Lower Lobectomy Research Articles

This video shows a left lower lobectomy and lymph node dissection in a 77-year-old women with a 1.5 cm adenocarcinoma

This video shows a left lower lobectomy and lymph node dissection in a 77-year-old women with a 1.5 cm adenocarcinoma

How to deal with benign hilar or interlobar lymphadenopathy during video-assisted thoracoscopic surgery lobectomy-firing the bronchus and pulmonary artery together.

Anatomic lung resection for lung cancer by video-assisted thoracoscopic surgery (VATS) has become popular for resectable lung cancer. However, complicated situations with hilar or interlobar lymphadenopathy were tough for surgeons. We'd like to introduce a method of "firing the bronchus and pulmonary artery together" via a video demo demonstration for troubleshooting situations with severe inflammatory or calcified peri-arterial/peri-bronchial lymphadenopathy. The inflammatory and calcified lymph nodes surrounding the target bronchus and artery were firstly dissected via sharp dissection using scissors. There was no clearance between the right lower bronchus and artery, then we fired them together using endo-stapler. At last, the stumps were shortened and reinforced via complementary cross mattress suture. This video shows a classic three portal VATS right lower lobectomy, which was complicated with severe inflammatory and calcified lymph nodes. The operation went through smoothly. The postoperative course of the patient was uneventful. If there was no clearance between the target bronchus and artery during a complicated VATS lobectomy caused by severe lymphadenopathy, firing the bronchus and pulmonary artery together was an optimal option.

Necrotizing pneumonia and acute purulent pericarditis caused byStreptococcus pneumoniaeserotype 19A in a healthy 4-year-old girl after one catch-up dose of 13-valent pneumococcal conjugate vaccine

Streptococcus pneumoniae is a common cause of infectious diseases in children that may lead to life-threatening complications. Acute purulent pericarditis is an uncommon complication of S. pneumoniae in the antibiotic era. A healthy 4-year-old girl was admitted with pneumonia and pleural effusion. She had received one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age. She rapidly developed necrotizing pneumonia, complicated by bronchopleural fistula presenting as subcutaneous emphysema and pneumothorax and acute purulent pericarditis. S. pneumoniae serotype 19A was subsequently identified from blood, empyema and pericardial fluid cultures. After appropriate antibiotic therapy and a right lower lobectomy, her condition stabilized and she promptly recovered. This case highlights two rare potential clinical complications of pneumococcal disease in a child: necrotizing pneumonia and acute purulent pericarditis. This is the first report of a child who received just one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age, as per the United States’ Advisory Committee on Immunization Practice's recommendations, but who still developed severe invasive pneumococcal disease with life-threatening complications caused by S. pneumoniae serotype 19A.

Successful Treatment of <i>Aspergillus</i> Empyema Using Open Window Thoracostomy Salvage Treatment and the Local Administration of an Antifungal Agent

A 76-year-old woman received long-term immunosuppressive treatment for collagen vascular disease-associated interstitial pneumonia. The patient developed a cavitary mass lesion in the right lower lung field, and both nontuberculous mycobacteria and Aspergillus spp. were isolated after bronchial washing. The patient underwent a right lower lobectomy but developed Aspergillus empyema. Empyema due to Aspergillus spp. is a rare and life-threatening condition; however, the standard therapeutic strategies for treating Aspergillus empyema are not clear. We herein report a case of Aspergillus empyema that was successfully treated with a combination therapy which included open-window thoracostomy and the administration of antifungal agents (systemic micafungin and local amphotericin-B).

Treatment of Tuberculous Empyema by Intrathoracic Transposition of a Latissimus Dorsi Muscle Flap.

Treatment of Tuberculous Empyema by Intrathoracic Transposition of a Latissimus Dorsi Muscle Flap.

Hemopericardium after Lung Lobectomy

Cardiac tamponade after lung resection is a very rare but life-threatening complication. The present case illustrates another of this uncommon complication, wherein the exact mechanism of injury remained undefined. Hemorrhagic cardiac tamponade occurred few hours after left lower lung lobectomy and re-thoracotomy surprisingly revealed that a left coronary artery branch rupture was the cause.

Single utility port or single port complete video-assisted thoracoscopic surgery for pulmonary lobectomy

Objective To explore clinical application of single utility port or single port video-assisted thoracoscopic lobectomy. Methods Conducting a prospective study to 191 patients with lung disease who underwent complete video-assisted thoracoscopic surgery (VATS) lobectomy in Department of Thoracic Surgery of The People's Hospital of Wuhan University from June 2013 to Dec 2014. Results Of the 191 patients, 35 underwent left upper lobectomy, 42 underwent left lower lobectomy, 43 underwent right upper lobectomy, 11 underwent right middle lobectomy, 47 underwent right lower lobectomy, and 13 underwent bilobectomy. Operations were successful in all patients with 3 patients transferred for open thoracotomy for severe adhesion or bleeding. A total of 7 of 78 upper lobectomy and 8 of 113 middle or lower lobectomy was done with adding another incision for severe adhesion. The mean operative time was 50~190 (80.3±43.2)min. The mean blood losing was 90~350(145.4±56.2)ml. Thirty nine patients underwent upper lobectomy, who were placed two chest tubes, respectively. The upper chest drainage duration was(1.5±0.8)d, and the lower chest drainage duration was(4.2±1.3)d. Forty eight patients underwent lower lobectomy, middle lobectomy, or bilobectomy, who were placed one chest tube, respectively. The chest drainage duration was(4.0±1.7)d. The mean recovery time after operation was (6.1±2.5) d. Seventy six patients were diagnosed with lung cancer, and the average number of dissected lymph nodes from each patient was (14.7±6.9). The lung cancer was classified as tumor node metastasis (TNM) stage ⅠA, ⅠB, ⅡA, ⅡB and ⅢA in 67, 61, 34, 22 and 7 cases, respectively. No serious complications, such as bronchopleural fistula or death, occurred in perioperation. Conclusions In consideration of placing two chest tubes after upper lobectomy and placing one chest tube after lower lobectomy, middle lobectomy, or middle and lower lobectomy, we think single utility port-VATS (2-port) for upper lobectomy and single port-VATS lobectomy for lower lobectomy, middle lobectomy, or middle and lower lobectomy are technically safe and have the advantages of drainage, lessening pain, rapid postoperative recovery, and have no significant difference in operation time, the incidence of complications and the number of removed lymph nodes, compared to traditional 3-port-VATS. Key words: Thoracoscopy/MT; Pneumonectomy

Intraoperative bronchial stump air leak control by Progel® application after pulmonary lobectomy.

Diffuse tracheobronchial calcification is a physiological condition associated with advanced age, especially in women. A calcified bronchus can be fractured during major lung resections (lobectomy, bilobectomy, and pneumonectomy), exposing patients to intraoperative air leakage and broncho-pleural fistula (BPF) occurrence. We retrospectively evaluated the use of Progel® application on the suture line of bronchial stump after pulmonary lobectomy analysing the intraoperative air leak and BPF occurrence. Between January 2014 and December 2014, Progel® was applied in 11 patients who presented intraoperative bronchial fractures after suture resection by mechanical staplers and air leak from bronchial stump, in order to treat air leakage. Patients were 7 men and 4 women, aged between 56 and 81 years (mean age 71.2 ± 12.1 years). Surgical procedures included 6 upper lobectomies (4 right, 2 left), 1 bilobectomy and 4 lower lobectomies (3 right, 1 left). Mean hospital stay was 4.5 ± 2.6 days (2-8 days). None of the patients had postoperative air leakage. No Progel® application-related complications occurred. No other major complications occurred. No mortality occurred. Progel® proved to be useful in treating intraoperative air leakage during major lung resections, particularly those occurring as a result of fracture of the bronchus from a mechanical stapler.

A challenging case of tracheal bronchus with concurrent tracheal stenosis for one lung ventilation

BackgroundTracheal bronchus is a rare congenital anomaly that may remain asymptomatic or present with symptoms that mimic other respiratory diseases. We present a particularly challenging case of tracheal bronchus combined with tracheal stenosis that had remained asymptomatic until it was diagnosed incidentally. ObjectiveTo describe our findings in a 66-year-old lady who presented for an elective resection of lung tumour. MethodsThe medical and surgical records plus biomedical images were reviewed together with a literature search on the subject. ResultsWe describe a patient found to have tracheal stenosis with a large tracheal bronchus during right lower lobectomy. Attempts to isolate and collapse the right lung failed with both double lumen tube (DLT) and bronchial blocker. A CT Scan done preoperatively showed a right upper lobe bronchus originating high in the trachea and interestingly a reconstructed three dimensional (3-D) image later, revealed an unusually large tracheal bronchus with a stenotic remnant of the trachea before the true carina begins. ConclusionThere are many anatomical variations of tracheal bronchus but none so far describes an entirely asymptomatic anomaly with concurrent tracheal stenosis. Specific CT imaging to reconstruct tracheobronchial anomalies in a 3-D view is suggested whenever the diagnosis is detected during staging CT. A plain description on its own would not suffice in estimating the depth or parameters of the structures involved to allow adequate pre operative planning of any airway intervention especially when ventilating one lung is the strategy.

Thoracoscopic lobectomy in a lung cancer patient with severe hemophilia: A case report.

Hemophilia is a hereditary disease with impaired blood coagulation due to a genetic deficiency of blood coagulation factors. Hemophilia often causes spontaneous life-threatening bleeding, so patients with hemophilia are often not suitable for any surgery that may cause iatrogenic bleeding and threaten the life of the patient. Therefore, surgery in lung cancer patients with hemophilia is extremely rare. The present study reported the case of a lung cancer patient with hemophilia who presented with a persistent cough. A mass was revealed by computed tomography and the patient underwent a successful thoracoscopic right lower lobectomy. The study discusses the patient's diagnosis and treatment options for hemophilia A and lung cancer, including indications for thoracoscopic lobectomy, pre-operative preparation and post-operative care, and other treatment options are discussed. The literature is also reviewed on this subject.

Micropapillary structure of lung adenocarcinoma and spread through air space (STAS) in thick-section histology

The patient was a 61-year-old woman, a current smoker, who presented with a solid spiculated mass in right lower lobe of the lung detected by chest computed tomography. The diagnosis of adenocarcinoma was made by aspiration cytology. Right lower lobectomy was performed, and the diagnosis of acinar predominant lung adenocarcinoma was confirmed on histology. The histology also showed isolated intra-alveolar micropapillary clusters of malignant cells around the main tumor, additionally involving lung segments beyond the main tumor. We examined 150 μm thick-sections, stained with hematoxylin and eosin, which showed these intra-alveolar cancer cell clusters in three-dimensions. This method of tissue examination confirmed that these were metastatic intra-alveolar micropapillary clusters with spread through air spaces and were not due to direct extension from the main tumor mass. In the lung, “spread through air spaces” (STAS) has been recently described as an important prognostic indicator in adenocarcinoma of the lung. In this case, tumor cells were found as micropapillary structures, cell nests, and single cells within air spaces and beyond the edge of the main tumor. Because of their association with poorer prognosis, it is important to recognize the micropapillary variant of primary lung adenocarcinoma and to identify STAS. We would recommend the use of thick-section histology in evaluation of STAS in adenocarcinoma of the lung.

Intralobar Pulmonary Sequestration

A 28-year-old patient was diagnosed by CT scan with intralobar pulmonary sequestration in the left lower lobe associated with cystic images, one of which was probably infected (Fig. 1). Lung auscultation was normal; no lymphadenopathies were palpated. Respiratory function tests showed: FVC 5.28 L (97%), FEV1 4.14 L (95%), and IT 98%. Surgical resection was performed with video-assisted thoracic surgery (VATS). The left lower lobe was pathologic in appearance; we identified and resected an artery originating at the thoracic aorta that fed the posterior inferior segment (Fig. 2). Lower lobectomy was completed with no intraor postoperative complications. c i r e s p . 2 0 1 5 ; 9 3 ( 7 ) : e 5 9

Mélanome pulmonaire achromique

We report a case of amelanotic pulmonary melanoma in a 52-year-old man. Histological diagnosis was established after right lower lobectomy. The primary source was not found. We describe the diagnosis, treatment and surgical follow-up of this type of pulmonary tumour.

Giant Pulmonary Hydatid Cyst and Trauma in a 9 Year-Old Child: A Case Report.

Herein, we report a case of giant lung hydatid cyst in a nine-year-old boy. For four years, he experienced mild chest pain and chronic nonproductive cough. He had a trauma resulted from a fall two days before admission. Chest X-ray showed misdiagnosed massive pleural effusion, and was aspirated in the other hospital. However, after admission, the computed tomography revealed a giant lung hydatid cyst filling the right hemithorax completely. Being considered by the diagnosis of ruptured lung hydatid cyst, he was treated surgically by right-thoracotomy. The existing hydatid cyst, (e.g., with a dimension of 30*22*20cm) filled all cavity of hemithorax extended from the right diaphragm to the apex of the lung situated in the right lower lobe. After evacuation of the hydatid fluid and laminated membrane, right lower lobectomy was carried out due to remaining no salvageable parenchyma without any complications. Also, the pathologic examination have confirmed hydatid cyst. In conclusion, giant hydatid cysts are probably misdiagnosed with massive pleural effusion in the endemic area. And, because of the risk of allergic reactions, anaphylactic shock and dissemination, it should not be aspirated.

Coexistence of lung alveolar adenoma with cerebral arteriovenous malformations: A case report and literature review.

Alveolar adenoma is an extremely rare benign tumor of the lung derived from type II pneumocytes. To date, only a limited number of alveolar adenoma cases have been reported in the literature. These tumors are usually discovered incidentally on radiographic images. However, other tumor types must be excluded when the characteristics of alveolar adenoma are not typical on the radiographic images. Therefore, diagnosis of alveolar adenomas is based on the combination of gross structural analysis and immunohistochemistry. The present study described a case of alveolar adenoma in a 47-year-old female patient. A chest X-ray revealed a pulmonary lesion in the right lower lobe and, subsequently, the patient underwent a right lower lobectomy. Pathological examination of the surgically resected tissue confirmed the initial diagnosis of alveolar adenoma. In addition, intracranial vascular malformations were detected on a computed tomography scan, but the patient did not experience any notable symptoms. Considering the benign nature of the malformations, as determined by digital subtraction angiography, the patient selected to undergo follow-up with observation only. The postoperative course was uneventful and no recurrence of pulmonary lesions was noted after >4 years, while the condition of the intracranial lesion was stable. In conclusion, the current study described a unique case of adenoma alveolar coexisting with intracranial vascular malformations. A literature review of previously-reported alveolar adenoma cases was also conducted.

Primary enteric adenocarcinoma with predominantly signet ring features of the lung: A case report with clinicopathological and molecular findings

Primary signet ring adenocarcinoma (SRA) of the lung is a rare condition. An 81-year-old man was referred to our hospital because of bloody sputum. Chest radiography showed a tumor in the right lung and biopsies revealed typical SRA. No tumors except for the one in the right lung were found. Therefore, diagnosis of primary lung SRA was made. The SRA cells showed intracytoplasmic mucin that were characterized by crescentic nuclei displaced toward one end of the cell. The tumor cells showed negative immunostaining for thyroid transcription factor 1 (TTF-1), but positive immunostaining for CDX2, cytokeratin-20 (CK20), Ki-67 (labeling = 50%), p53, and focally CK7. A right lower lobectomy and lymph node dissection were performed via video-assisted thoracic surgery. After surgery, uracil-tegafur (184 mg/m 2 /day) was administered for five days, followed by a 2-day rest period for a duration of two years in total. No recurrence was observed during the monthly-follow ups, and the patient did not experience any complications. In conclusion, we describe an extremely rare case of primary enteric adenocarcinoma with predominantly signet ring features of the lung. Our case report includes in-depth immunohistochemical and molecular data.

Bilateral Thoracic Impalement Through Mediastinum

Fig 2. Adepartment, after falling from the balcony of a second-floor-apartment, on a projecting iron bar. The bar impaled her chest, bilaterally, and was carefully left in situ. The patient was conscious, oriented, and hemodynamically stable. The entrance wound site was at the fourth intercostal space, midaxillary line of the right lateral chest wall, and exit wound site at the tenth intercostal space, posterior axillary line of the left lateral chest wall, as shown by the arrows (Fig 1). Due to the patient’s stable condition, preoperative x-ray and computed tomography scan (Figs 2, 3) were performed. A metallic bar (yellow arrows in Figs 1, 2 and 3) penetrated the chest from the right side to the left, through the mediastinum, leaving intact the major structures of the thoracic cavity. The patient was transferred to the operating room. A right thoracotomy, middle lobe wedge rejection, and right lower lobectomy were initially performed and followed by a left thoracotomy and parenchymal lacerations repair. The iron bar was extracted under direct vision with careful manual control. The patient made an uneventful recovery. Impalement injuries limited to the chest are quite rare [1]. Mortality rate is extremely high, especially when the heart or great vessels are impaled, while factors like young age and injuries restricted to lungs, may contribute to a favorable outcome.

Uncommon lymphoepithelial cyst with sebaceous glands of the pancreas.

Lymphoepithelial cysts with sebaceous glands of the pancreas are extremely rare, with only 7 cases, including this case, published in English literature. We herein present the case of a 67-year-old Asian man who underwent a resection of a lymphoepithelial cyst of the pancreas during the follow up care for lung cancer. Fourteen years previously he underwent a right lower lobectomy at the right segment nine for lung cancer. A 20 mm mass in the body of the pancreas was identified by CT scan 4 years ago, and the diagnosis was intraductal papillary mucinous neoplasm (IPMN) at that time. Over a 5-year period, this mass grew to 42 mm without dilatation of the main pancreatic duct. The preoperative evaluation, including endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), indicated a cystic neoplasm with suspicion of malignancy. Intraoperative frozen section revealed a squamous-lined cyst accompanied by sebaceous glands without any malignant findings. Following this pathological finding, resection of the cyst was performed. Consequently, microscopic examination revealed that it was a lymphoepithelial cyst with sebaceous glands of the pancreas. Pancreatic lymphoepithelial cysts can be cured by conservative resection, but if they are asymptomatic and are diagnosed before surgery, no treatment is necessary. To our knowledge, this is the first ever published case of a lymphoepithelial cyst with sebaceous glands of the pancreas, which was found during the follow up care for lung cancer.

A case report: right upper lobectomy with middle lobe preservation after right lower lobectomy.

Few reports have described right upper and lower lobectomy with preservation of the middle lobe because of the risk of middle lobe torsion or emphysematous change. Herein we describe a successful result following lobectomy with preservation of the middle lobe for metachronous pulmonary metastasis originating from colon cancer in the right upper lobe after initial right lower lobectomy. A 69-year-old man who had undergone right lower lobectomy for pulmonary metastasis originating from colon cancer 3 years earlier was diagnosed as having suspected metachronous pulmonary metastasis in the right upper lobe. Because preoperative computed tomography (CT) indicated that the distance between the tumor and the entrance of the upper bronchus was 20 mm, it was considered difficult to achieve complete resection by a wedge resection or segmentectomy. Furthermore, preoperative CT demonstrated compensatory hypertrophy of the middle lobe and elevation of the right diaphragm, thus reducing the size of the thorax. Therefore, right upper lobectomy with middle lobe preservation was planned. The operation was performed using a totally thoracoscopic approach. Adhesion of the upper lobe to the chest wall was easily detached. As the middle lobe adhered to the chest wall, this served to prevent middle lobe torsion. The fissure between the upper and middle lobes had fused because of adhesion resulting from the initial lower lobectomy. Therefore, an ‘anterior fissureless approach’ was adopted to avoid any postoperative air leakage. There were no intraoperative problems, and the postoperative course was uneventful. The patient was discharged on postoperative day 6. Pathological examination of the specimen confirmed that the tumor was a metachronous pulmonary metastasis originating from the colon cancer. Four months after the operation, he had no requirement for additional oxygen support, and postoperative CT demonstrated a sufficiently expanded residual middle lobe without emphysematous change.

膵癌孤立性肺転移の 1 切除例

A 73-year-old female underwent distal pancreatectomy in 2009. In 2011, chest CT revealed a nodular lesion. Based on the suspicion of primary lung cancer, right lower lobectomy was performed. Cytology of the tumor stump showed atypical cell clusters showing palisading and formation of tubular structures. The tumor cells had comparatively small and elliptic nuclei and were elliptical in shape cytoplasm. Histologically, the lesion was a metastatic tumor in the lung from primary pancreatic cancer. In addition to the past history, the presence of a solitary lung nodule composed of cylindrical cells forming tubular structures led to the presumptive diagnosis of a pulmonary metastasis from primary pancreatic cancer.