Lower Lobectomy For Lung Cancer Research Articles

392. PLANNING IS THE KEY—ESOPHAGECTOMY WITH COLONIC INTERPOSITION FOLLOWING: WHIPPLE’S, LEFT LOWER LOBECTOMY, RIGHT PLEURECTOMY AND COLONIC SURGERY

Abstract Link to Video: https://www.dropbox.com/s/wpr3s097g50oadl/Colonic%20interposition%20%28ISDE%20SUBMISSION%29.mp4?dl=0. Description of Video: We report our learnings from a complex surgical case of Ivor Lewis esophagectomy with colonic conduit in a patient who had undergone multiple previous abdominal and thoracic operations. This seventy-two-year-old man was found to have an esophageal adenocarcinoma (T4N0M0) in the distal esophagus with a significant surgical background: Whipple’s procedure for pancreatic cancer; Left lower lobectomy for lung cancer; Right pneumonectomy for recurrent pneumothoraces and a defunctioning stoma for chemotherapy associated anal fistula. To our knowledge, no such case of colonic interposition for esophagectomy has been reported in the literature for a patient with such extensive surgical history. This presented significant surgical and anaesthetic challenges which are explored in the video. Principally the need for extensive planning to anticipate risk and modify procedural steps to account for these accordingly. For example, the operation began with a right thoracotomy, given the possibility that dense adhesions from previous surgery could obstruct safe dissection and subsequently the procedure could be aborted before any critical steps were made. Additionally, we consider the importance of involving other surgical specialities to aid with safe dissection and delineation of anatomy. Each of the key operative steps are described and paired with real-time video footage. Post-operatively we describe how the risk of anastomotic leak given a high-risk anastomosis may be reduced through pre-emptive Endoluminal Vacuum therapy. We also discuss the importance of recognising and managing feculent aspiration pneumonia which is common following this surgery. Discussion of this case and our operative approach would serve to highlight how surgery remains a feasible option for patients despite complex anatomy and surgical history; provided risks are anticipated and appropriately managed.

Right lower lobectomy for lung cancer after successful recovery from COVID-19

Right lower lobectomy for lung cancer after successful recovery from COVID-19

Aberrant mediastinal mediobasal segmental pulmonary artery in a patient with lung cancer undergoing right lower lobectomy: a case report

BackgroundA mediastinal mediobasal segmental pulmonary artery (A7) from the right main pulmonary artery is extremely rare.Case presentationWe report the case of a 71-year-old woman with an aberrant mediastinal A7 who underwent right lower lobectomy for lung cancer (cT1bN0M0, stage IA2). Preoperative three-dimensional computed tomography (CT) angiography revealed an aberrant mediastinal A7 in the right main pulmonary artery. Right lower lobectomy and mediastinal lymph node dissection were performed. Intraoperatively, A7 was observed between the superior and inferior pulmonary veins and in the front of the lower bronchus near the anterior hilum. The artery was carefully dissected from the caudal side after inferior pulmonary vein dissection. The lung parenchyma, which was within the fissure due to poor lobulation between the middle and lower lobes, was safely divided.ConclusionsThoracic surgeons need to carefully evaluate CT angiography or enhanced multidetector CT findings at preoperative conferences and always keep this anomaly in mind.

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

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

Thoracoscopic surgery using omental flap for bronchopleural fistula

BackgroundA bronchopleural fistula (BPF) can lead to empyema and death after pulmonary resection. A minor leakage from a BPF has been reported to be successfully closed endobronchially, although thoracoplasty is usually needed.Case presentationA case of successful thoracoscopic BPF closure using an omental flap in a 74-year-old man with emphysema who developed a BPF after right lower lobectomy for lung cancer is reported. Reoperation was performed to close the BPF using an omental flap. After successful closure of the BPF, the empyema resolved with intravenous antibiotics.ConclusionsThoracoscopic single-stage omentoplasty without thoracotomy might be a useful treatment method when a BPF is diagnosed early.

Pulmonary Resection of Lung Cancer in a Patient With Partial Anomalous Pulmonary Venous Connection

We report a case of a 64-year-old man in whom a partial anomalous pulmonary venous connection (PAPVC) was found before right lower lobectomy for lung cancer. In addition to lung cancer, there was a right superior pulmonary vein that drained into the superior vena cava (SVC). There was a concern of right ventricular heart failure resulting from increased left-to-right shunt flow after lobectomy. Therefore cardiac catheterization was performed to calculate the pulmonary-to-systemic flow rate in the presence of blocked blood flow to the lower lobe pulmonary artery. As a result, we successfully performed lobectomy without correcting the PAPVC.

Three-Dimensional Computed Tomography for a Mediastinal Basal Pulmonary Artery

Anatomic variations of the pulmonary artery increase the risks for vessel injury and critical mistakes during pulmonary artery resection. A patient who underwent left lower lobectomy for lung cancer with a mediastinal lingular and basal pulmonary artery that had been detected preoperatively by three-dimensional computed tomography is presented. During thoracoscopic surgery, the mediastinal basal pulmonary arteries were found with careful dissection. The pulmonary arteries were divided, and left lower lobectomy was performed safely. This rare variation of the left pulmonary artery is important to detect before lobectomy to ensure safe surgery. In such cases, three-dimensional computed tomography is necessary.

Extrapleural hematoma as a complication following thoracotomy for pulmonary lobectomy

Extrapleural hematoma as a complication following thoracic surgery is rare. We report a case of an extrapleural hematoma following pleural lobectomy that resolved completely with nonsurgical treatment. A 63-year-old woman underwent left lower lobectomy for lung cancer through a left posterolateral thoracotomy. She had been prescribed the anticoagulant cilostazol to increase her heart rate for atrioventricular dissociation. Preoperatively, it was stopped, and a temporary pacemaker was placed to counteract bradycardia via the right jugular vein without complication. The chest tube was removed, and cilostazol was resumed on the third postoperative day. On day 7, she suddenly experienced left shoulder pain followed by hypotension, tachycardia, and anemia. Enhanced computed tomography (CT) revealed an extrapleural hematoma rather than a hemothorax. She became symptomatic after rapid infusion. The hematoma resolved without an invasive intervention. The CT results 189 days after the onset showed almost complete regression of the hematoma.

Acute Exacerbation of Idiopathic Pulmonary Fibrosis of Microscopic Usual Interstitial Pneumonia Pattern after Lung Cancer Surgery

A 78-year-old man underwent right lower lobectomy for lung cancer. Histopathological examination led to the diagnosis of adenosquamous cell carcinoma. The background lung adjacent to the pleura showed idiopathic pulmonary fibrosis of microscopic usual interstitial pneumonia pattern, although preoperative computed tomography showed no apparent findings of interstitial pneumonia. The patient showed an acute exacerbation of idiopathic pulmonary fibrosis on the third postoperative day. We herein report a case of acute exacerbation of idiopathic pulmonary fibrosis of microscopic usual interstitial pneumonia pattern after lung cancer surgery.

Abdominal Pain and Severe Hyponatremia After Lung Cancer Surgery

We report a 54-year-old man who presented with abdominal pain and severe hyponatremia a few days after a left lower lobectomy for lung cancer. An abdominal computed tomography scan without contrast showed a bilateral adrenal hemorrhagic infarction, mainly on the right side. Serum sodium level was 113 mmol/L, and cortisol level was 0 microg/L. Anticardiolipin-type antibodies (immunoglobulin G isotype) level was 75 GPL/mL (normal value < 10). With hydrocortisone supplementation and curative doses of low-molecular-weight heparin, the patient recovered progressively and was discharged on postoperative day 17. Final diagnosis was bilateral adrenal gland hemorrhagic necrosis leading to adrenal insufficiency, associated with antiphospholipid syndrome. We discuss the mechanism and the role of the operation in the occurrence of this particularly rare and potentially life-threatening complication. Recommendations to prevent thrombosis in surgical patients who have antiphospholipid antibodies are lacking.

Spinal Metastasis From Lung Cancer Fifteen Years After Surgery Presenting a Pseudohemangioma Appearance of the Vertebra

Case report. To describe a case of solitary metastasis of the seventh thoracic vertebra (T7) from lung cancer 15 years after surgery. Late recurrence of the bone over 5 years after curative surgery for lung cancer is highly exceptional. In addition, bone metastasis from lung cancer showing a coarse trabecular pattern of the vertebra on computed tomography (CT) is quite unusual. A case of solitary metastasis of T7 from lung cancer 15 years after surgery showing a pseudohemangioma appearance of the vertebra on CT is presented. A 66-year-old man presented with a 2-month history of gradually progressed numbness and muscle weakness of the bilateral leg, with a more recently developed spastic gate. He had undergone a left lower lobectomy for lung cancer 15 years previously. Magnetic resonance imaging showed an ill-defined mass lesion involving the entire vertebral body of T7 with extension into the posterior element and surrounding soft tissue, which resulted in moderate spinal canal stenosis. CT showed a coarse trabecular pattern at T7 with a mild compression fracture. No other lesion was detected by whole-body CT and bone scintigraphy. Tumor resection and T5-T9 posterior spinal fusion had been performed, and a pathologic diagnosis of metastatic pulmonary adenocarcinoma of the bone was established. Additional radiation therapy (40 Gy) was added, and the patient recovered and continued to survive uneventfully at the 3-month follow-up. We have reported a rare case of solitary metastasis to T7 appearing 15 years after surgery for lung cancer. The incidence of lung cancer recurrence more than 5 years after surgery is exceedingly low; however, even in patients with lung cancer, late occurrence of bone metastasis should be considered and included in the differential diagnosis of a pseudohemangioma appearance of the vertebra.

Anomalous pulmonary vein detected using three-dimensional computed tomography in a patient with lung cancer undergoing thoracoscopic lobectomy

Few clinicians are familiar with the anatomy of anomalous pulmonary veins, and studies reporting patients who required right lower lobectomy for lung cancer and who had anomalies of the middle and lower pulmonary veins are even rarer. This report describes the case of a lung cancer patient who had an anomalous lateral part of the middle lobe vein (V4) draining into the right inferior pulmonary vein, which was confirmed by three-dimensional 64-row multidetector computed axial tomography (3D-MDCT) angiography. She was then successfully treated with video-assisted thoracic surgery. The preoperative 3D imaging of the pulmonary vein and artery allowed us to comprehend fully the patient's vascular anatomy before the operation. Thus, we recommend preoperative 3D-MDCT angiography for patients with lung cancer undergoing thoracic surgery, especially video-assisted thoracic surgery.

Gastropleural fistula due to gastric perforation after lobectomy for lung cancer

We report a case of acute gastropleural fistula due to gastric perforation after a left lower lobectomy for lung cancer. A 76-year-old male, who received a left hemicolectomy 20 years previously, came to our hospital for surgical treatment of lung cancer, which was performed uneventfully as a left lower lobectomy with combined resection of the diaphragm. On the postoperative day 2, acute dilatation of the stomach followed by gradual cardiopulmonary collapse, and then gastric perforation into the thorax occurred. The perforated stomach wall and diaphragm became paper-thin and necrotic, though the abdominal cavity was free of contamination. This life-threatening condition was treated by an emergency thoracotomy and partial gastrectomy through the thorax, as the left hemidiaphragm was remarkably elevated. An oeganoaxial torsion gastric volvulus caused by anatomic rotation following the lobectomy was speculated as the disease process, with loss of suspended tissue of the gastro-colic ligament from the left hemicolectomy being a possible predisposing factor. Such an episode is rare, however, it should be looked for during perioperative care following a lobectomy.

Late-onset chylothorax after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer

Late-onset chylothorax occurred 49 days after right lower lobectomy for lung cancer in a 76-year-old man. Chylothorax was successfully managed by conservative treatment with chest tube drainage and an enteral low-fat diet. Chylothorax may occur in the late period after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer, for which conservative management is the treatment of choice.

Case 5—2002 selective bronchial blockade in patients with previous contralateral lung surgery

Case 1. A 58-year-old man was scheduled for right middle lobe lobectomy to remove a lung tumor. He previously had a cystectomy and an iliac conduit for bladder cancer and left pneumonectomy for lung cancer. After left pneumonectomy, respiratory function data showed forced vital capacity (FVC) was 3.14 L (82.8%) and forced expiratory volume at 1 second (FEV1.0) was 1.74 L (53.6%). Breathing room air, blood gas analysis showed pH 7.392; PaO2, 80.9 mmHg; PaCO2, 44.5 mmHg; SaO2, 96.3%; and base excess, 1.7 mEq/L. After placement of an epidural catheter at T5-6, anesthesia was induced with 3 mg/kg of thiopental followed by 0.15 mg/kg of vecuronium. To use the bronchial blocker of a Univent tube (Fuji Co Ltd, Tokyo, Japan) as an independent blocker, the authors detached it from a Univent tube. The bronchial blocker initially was introduced into the trachea, after which the patient was intubated with a standard 9.0-mm internal diameter tube. The bronchial blocker was used outside the endotracheal tube. After this, radial artery and right internal jugular vein catheters were placed. Arterial blood gases were continuously monitored by a Paratrend7 (Biomedical Sensors Ltd, High Wycombe, UK). Anesthesia was maintained with fentanyl, isoflurane and oxygen, and epidurally administered 1% lidocaine. Fig 1 shows the changes in PaO2 and PaCO2 during the operation. Guided by fiberoptic bronchoscopy, initially the blocker was advanced to the bronchus intermedius, and the middle and lower lobes were collapsed, but PaO2 rapidly decreased and PaCO2 continued to increase. The authors then ventilated the whole lung and tried to block the middle lobe. This was successful, allowing normocapnia to be maintained throughout the operation with PaO2 at 80 mmHg. Collapse of the middle lobe also provided adequate surgical exposure and facilitated surgical procedures. When the middle lobe bronchus was stapled, ventilation was transiently stopped, and the blocker was withdrawn. Middle lobe lobectomy was performed uneventfully. After the operation, the patient was extubated and transferred to the recovery room for postoperative care. Case 2. A 65-year-old woman was scheduled for basal segmentectomy (S7-10) of the right lung for lung cancer. She previously had a left lower lobectomy for lung cancer. After lobectomy, respiratory function data showed FVC was 2.47 L (103.4%) and FEV1.0 was 1.4 L (69.9%). Breathing room air, blood gas analysis showed pH 7.415; PaO2, 86.6 mmHg; PaCO2, 42.9 mmHg; SaO2, 96.9%; and base excess, 2.6 mEq/L. After placement of an epidural catheter at T5-6, anesthesia was induced with 3 mg/kg of thiopental followed by 0.15 mg/kg of vecuronium. Similar to case 1, a bronchial blocker detached from a Univent tube initially was introduced to the trachea, after which the patient was intubated with a standard 8.0-mm internal diameter tube and received a radial artery catheter. One-lung ventilation initially was tried, but oxygen saturation as measured by pulse oximetry (SpO2) rapidly decreased to 82%. One-lung ventilation was abandoned, and both lungs were ventilated until SpO2 returned to 100%; then, guided by fiberoptic bronchoscopy, the blocker was advanced into the bronchus intermedius and blocked the middle and lower lobes. Using this technique, SpO2 subsequently was maintained at 100% throughout the operation. Case 3. A 64-year-old man was scheduled for segmentectomy (S1) of the right lung to remove a tumor. He previously had a left upper lobectomy for lung cancer. After lobectomy, respiratory function data showed FVC was 2.82 L (87.3%) and FEV1.0 was 2.00 L (70.9%). Breathing room air, blood gas analysis showed pH 7.375; PaO2, 70.6 mmHg; PaCO2, 45.5 mmHg; SaO2, 93.0%; and base excess, 0.9 mEq/L. After placement of an epidural catheter at T7-8, anesthesia was induced with 1.5 mg/kg of propofol and 2 g/kg of fentanyl followed by 0.15 mg/kg of vecuronium. The trachea was intubated with an 8.0-mm internal diameter Univent tube. Anesthesia was maintained with propofol, 5 to 10 mg/kg/h, with intermittently administered 1.5% lidocaine epidural anesthesia. A radial artery catheter also was placed. Guided by fiberoptic bronchoscopy, a bronchial blocker was introduced into the right upper bronchus and blocked only the right upper lobe. Subsequently, normocapnia was maintained with sufficient oxygenation (SpO2, 100%) throughout the operation. *S. Hagihira, N. Maki, and M. Kawaguchi

PEDICLED OM ENTOPLASTY FOR POSTOPERATIVE BRONCHOPLEURAL FISTULA : A CASE REPORT

A 69-year-old female successfully underwent the closure of bronchopleural fistula 10 weeks after right lower lobectomy for lung cancer. The fistula was identified at the bronchial stump and the lateral wall of the middle lobe bronchus. Empyema was treated by tube drainage and followed by open window thoracotomy for eight weeks. The bronchopleural fistula was then closed with an omental pedicle. The omentum placed into the pleural cavity was fixed on the fistula as a patch graft. Chest tube drainage was discontinued one week later with no signs of fistula or abscess formation. The postoperative course has been uneventful.

Esophagectomy for metastatic carcinoma of the esophagus from lung cancer

A patient with metastatic carcinoma of the esophagus from lung cancer is reported. The patient was a 54-year-old woman who underwent a left lower lobectomy for lung cancer 5 years previously. The authors performed a thoracic esophagectomy, dissection of mediastinal lymph nodes, and reconstruction of the esophagus; the surgery was followed by chemotherapy. Because the histologic pattern of the esophageal tumor was similar to that of lung cancer and mucosal involvement was not seen, the esophageal tumor was interpreted to be a metastasis from lung cancer. The patient is well without recurrence of disease 23 months after operation. This is the first report of a successful esophagectomy for metastatic carcinoma of the esophagus from lung cancer.