Intrapericardial Pneumonectomy Research Articles

Risk Factor Analysis Including Inflammatory Markers for ICU Admission and Survival After Pneumonectomy

Background and Objectives: To assess the impact of preoperative inflammatory parameters on the necessity for intensive care unit (ICU) admission and survival after pneumonectomy. Materials and Methods: We enrolled 207 adult patients who underwent pneumonectomy between December 2016 and January 2022. We collected data from patients’ electronic medical records. Results: The preoperative albumin level was statistically lower, need for blood transfusion was higher, and length of hospital stay was longer in ICU-admitted patients (p = 0.017, p = 0.020, and p = 0.026, respectively). In multivariate analysis, intra-pericardial pneumonectomy and postoperative complications were predictive factors for ICU admission (OR = 3.46; 95%CI: 1.45–8.23; p = 0.005 and OR = 5.10; 95%CI: 2.21–11.79; p < 0.001, respectively). Sleeve or pericardial pneumonectomy (p = 0.010), intraoperative vascular injury (p = 0.003), the need for mechanical ventilation (p < 0.001), acute renal failure (p = 0.018), sepsis (p = 0.008), respiratory failure (p < 0.001), pneumonia (p = 0.025), the need for blood transfusion (p = 0.047), elevated blood urea nitrogen (BUN) (p = 0.046), and elevated creatinine levels (p = 0.004) were more common in patients who died within 28 days. Patients who died within 90 days exhibited higher preoperative neutrophil-to-lymphocyte ratio (NLR) values (p = 0.019) and serum creatinine levels (p = 0.008), had a greater prevalence of sleeve or intra-pericardial pneumonectomy (p = 0.002), the need for mechanical ventilation (p < 0.001), intraoperative vascular injury (p = 0.049), sepsis (p < 0.001), respiratory failure (p = 0.019), and contralateral pneumonia (p = 0.008) than those who did not. Conclusions: Intra-pericardial pneumonectomy and postoperative complications are independent predictors of ICU admission after pneumonectomy. Tracheal sleeve and intra-pericardial procedures, intraoperative and postoperative complications, the need for blood transfusion, preoperative NLR ratio, BUN and creatinine levels may also be potential risk factors for mortality.

A new technique for closure of pericardial defects: pericardial rug weave

BackgroundPericardial defect that occurs after intrapericardial pneumonectomy can cause many fatal complications, and closing the defect with mesh is a widely used surgical method to prevent these complications.MethodsData of patients who underwent intrapericardial pneumonectomy and pericardial resection in our clinic between October 2010 and June 2022 were retrospectively reviewed. Patients were divided into two groups, those who had prolene mesh used to close the pericardial defect and those who underwent the “Rug Weave” technique we proposed as an alternative, and the results were compared.ResultsThe study included 23 patients, one of whom was female. All patients underwent surgery due to malignancy. The vast majority of the patients had a diagnosis of squamous cell lung carcinoma (86.9%). Atrium was added to three patients and rib resection was added to one patient during intrapericardial pneumonectomy and pericardial resection. There was no significant difference between the two groups in terms of average age, gender, and length of hospital stay. There was no significant difference between the two groups in terms of complications, including atrial fibrillation, which is commonly seen in these patients (p = 0.795). The Rug Weave group had an average defect width of 23.96 cm2 and was found to be advantageous in terms of overall survival compared to the mesh group (p = 0.017).ConclusionsThe “Rug Weave” technique we proposed for closing pericardial defects after pneumonectomy can be used as a cheaper method safely and effectively that reduces complications as much as the traditional method of using mesh.

Central lung Inflammatory Myofibroblastic Tumor after aspergillosis and total occlusion of the left pulmonary artery

Inflammatory Myofibroblastic Tumor (IMT) is an exceptionally uncommon benign tumor. We present a 54-year-old man with IMT, frequent episodes of respiratory infections, aspergillosis, and hemoptysis, who has received 23 years of conservative treatment. A successful left intrapericardial pneumonectomy was performed. During chest closure, the left atrial auricle lesion caused a massive hemorrhage owing to contact with the staplers of the left pulmonary artery stapler line. The bleeding was immediately controlled. One year after surgery, the patient has fully recovered and no adverse events or relapses have occurred.

Central lung inflammatory myofibroblastic tumor after aspergillosis and total occlusion of the left pulmonary artery

Inflammatory Myofibroblastic Tumor (IMT) is a benign tumor that is extremely rare. We present a 54-year-old man who has received 23 years of conservative treatment for IMT, respiratory infections, aspergillosis, and hemoptysis. A left intrapericardial pneumonectomy was performed with efficacy. The left atrial auricle lesion created a massive hemorrhage during chest closure due to contact with the staplers of the left pulmonary artery stapler line. The hemorrhaging was stopped immediately. The patient has entirely recovered one year after surgery, and no adverse events or relapses have occurred.

Central lung inflammatory myofibroblastic tumor after aspergillosis and total occlusion of the left pulmonary artery

Inflammatory Myofibroblastic Tumor (IMT) is a benign tumor that is extremely rare. We present a 54-year-old man who has received 23 years of conservative treatment for IMT, respiratory infections, aspergillosis, and hemoptysis. A left intrapericardial pneumonectomy was performed with efficacy. The left atrial auricle lesion created a massive hemorrhage during chest closure due to contact with the staplers of the left pulmonary artery stapler line. The hemorrhaging was stopped immediately. The patient has entirely recovered one year after surgery, and no adverse events or relapses have occurred.

Extended resections in the treatment of locally advanced lung cancer

Background: This study aims to evaluate surgical outcomes and prognosis in patients who underwent extended lung resection for locally advanced lung cancer. Methods: Between January 2015 and December 2019, a total of 61 patients (60 males, 1 female; mean age: 61.7±12.2 years; range, 32 to 90 years) with locally advanced non-small-cell lung cancer who underwent extended lung resection were retrospectively analyzed. Data including age, sex, comorbid diseases, symptoms, smoking status, pulmonary function test results, tumor location, methods used for preoperative tissue diagnosis, histopathological cell type, type of surgical resection, pathological stage, nodal involvement, postoperative complications, types of adjuvant therapy, and mortality rate were recorded. Survival and the factors affecting survival were examined. Results: Seven (11.4%) patients had Stage IIIB, 40 (65.5%) patients had Stage IIIA, and 14 (22.9%) patients had Stage IB disease. Intrapericardial pneumonectomy accounted for 30 (49.1%) of all extended lung resections. Chemotherapy was administered to 31 (50.8%) patients and chemoradiotherapy to 24 (39.3%) patients in the postoperative period. In the survival analysis, 70-month survival rate was calculated as 63.9% and the median survival was 48 months. There was a statistically significant association between survival with adjuvant chemotherapy and chemoradiotherapy (p=0.003). The mortality rate at 70 months of follow-up was 36.1%. Conclusion: Extended lung resection contributes significantly to the improvement of survival rates in carefully selected locally advanced cases. Particularly with adjuvant chemotherapy, local recurrences can be prevented, and survival rates can be improved.

Preliminary Results of Extracorporeal Membrane Oxygenation Assisted Tracheal Sleeve Pneumonectomy for Cancer.

Tracheal sleeve pneumonectomy is a challenge in lung cancer management and in achieving long-term oncological results. In November 2018, we started a prospective study on the role of extracorporeal membrane oxygenation (ECMO) in tracheal sleeve pneumonectomy. We aim to present our preliminary results. From November 2018 to November 2019, six patients (three men and three women; median age: 61 years) were eligible for tracheal sleeve pneumonectomy for lung cancer employing the veno-venous ECMO during tracheobronchial anastomosis. Only in one patient, an intrapericardial pneumonectomy without ECMO support was performed, but cannulas were maintained during surgery. The median length of surgery was 201 minutes (range: 162-292 minutes), and the average duration of the apneic phase was 38 minutes (range: 31-45 minutes). No complications correlated to the positioning of the cannulas were recorded. There was only one major postoperative complication (hemothorax). At the time of follow-up, all patients were alive; one patient alive with bone metastasis was being treated with radiotherapy. ECMO-assisted oncological surgery was rarely described, and its advantages include hemodynamic stability with low bleeding complications and a clean operating field. As suggested by our preliminary data, ECMO-assisted could be a useful alternative strategy in select lung cancer patients.

Bronchoscopic treatment of a bronchopleural fistula after pneumonectomy.

Bronchoscopic treatment of a bronchopleural fistula after pneumonectomy.

Case report: cardiac herniation following robotic-assisted thymectomy

BackgroundThe first reported case of cardiac herniation was in 1948 and occurred following pericardiectomy during a lung cancer resection. Although rare, this potentially fatal surgical complication may occur following any operation in which a pericardial incision or resection is performed. The majority of literature on cardiac herniation involves case reports after intrapericardial pneumonectomy. Currently, there are no reports of cardiac herniation after thymectomy with pericardial resection.Case presentationA 44-year-old Asian female with symptomatic myasthenia gravis was referred for thymectomy. Originally thought to have Bell’s Palsy, her symptoms began with right eyelid drooping and facial weakness. Over time, she developed difficulty holding her head up, upper extremity weakness, difficulty chewing and dysarthria. These symptoms worsened with activity. She was found to have positive acetylcholine receptor binding antibody on her myasthenia gravis panel. A preoperative CT scan demonstrated a 3.5 cm × 2 cm anterior mediastinal mass along the right heart border and phrenic nerve. A complete thymectomy, via right-sided robotic-assisted approach was performed en bloc with a portion of the right phrenic nerve and a 4 cm × 4 cm portion of pericardium overlying the right atrium and superior right ventricle. Upon undocking of the robot and closure of the port sites, the patient became acutely hypotensive (lowest recorded blood pressure 43/31 mmHg). The camera was reinserted and demonstrated partial cardiac herniation through the anterior pericardial defect toward the right chest. An emergent midline sternotomy was performed and the heart was manually reduced. The patient’s hemodynamics stabilized. A vented Gore-Tex 6 cm × 6 cm patch was sewn along the pericardial edges with interrupted 4–0 prolene to close the pericardial defect.ConclusionThis potentially fatal complication, although rare, should always be considered whenever there is hemodynamic instability entry or resection of the pericardium during surgery. We now routinely sew in a pericardial patch using our robotic surgical system for any defect over 3 cm × 3 cm that extends from the mid- to inferior portions of the heart.

A novel conservative treatment to reduce cardiac herniation following intrapericardial pneumonectomy.

A novel conservative treatment to reduce cardiac herniation following intrapericardial pneumonectomy.

Extrapleural and Intrapericardial Pneumonectomy and Replacement of Descending Thoracic Aorta for Primary Posterior Mediastinal Synovial Sarcoma

This study described a 36-year-old woman who was diagnosed with posterior mediastinal spindle cell tumour. She underwent chemo-radiotherapy with untoward effects of increase in tumour size with possible involvement of the descending thoracic aorta. She underwent extensive surgical treatment with extra-pleural and intra-pericardial pneumonectomy as well as replacement of the descending thoracic aorta. In addition, she also underwent postoperative chemo-radiotherapy. She has been well for the last 13 months and there is no evidence of recurrence of the disease.

Reduction of cardiac herniation following intrapericardial pneumonectomy with pleural perfusion of saline.

Reduction of cardiac herniation following intrapericardial pneumonectomy with pleural perfusion of saline.

Salvage Surgery After Definitive Chemoradiotherapy for Non–small Cell Lung Cancer

Following definitive chemoradiation therapy, 24%-35% of patients with locally advanced non-small cell lung cancer have recurrence. We aimed to evaluate the feasibility of salvage surgery after definitive chemoradiotherapy and perioperative morbidity and mortality rates to determine long-term survival. From June 2003 to June 2013, 35 patients were eligible for lung cancer resection owing to relapse after definitive chemoradiation therapy. All patients received cisplatin-based chemotherapy and definitive radiotherapy (mean Gy: 58) with curative intent and all underwent total body computed tomography scan and 18-fluoro-deoxyglucose positron emission tomography scan after the end of medical treatment and before surgery. Cyto-histologic confirmation was attempted in 20 (57%) patients. Six patients had exploratory thoracotomies. Twenty-nine patients underwent lung cancer resection: 11 lobectomies, 1 bilobectomy, and 17 pneumonectomies (7 right, 10 left). Complete resection was obtained in 27 of 35 (77%) patients. Thirteen (45%) patients underwent extended resection: intrapericardial pneumonectomy in 5 patients, vascular or bronchial sleeve resection in 2, atrial resection in 1, tracheal sleeve in 1, superior vena cava resection and reconstruction in 2 (1 with tracheal-sleeve resection), and chest wall resection in 2. Median time from chemoradiation therapy to resection was 7 months (range: 1-39). Viable tumor was found in 26 of 29 (89.6%) patients. Major complications occurred in 9 patients (25.7%). There were 2 (5.7%) perioperative deaths within 30 days. With a median follow-up of 13 months, postoperative 2- and 3-year survival rates after complete resection were 46% and 37%, respectively. Salvage lung resection after definitive chemoradiation therapy is feasible, with acceptable postoperative survival and complication rates.

Pneumonectomie pour poumon détruit post-tuberculeux : une série de 26 cas opérés

A retrospective study over a period of 5years (2009to 2014) was realized. Are involved in the study all patients admitted to the thoracic surgery department of CHU Hassan II with tuberculosis lung destroyed and operated during the study period. This is a series of 26patients, including 17men and 9women treated and cured for pulmonary tuberculosis of which 2for multiresistant tuberculosis. The average age was 38.8years. Hemoptysis (77%) and recurrent respiratory infections (65.4%) were the major clinical signs. Aspergilloma have been reported on cavitary lesion in 23% of cases and in 11.5% pyothorax was associated. Extra-pericardial pneumonectomy was performed in 65.4%, intra-pericardial pneumonectomy in 19.3% and pleural-pneumonectomy in 15.3%. The outcome was favorable in 23patients. We noted a pyothorax on pneumonectomy cavity in 3patients. Postoperative mortality was 7.7%. The regularly clinical and radiological control of all patients is satisfactory with a mean of 41months. Pneumonectomy for tuberculosis lung destroyed remains effective in young patients with an acceptable complication rate.

Gastric Volvulus Following Left Pneumonectomy in an Adolescent Patient.

Gastric volvulus is a rare post-pneumonectomy complication. Although it has been described previously, published cases are limited to an older patient population. We report the youngest case of postpneumonectomy gastric volvulus to date, occurring in an 18-year-old male with a history of inflammatory myofibroblastic pseudotumor who underwent left intrapericardial pneumonectomy, and presented 13 years later with chronic intermittent mesenteroaxial gastric volvulus. While postpneumonectomy gastric volvulus is a rare occurrence, it should remain in the differential diagnosis in postoperative thoracic surgical patients presenting with chest pain.

A Rare Central Thoracic Tumor

Journal of Thoracic Oncology ® • Volume 9, Number 6, June 2014 CASE HISTORY A 51-year-old male former smoker, without relevant medical history, had progressive dyspnea on exertion, cough, minor hemoptysis, and a large suprahilar tumor-like mass on chest radiography. A positron emission tomography–computed tomography scan at the referring center showed a lobulated mass invading the mediastinum and right pulmonary artery, and filling defects suspect for pulmonary emboli (Fig. 1). The lesion had moderate F-fluorodeoxyglucose uptake. At bronchoscopy, the right upper lobe was suboccluded by a smooth mass. Forceps biopsies revealed necrosis of unclear origin. The patient was referred for workup. The absence of venous thrombosis, intracardiac clots, pulmonary hypertension, and arterial hypoxemia reduced the likelihood of widespread pulmonary emboli. After reassessment at our thoracic oncology multidisciplinary meeting, a surgical procedure was proposed based on the suspicion of a tumor mass originating from the pulmonary artery. A right-sided intrapericardial pneumonectomy and left-sided pulmonary endarterectomy (PEA) through sternotomy was performed on extracorporal cardiopulmonary bypass. The procedure and postoperative recovery were uncomplicated. The pneumonectomy specimen showed a tumor completely obliterating the right pulmonary artery and protruding into the right upper lobe bronchi. Left PEA from pulmonary valve level to the subsegmental branches was able to remove a pale smooth mass (Fig. 2). Pathology showed a tumor in the pulmonary artery wall with a heterogeneous aspect. Essentially, it concerns a spindle cell process with cellular fascicular to myxoid areas. The tumor cell nuclei were atypical with a mitotic count of 5 of 10 hpf. Immunohistochemistry revealed (nuclear) MDM2 expression and diffuse epidermal growth factor receptor expression (Fig. 3). Stains for desmin, α-smooth muscle actin, CD31, and CD34 were negative. FISH analysis showed strong amplification of the MDM2 and PDGFRA genes, thus confirming an intima sarcoma.

Giant solitary fibrous tumor of the pleura requiring left pneumonectomy.

A 57-year-old man was referred to our department from another hospital after major bleeding following thoracoscopic biopsy of an undiagnosed giant mass in the posterior mediastinum. The bleed had been controlled by emergency posterolateral thoracotomy and diagnosis of low grade malignant solitary fibrous tumor of the pleura (SFTP) then obtained, but radical resection was not performed. A chest computed tomography (CT) scan showed a large hypervascular posterolateral mediastinal mass adherent to the mediastinal pleura, the left lung, the thoracic aorta, and close to the esophagus (Figs 1, ​,22). Figure 1 Axial post-contrast computed tomography (CT) images at four different levels of the chest (shown here at the mediastinum window level), disclosed a large left-posterior mediastinal lesion characterized by many intralesional and surrounding vessels, strictly ... Figure 2 Sagittal reformatted computed tomography (CT) image shows the craniocaudal extension of the mass and its extensive contact with the thoracic aorta. We performed redo posterolateral thoracotomy. The mass was then dissected and effectively separated from the esophagus and pericardium. However, the mediastinal pleura of the left lung was widely infiltrated and intrapericardial left pneumonectomy was required to achieve radical en bloc resection (Fig 3). No residual disease was observed at the end of the procedure. Figure 3 Surgical specimen disclosing the radically resected solitary fibrous tumor of the pleura involving the mediastinal surface of the left lung completely resected en bloc by left intrapericardial pneumonectomy. Histological examination confirmed malignant SFTP CD 34 and CD 99 positive, cytokeratin negative, weighing 985 grams without the left lung. Postoperative paramedian left vocal cord paralysis resulting in moderate dysphonia was documented by video laryngoscopy and a speech therapy program was instituted. The patient was discharged two weeks after surgery without any major complication. Two years of follow up, performed by chest CT scan every four months, did not disclose any local or distant relapse. SFTP is a rare, slow-growing tumor whose origin is widely recognized as the mesenchymal cells of submesothelial tissues of the pleura, rather than mesothelial cells.1 The tumor tends to grow into a huge mass before local compression symptoms develop. Angiography or CT scan frequently discloses multiple feeding vessels, including several intercostal, internal mammary, inferior phrenic, and bronchial arteries.2 The ideal treatment of SFTP is based on radical surgical excision that is generally curative in all benign cases and in approximately half of malignant ones.1 Complete resection of giant SFTP may be challenging because of poor exposure, significant blood supply, strong adhesions, and often the direct involvement of nearby structures, however, there is little evidence for alternative management of this particular tumor (radiotherapy and chemotherapy).3 The prognosis for patients with benign SFTP is generally favorable with a five-year overall survival rate ranging from 79 to 100%, however, the risk of recurrence is high after the resection of a malignant sessile SFTP, although long-term survival is possible, ranging from 46 to 100%.4 Adequate pre-operative blood storage is recommended in cases of planned giant SFTP resection, together with a detailed explanation to acquaint patients with details of the therapeutic schedule, including major lung and mediastinal resection.

Intravascular plasma cell granuloma of the pulmonary artery

A 29-year old man presented with chronic cough. A chest X-ray revealed several faint round opacities in the right upper zone (Fig. 1a). Computed tomography showed a mass occluding the right main pulmonary artery (Fig. 1b). Positron emission tomography showed increased activity (Fig. 1c). He underwent median sternotomy and intrapericardial right pneumonectomy. Histopathology revealed an intravascular plasma cell granuloma (Fig. 1d).

Initial Experience With the Use of Biological Implants for Soft Tissue and Chest Wall Reconstruction in Thoracic Surgery

Synthetic materials have traditionally been used for tissue reconstruction in thoracic surgery. New biomaterials have been tested in other areas of surgery with good results. The aim of our study is to evaluate our initial experience using prostheses in extended thoracic surgery. A review was performed of all patients who underwent extended surgical procedures requiring soft tissue reconstruction with bioprosthetic materials after thoracic surgery from August 2009 to August 2011. A total of 44 consecutive patients were included. Operations involved radical pleurectomy and decortication for mesothelioma (n = 29), extended operations for thoracic malignancies (n = 8), surgery for trauma or perforated organs or complications (n = 6), and for benign infectious causes (n = 1). A total of 76 patches were used in 44 patients (median of 2; range 1 to 3 per patient). Median hospital stay was 13 (range 5 to 149) days. Three patients died during the postoperative period (6.8%); pulmonary embolism 5 days after intrapericardial pneumonectomy with chest wall reconstruction, fatal pneumonia 26 days after radical pleurectomy and decortication for mesothelioma, and bronchopleural fistula 11 days after pneumonectomy with diaphragm and atrium excision for lung cancer after initial chemoradiotherapy. No other surgical exploration or removal of patches has been required for infection. Our initial experience of using bioprosthetic patches for soft tissue reconstruction in thoracic surgery has proven satisfactory with overall acceptable results. The infection rates are low even when a proportion of procedures were performed under contaminated environments. Biologic prosthesis should be part of the surgical options to reconstruct soft tissues in thoracic surgery.

Pulmonary Infarction After Repair of Type B Aortic Dissection

Lung infarction after intrathoracic surgery is a life-threatening complication that needs urgent intervention. Although the exact etiology is not known, pulmonary infarction may be suspected for patients presenting with consolidation of the lung after intrathoracic surgery. We report a very rare case of pulmonary infarction after successful surgical treatment of a type B aortic dissection. The pulmonary infarction was treated by intrapericardial pneumonectomy. This article discusses possible etiology and management of such patients. A high index of clinical suspicion and timely investigations may allow early detection of this unusual event and avoid fatal outcomes.