Left Upper Bronchus Research Articles

Usefulness of final transection of the proximal pulmonary artery in robotic left upper lobectomy.

The pulmonary artery runs around the left upper bronchus, which poses the risk of blood vessel injury when cutting in the blind spot of the bronchus. During robotic surgery, the robotic arm holds the tissue under constant tension; therefore, even if the pulmonary artery is left for final transection, it is not injured by unexpected tension. In this study, we examined the usefulness of final transection of the proximal pulmonary artery in robotic left upper lobectomy. This retrospective single-institution study evaluated patients who had undergone robotic lung resection. Of the 453 robotic lung resections performed at our institution between 2017 and 2022, 49 patients who had undergone left upper lobectomy were evaluated. Patients who had undergone bronchial transection followed by pulmonary artery transection were assigned to the group, bronchus prior transection (BT group, n = 38), and those who had undergone pulmonary artery transection followed by bronchial transection were assigned to the group, pulmonary artery prior transection (AT group, n = 11). Patient characteristics and perioperative outcomes were compared between the groups. The groups did not differ significantly in age, sex, smoking history, tumour size, complication rates or 30-day mortality. The BT group inclined to shorter operative times and lesser blood loss. No active intraoperative bleeding occurred in the BT group. However, the AT group had 2 cases of intraoperative pulmonary artery bleeding, one of which required urgent conversion to thoracotomy. Final transection of the proximal pulmonary artery is a novel and effective surgical technique for robotic left upper lobectomy.

Distinguishing bronchoscopically observed anatomical positions of airway under by convolutional neural network.

Artificial intelligence (AI) technology has been used for finding lesions via gastrointestinal endoscopy. However, there were few AI-associated studies that discuss bronchoscopy. To use convolutional neural network (CNN) to recognize the observed anatomical positions of the airway under bronchoscopy. We designed the study by comparing the imaging data of patients undergoing bronchoscopy from March 2022 to October 2022 by using EfficientNet (one of the CNNs) and U-Net. Based on the inclusion and exclusion criteria, 1527 clear images of normal anatomical positions of the airways from 200 patients were used for training, and 475 clear images from 72 patients were utilized for validation. Further, 20 bronchoscopic videos of examination procedures in another 20 patients with normal airway structures were used to extract the bronchoscopic images of normal anatomical positions to evaluate the accuracy for the model. Finally, 21 respiratory doctors were enrolled for the test of recognizing corrected anatomical positions using the validating datasets. In all, 1527 bronchoscopic images of 200 patients with nine anatomical positions of the airway, including carina, right main bronchus, right upper lobe bronchus, right intermediate bronchus, right middle lobe bronchus, right lower lobe bronchus, left main bronchus, left upper lobe bronchus, and left lower lobe bronchus, were used for supervised machine learning and training, and 475 clear bronchoscopic images of 72 patients were used for validation. The mean accuracy of recognizing these 9 positions was 91% (carina: 98%, right main bronchus: 98%, right intermediate bronchus: 90%, right upper lobe bronchus: 91%, right middle lobe bronchus 92%, right lower lobe bronchus: 83%, left main bronchus: 89%, left upper bronchus: 91%, left lower bronchus: 76%). The area under the curves for these nine positions were >0.98. In addition, the accuracy of extracting the images via the video by the trained model was 94.7%. We also conducted a deep learning study to segment 10 segment bronchi in right lung, and 8 segment bronchi in Left lung. Because of the problem of radial depth, only segment bronchi distributions below right upper bronchus and right middle bronchus could be correctly recognized. The accuracy of recognizing was 84.33 ± 7.52% by doctors receiving interventional pulmonology education in our hospital over 6 months. Our study proved that AI technology can be used to distinguish the normal anatomical positions of the airway, and the model we trained could extract the corrected images via the video to help standardize data collection and control quality.

Emergent salvage surgery for massive hemoptysis after proton beam therapy for lung cancer: a case report

BackgroundSalvage surgery is an effective therapeutic option for patients experiencing relapses after chemoradiotherapy for advanced-stage lung cancer or after high-dose radiotherapy for early-stage lung cancer. We report a case involving an emergent salvage surgery for a patient with massive hemoptysis who developed lung cancer recurrence after undergoing proton beam therapy 7 years prior to presentation.Case presentationA 70-year-old male patient was emergently admitted due to massive hemoptysis. He had undergone proton beam therapy for a stage I adenocarcinoma of the left upper lobe 7 years ago, and was receiving chemotherapy for local recurrence. We performed an emergent salvage pulmonary resection to achieve hemostasis. During the operation, we confirmed the presence of a left broncho-pulmonary arterial fistula, which was considered as the origin of the massive hemoptysis. We repaired the fistula between the pulmonary artery and left upper bronchus without incident; an orifice of the fistula at the left pulmonary artery was sutured using a non-absorbable monofilament, and the central portion of the orifice of the fistula at the left upper bronchus was closed with a mechanical stapling device. The postoperative diagnosis was of an adenocarcinoma—ypT3(pm1) N0M1a (dissemination)-IVA, ef1b. The patient has survived for over a year with the cancer in almost complete remission following the administration of an epidermal growth factor receptor tyrosine kinase inhibitor.ConclusionsEmergent salvage surgery demands high skill levels with optimal timing and correct patient selection. Our case suggested that the procedure played an important role in controlling serious bleeding and/or infectious conditions. Consequently, he could receive chemotherapy again and survive for over a year.

Fissureless trans-pericardial left upper lobectomy of the lung: a technique to avoid pneumonectomy

Fissureless lobectomy of the lung is an operative technique in which hilar vessels and bronchus are divided before the interlobar fissure is separated. When hilar vessels and bronchus cannot be exposed because of tumor progression, this procedure cannot be used. As an alternative, we propose here trans-pericardial fissureless left upper lobectomy, in which the left upper bronchus is exposed by dividing the posterior wall of the pericardium after the left upper pulmonary vein is divided in the pericardial cavity. This technique enables us to perform fissureless left upper lobectomy even when hilar vessels cannot be accessed outside the pericardium.

Analysis of risk of endobronchial biopsy-induced bleeding in different locations of lung cancer

Objective To investigate risk of endobronchial biopsy (EBB)-induced bleeding in different locations of lung cancer. Methods The clinical data of 643 patients diagnosed with lung cancer were collected from January 2014 to February 2018. The association of lesions of location with the risk of EBB-induced bleeding was evaluated using multivariate regression analysis adjusted for demographics, tumor characteristics, and comorbidities. Results After adjusting for sex, age, smoking history, pathological type and stage of tumor, complications [chronic obstructive pulmonary disease (COPD), hypertension, diabetes and coronary heart disease], platelet count, prothrombin time and activated partial thromboplastin time, multivariate regression analysis showed that compared to incidence of EBB-induced bleeding in right lower bronchus, the odds ratio (95% confidence interval) of left main bronchus, left upper bronchus, left lower bronchus, right main bronchus, right upper bronchus, right middle bronchus, right middle lobar bronchus and the trachea were 5.24(2.23, 12.31), 2.08(1.14, 3.80), 1.93(1.01, 3.67), 2.92(1.14, 7.47), 1.81(1.00, 3.30), 4.91(1.94, 12.45), 1.33(0.48, 3.63) and 2.19(0.58, 8.30). Conclusions Patients with lung cancer located in the central airways were more likely to bleed upon EBB when compared lesions located in the peripheral bronchi. Lesions located in left main bronchus, left upper bronchus were the most likely to bleed upon EBB among the central airways and peripheral bronchi, respectively. Key words: Lung neoplasms; Bronchoscopy; Biopsy; Hemorrhage

Implantation of 125I radioactive seeds via c-TBNA combined with chemotherapy in an advanced non-small-cell lung carcinoma patient

BackgroundThe critical management of advanced non-small-cell lung carcinoma (NSCLC), especially when complicated by severe airway stenosis, is difficult and often leads to high clinical risks and medical costs.Case presentationA 51-year-old previously healthy male was admitted to the Department of Respiratory and Critical Care Medicine, Taizhou People’s Hospital, in November 2018 for haemoptysis and difficulty breathing during a 15-d period. Following admission, chest computed tomography (CT) showed a large mass in the left hilum with atelectasis in the left upper lobe and obstructive pneumonia in the left lower lobe. Bronchoscopy revealed that the lesions occurred in the distal segment of the left main trachea, with occlusion of the left upper bronchus and significant narrowing of the lower bronchus. A basal mucosal biopsy of the lump tissue was performed after haemostasis treatment with sub-plasma coagulation (APC), and squamous lung carcinoma was confirmed. Following the final diagnosis, the patient was successfully treated with implantation of 125I radioactive seeds via transbronchial needle aspiration (c-TBNA) combined with chemotherapy.ConclusionWe believe that implantation of 125I radioactive seeds via c-TBNA is an effective treatment for patients with advanced lung cancer and those presenting with severe and mixed main bronchus stenosis.

Composite resection of the left upper lobe and superior segment (S6) of the lower lobe for lung cancer with a mediastinal lingular and basal pulmonary artery

BackgroundPreoperative evaluation and awareness of anatomical variations in the pulmonary vessel is essential for a secure pulmonary resection. We herein present a patient who underwent complex pulmonary resection for lung cancer with a mediastinal lingular and basal pulmonary artery that had been detected by preoperative three-dimensional computed tomography.Case presentationThe patient was an asymptomatic 66-year-old woman who had a 39-pack-year smoking habit. Chest computed tomography (CT) revealed the tumor invading the left upper bronchus and pulmonary artery branches in the left upper lung lobe. Enhanced CT and three-dimensional (3D) images of the pulmonary artery revealed that pulmonary artery branches (A4 + 5, A8, and A9 + 10) were extending into the lingular and basal segment in ventral side of the left upper bronchus. We completed the resection by means of a composite resection of the left upper lobe and the superior segment of the lower lobe, avoiding pulmonary angioplasty to preserve the left lower lobe or pneumonectomy.Conclusions3D-CT is useful for detecting this rare variation of the left pulmonary artery before operation, allowing for proper resection.

Foreign Body Aspiration in the Left Bronchial Tree: Apropos of Two Cases

Foreign body aspiration (FBA) is a potentially life-threatening event. The most common site of aspiration is the right main bronchus. We present the cases of two patients with a history of intravenous drug abuse, both with foreign bodies logded in the left upper lobar bronchus (ULB) probabily aspirated during a period of unconsciousness, immediately after drug injection. We believe that the position in which individuals were injected was possibly related to the location of the object. J Med Cases. 2018;9(4):112-113 doi: https://doi.org/10.14740/jmc3025w

Left side sleeves

Left bronchial sleeve resection is a particular surgical technique sometimes required for treating lung cancer arising at the origin of a lobar bronchus. In some cases, this technique is required for resecting a neoplastic hilar node infiltrating the upper left bronchus. In some instances, these neoplastic lesions may infiltrate also the pulmonary artery requiring a double sleeve resection (bronchial and arterial) and reconstruction in order to preserve as much lung parenchyma as technically and oncologically possible. Bronchial reconstruction (the anastomosis between the main left bronchus and the left lower bronchus) is performed with two running sutures with a non-absorbable monofilament in order to obtain a telescopic anastomosis. PA can be infiltrated by the tumor to various levels, from partial infiltration to a more extensive and even circumferential involvement. In case of partial involvement, a partial resection with suture of the PA is indicated; in case of extended involvement, the reconstruction of the PA may be made by using pericardial patch, end-to-end anastomosis, or by the interposition of a prosthetic conduit. In this review, we report our experience in treating lung cancer infiltrating the left pulmonary artery and the left upper bronchus requiring a double sleeve resection and reconstruction. We also describe the workup of these patients and we illustrate in details our surgical technique.

Pneumonectomy of Primary Pulmonary Angiosarcoma with Malignant Effusion and Intrapleural Hypotonic Hyperthermic Chemotherapy: Case Report and Review of the Literature

Background: Primary pulmonary angiosarcoma is extremely rare and the prognosis is very poor. We report a combination therapy of pneumonectomy and intrapleural hypotonic hyperthermic chemotherapy (IPHHC). Case report: A 48-year-old male with exertional dyspnea was found to have a left massive pleural effusion. Bronchoscopic examination displayed endobronchial stenosis of the left lower bronchus B8,9,10 and diagnosed with pulmonary angiosarcoma. Chest computed-tomographic scanning revealed a 5-cm mass in the left inferior lobe, which invaded the left upperbronchus. Intrapleural dissemination and malignant pleural effusion were also suspected (cT3N1M1a, c-stage IV). As a palliative initial therapy, we performed a pneumonectomy. On the 7th postoperative day, under general anesthesia, we performed video-assisted IPHHC (43°C, 60 min, 200 mg/m2 of CDDP). After the IPHHC, there was no major adverse event (more than Grade 3) during the postoperative course. Histological examination of the resected specimen revealed a highly-cellular growth of atypical spindle cells with a storiform pattern. By immunohistochemical testing, the tumor cells stained positive for markers including CD31 and the factor VIII related antigen, and the diagnosis of pulmonary angiosarcoma was made. No adjuvant chemoradiotherapy was given, and the postoperative clinical course was uneventful. Although there had been a recurrence in the chest wall, the patient eventually died twenty-one months later. Conclusion: As a new therapeutic option, we performed IPHHC after the pneumonectomy for an advanced pulmonary angiosarcoma with malignant pleural effusion. Although the patient had a recurrence in the chest wall, he had a reasonable postoperative outcome, that is, he returned to a work, retained a good quality of life and had a longer survival in spite of the poor prognosis of the pulmonary angiosarcoma.

The Effectiveness and Tolerance of TS-1 a Monotherapy for Relapsed Thymic Cancer Patient Who could not Tolerate Platinum Compounds

Background: The optimal chemotherapeutic regimens for thymic cancers still remain controversial, although systemic chemotherapy is an important therapeutic modality for unresectable thymic cancer. In general, platinumbased regimens such as CODE and ADOC are widely used. However, several serious side effects of the platinum therapy may significantly restrict its efficacy for clinical application. We herein describe a case with a good response to TS-1 treatment for relapsed thymic cancer in a patient who could not tolerate platinum compounds. Case report: A 73-year-old woman was diagnosed with thymic cancer, Masaoka stage IVa, in May 2009. She underwent the concurrent chemoradiation therapy. In September 2011, lung metastasis of the thymic cancer was noted in the right upper lobe. It was difficult to continue platinum-based chemotherapy due to various life-threatening side effects of the treatment. In June 2013, the chest CT scan revealed the growth of the right upper lobe metastatic tumor and left upper lobe atelectasis due to a metastatic polyploidy lesion in the left upper bronchus. The patient underwent partial resection of the lesion and repeat resections in June and September 2014. At the same time, the right upper lobe metastatic tumor had continued to grow. The patient received chemotherapy with TS-1 monotherapy. There were no severe toxicities and the right upper lobe metastatic tumor showed a marked reduction in size. At present, TS-1 therapy has been continued and the patient remains well with an excellent performance status. Conclusion: TS-1 may be a good alternative treatment for patients who cannot tolerate platinum compounds.

Management of bronchopleural fistula using a modified single lumen tube

Bronchopleural fistula (BPF) is defined as a pathologic connection between the tracheobronchial tree and the pleural space with persistent air leak for more than 24 hours. It is associated with poor prognosis after pneumonectomy [1], which mainly contributes to the occurrence among elective lung resections despite the outstanding advances in surgical techniques. Mechanical ventilation is always problematic for balancing the actual ventilation and the leakage in patients who present a BPF after pulmonary resections. High airway pressure to achieve sufficient minute ventilation may aggravate air leakage and interfere the healing process [2]. We describe a case in which a modified single-lumen endobronchial tube was used in a patient who developed BPF after right lower lung lobectomy in order to improve ventilation and allow adequate suctioning.

Asthma-Like Tracheo-Bronchial Amyloidosis

Localized bronchial Amyloidosis is an uncommon disease of unknown origin. Clinical signs are not specific. Tracheobronchial symptoms are the most frequent. We report a case of a 31 year-old man complaining of asthma-like dyspnea. Bronchoscopy was performed because of ineffectiveness of antiasthmatic treatment, showed a submucosal infiltration with stenosis of both right and left upper bronchi and a complete stenosis of intermediate troncus. Multiple biopsies were performed and concluded to Amyloidosis of AL type. Oral corticosteroids were indicated with clinical improvement.

Successful Treatment of Bronchial Mucoepidermoid Carcinoma in a Longstanding Collapsed Lung

Mucoepidermoid carcinoma is a rare tumor of the lung that accounts for 0.1% to 0.2% of all pulmonary tumors. Herein we report our experience with a patient who suffered from bronchial mucoepidermoid carcinoma and 2-year left lung atelectasis. The tumor originated from the orifice of the left upper bronchus and obstructed the left main stem bronchus. A left upper sleeve lobectomy was performed and the remaining atelectatic lower lobe was fully expanded by 6 months postoperatively. The patient's pulmonary function significantly improved.

Lung cancer at a university hospital in Saudi Arabia: A four-year prospective study of clinical, pathological, radiological, bronchoscopic, and biochemical parameters

OBJECTIVES AND BACKGROUND:Lung cancer accounts for 4% of all newly diagnosed cancers in Saudi Arabia. The pattern of presentation is unknown. The objectives of this study were to assess the clinical, radiological, pathological, biochemical and bronchoscopic abnormalities in lung cancer patients and to compare our findings with those reported in the literature.METHODS:A total of 114 patients with proven lung cancer were selected for the study. A questionnaire concerning patients' demographic data was obtained; the abnormalities and the cell types of lung cancer were recorded prospectively in each subject.RESULTS:A total of 114 patients with lung cancer were studied. Mean age ± SD was (59.8 ± 10.8) years, and (71.1%) were smokers and 95.1% of them were male, (90.1%) smoked >20 pack/yr (96.2%) for 20 years or more. Cough (76.3%) and clubbing (40.4%) were the most common symptom and physical abnormality respectively. The right lung (64.9%) was more commonly affected than the left (37.7%). Metastases were present in (49.1%) at presentation. The right and left upper bronchi (24% vs. 16%) were the mostly affected. Hypercalcemia was more common in squamous cell, while hyponatremia was more common in adenocarcinoma, and small cell. Squamous cell carcinoma was the most common cell type (51.8%) and significantly associated with smoking (P ≤ 0.001)CONCLUSION:Squamous cell carcinoma was the most common cell type, and significantly associated with smoking. The incidence of metastasis was high at presentation. The right lung and right upper bronchus were often affected. Hypercalcemia and hyponatremia were the most common biochemical abnormalities.

Transanastomotic Endobronchial Migration of a Pericardial Flap

A 36-year-old woman underwent left main bronchus sleeve resection for a typical carcinoid. The bronchial anastomosis was reinforced with a bovine pericardial flap fixed by fibrin glue. Six months after the surgery the patient presented with acute dyspnea. Flexible bronchoscopy disclosed an endoluminal migration of the pericardial flap through the anastomotic dehiscence and a cicatricial stenosis of the left upper bronchus. The migrated flap was successfully removed and the stenosis segment of the bronchus was dilated using a rigid bronchoscope. Two months after complete recovery from the bronchial dehiscence, the patient developed an anastomotic cicatricial stenosis, which was effectively treated by laser photoresection and mechanical dilatation. Eight months after the last procedure the patient remains symptom free.

Transoesophageal endoscopic-ultrasonography-guided 125I permanent brachytherapy for unresectable mediastinal lymphadenopathy

A 59-year-old woman with an isolated nodal relapse of adenocarcinoma of the lung was referred to our institution for salvage therapy after lobectomy, adjuvant chemotherapy, and thoracic radiotherapy. Her oncological medical history dated back to November, 2001, when a solitary lung mass was found in the left upper lobe during routine chest radiography. Subsequent bronchoscopy showed a lesion in the left upper bronchus, and the subsequent biopsy was positive for adenocarcinoma of the lung. Work-up studies were negative for regional lymphadenopathy or metastatic disease (clinical stage T1N0M0).

A particular anatomic variation of the course of the left pulmonary artery

Clinical Summary PATIENT 1. A 61-year-old man underwent left upper lobectomy for T2 N0 squamous cell carcinoma. During the operation, an anomalous left pulmonary artery course was noted. The left pulmonary artery passed into the bifurcation between the common bronchus to the anterior and apical posterior segments and the lingular bronchus (Figure 1). The vascular anomaly prevented adequate exposure of the origin of the left upper bronchus. Sepa-

Myoepithelioma of the lung: Report of two cases and review of the literature

Myoepithelial tumors occur mainly in the salivary glands, the sweat glands or the breast, but uncommonly in the lung. Herein, we describe two cases of myoepithelioma of the lung. Both patients were 58-year-old men, in whom the tumors were located in the right-upper bronchus and in the left-upper bronchus, respectively, with endobronchial growth pattern. Surgery was performed, but metastasis occurred into the forearm and hip muscles in the former case, and into the liver in the latter. Histologically, the tumor in the former was a spindle-plasmacytoid type, and that in the latter was a plasmacytoid type in part with squamous differentiation. Based on histochemical, immunohistochemical and ultrastructual analyses, both were compatible with myoepithelioma. The clinicopathological uniqueness of this neoplasm is discussed, together with a review of reports of this disease in the literature.

A clinical study on 61 cases of tuberculous tracheobronchitis.

Tuberculous tracheobronchitis is defined as a specific inflammation of the trachea or major bronchi caused by the tubercle bacillus and recognized as one of the most common and serious complication of pulmonary tuberculosis. It had been a diagnostic challenge in prebronchoscopic era and since 1968, fiberoptic bronchoscopy has been accepted as a safe and valuable diagnostic procedure of tuberculous tracheobronchitis. Now, it remains a troublesome therapeutic problem due to its sequelae such as bronchostenosis, bronchiectasis and bronchial deformity. The authors analyzed the clinical features, radiological findings and bronchoscopic findings with pathologic and bacteriologic study on 61 cases of tuberculous tracheobronchitis and following results were obtained. 1) The peak incidence was in the fourth decade and male to female ratio was 1:3.4. 2) The most common symptom was cough (86.9%) and followed by sputum (49.2%), dyspnea (27.9%), fever (19.8%), weight loss (11.5%), hemoptysis (6.6%), hoarseness (6.6%) and chest discomfort (3.3%) and localized wheezing was heard in 18%. 3) In chest X-ray, consolidation with collapse was observed in 70.5%, and followed by consolidation only (18.0%), mediastinal node enlargement (8.2%), cavitary lesion (6.6%), suspicious hilar mass (3.3%) and miliary lesion (1.6%) and there was no abnormal findings in 4.9%. 4) Bronchoscopy showed hyperplastic lesion in 67.2%, mucosal lesion (18.0%), ulcerative lesion (9.8%) and stenotic lesion (4.9%). The most common site of bronchial lesion was right upper bronchus (36.1%) and followed by right main bronchus (34.4%), left main bronchus (29.5%), left upper bronchus (16.4%), right middle bronchus (8.2%), right lower bronchus (6.6%) and left lower bronchus (3.3%). 5) Chronic granulomatous inflammation with or without caseation necrosis on microscopic examination was confirmed in 69.7%, bronchial washing AFB stain was positive in 34.1%, prebronchoscopic sputum AFB stain was positive in 88.1% and postbronchoscopic sputum AFB stain was positive in 30.1%.