7) LND, we do not dissect between the dorsal side of the trachea and esophagus. Consequently, the bronchial artery (BA) is preserved and postoperative ischemic change in the bronchial stumps is prevented. We believe that our techniques are oncologically appropriate and enable the safe and straightforward execution of precise thoracoscopic lobectomy and systematic LND, even in cases of fused fissures.

Occlusion with Bronchial Covered Stent in the Management of Bronchial Stump Fistula after Right Middle and Lower Lobectomy: A Case Report and Literature Review

背景与目的支气管胸膜瘘是临床上较为严重且罕见的术后并发症之一，尤其是肺叶/全肺切除术后支气管残端瘘，处理起来较为棘手。常见治疗方案包括内科保守治疗联合外科手术，但由于瘘口迁延不愈导致胸腔持续与外界相通，患者容易合并严重的胸腔感染及呼吸衰竭等合并症，以至于身体状况无法耐受二次手术。而内镜下治疗，为该合并症的治疗提供了新的思路。方法回顾性分析了北京大学肿瘤医院胸外二科2016年6月收治的1例右肺鳞癌患者的诊断、治疗过程，并文献复习。结果患者男性，65岁，因“咳嗽伴痰中带血3月余”入院，胸部计算机断层扫描提示右肺下叶软组织密度肿块影，气管镜提示右肺中叶及下叶基底段开口可见肿物，活检病理证实为鳞癌。诊断考虑：右肺中下叶鳞癌(cT2aN2，IIIa期)。患者接受了吉西他滨+顺铂方案新辅助化疗2个周期，评效为疾病稳定(stable disease, SD)。末次化疗结束4周之后，患者接受了胸腔镜辅助右肺中下叶切除、纵隔淋巴结清扫术。术后第5天患者出现急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)再次气管插管转入重症加强护理病房(intensive care unit, ICU)，并给予激素冲击治疗。术后第7天患者出现右肺中间干支气管残端瘘，但由于合并ARDS，患者身体情况无法耐受二次手术。遂于体外人工膜肺(extracorporeal membrane oxygenation, ECMO)支持下，经硬质支气管镜在中间干支气管残端置入一枚定制的覆膜、可膨胀金属铰链支架，并成功封堵。由于患者的ARDS未见好转，出现不可逆的肺间质纤维化，经过系统的抗感染治疗之后，患者成功接受了双肺移植手术。结论内镜下放置覆膜支架是一种简单、安全、有效的支气管残端瘘闭合术。当患者的临床情况不适合立即手术时，内镜下支架植入可作为一种优选的治疗方法，为后续治疗创造机会。

Cerrahi doku yapıştırıcılar akciğer kanseri rezeksiyonu sonrası takip pozitron emisyon tomografisinde yanlış pozitifliğe neden olur mu?

Postoperative complications following thoracic procedures are a major cause of morbidity and mortality. Alveolar air leaks and/or bronchopleural fistulas are associated with increased risk of infection, prolonged chest tube, and hospital stay duration and therefore generate economical concern for health care providers. A variety of surgical sealants or adhesives have been introduced to overcome this complication. Since intraoperative BioGlue® application can also cause an inflammatory reaction and mimic tumor recurrence on FDG PET-CT, in the present study we aimed to investigate its potential role in false-positive PET-CT results in patients operated for NSCLC. Data of six patients who underwent resection for primary NSCLC at our institution (Department of Thoracic Surgery, Hacettepe University Medical Faculty) between January 2015 and December 2018 and had false positivity, due to BioGlue® application, at the bronchial stump in follow-up FDG PET-CT were retrospectively analyzed from a prospectively collected database. One of the 6 patients was female and 5 were male. The mean age was 68 years (range, 56-79 years). The average time interval between operation and postoperative FDG-PET imaging was 4.3 months (range, 4-6 months). Follow-up FDG-PET imaging SUVmax values ranged between 3.0 and 9.0 (median: 5.33). All patients have been evaluated by FDG-PET scan following the detection of soft tissue densities at the surgical site suspicious for recurrence at their follow-up chest CT scans. Four patients underwent a bronchoscopic examination, bronchial stumps were examined and multiple biopsies were taken from suspicious nodules or tissues and sent for pathologic examination. Histopathological results revealed inflammation which is compatible with foreign body granuloma, without any suspicion for malignancy, in all cases. Two patients were solely followed-up and subsequent FDG-PET imaging after 3 months revealed complete resolution of FDG uptake. To avoid unnecessary biopsies or surgical procedures, the possibility of false-positive results due to surgical adhesive product use should be taken into account while interpreting follow-up FDG-PET imaging results and the operative reports should be written in detail, describing which surgical materials used and their exact application sites.

A case report of right upper lung adenosquamous carcinoma resection following neoadjuvant targeted therapy

The patient was a middle-aged male smoker who had space-occupying lesions in the right upper lung, Positron emission tomography-computed tomography (PET-CT) suggested right upper lung cancer with multiple mediastinal lymph node metastases. Endobronchial ultrasound-guided transbronchial lung biopsy (EBUS-GS-TBLB) performed in the bronchus of the right apical segment confirmed the lesion as squamous cell carcinoma. Neoadjuvant therapy was planned. Because genetic testing revealed the epidermal growth factor receptor (EGFR) L858R mutation, the possibility of adenosquamous carcinoma was considered. The patient was clinically diagnosed with right upper lung squamous cell carcinoma c-T3N2M0, stage IIIB, and PS 1 point. Dacomitinib was selected for the targeted therapy. Eight weeks after the initiation of treatment, efficacy was assessed as a partial response (PR), suggesting a possibility of R0 resection. After sufficient communication with the patient and his family members, on July 1, 2020, thoracoscopic radical resection of the right upper lung cancer was performed under general anesthesia. Postoperative pathology confirmed adenosquamous carcinoma, of which 80% were adenocarcinoma and 20% were squamous cell carcinoma; no tumor thrombus was seen in the interstitial vessels; and the tumor did not invade the visceral pleura. There was no cancerous infiltration in the bronchial stump of the right upper lung. The following were the results for lymph nodes submitted for examination: L2 (0/1), L4 (0/4), L7 (0/3), L8 (0/7), L10 (0/1), L11 (0/2) and L11 (frozen 0/1) showed no cancer metastasis. The postoperative diagnosis was as follows: adenosquamous carcinoma of the right upper lung p-T2N0M0, stage Ib. After surgery, 4 cycles of the GC (gemcitabine + carboplatin) chemotherapy regimen were given, with continued targeted therapy recommended for 2 years. The patient has been followed-up and is in good condition.