Preservation Of Lung Parenchyma Research Articles

Double sleeve resections.

Double sleeve lung resections are complex surgical procedures that require specialized surgical expertise and careful patient selection. These procedures allow for the preservation of lung tissue while still achieving complete tumor resection for central tumors. Although initially considered high-risk operations, double sleeve lung resections have become a viable option for central tumors. Recent studies have shown that double sleeve lung resections are associated with lower morbidity and mortality rates than pneumonectomy. Furthermore, double sleeve lung resections may be associated with similar or even better long-term oncological outcomes compared to pneumonectomy, with the added benefit of preserving lung parenchyma and reducing the incidence of postoperative complications.

Are Sleeves the New Pneumonectomy?

Outcomes after sleeve resection are increasingly studied for patients with advanced non-small cell lung cancer.1 Sleeve lobectomies avoid pneumonectomy (PN) and preserve lung parenchyma. In this issue of The Annals of Thoracic Surgery, Hattori and colleagues2 evaluated 43 patients who underwent extended sleeve lobectomy (ESL) with complex reconstruction and resection of more than 1 lobe for centrally located non-small cell lung cancer. Of the 43 patients, long-term survival was relatively good. The 3-year overall survival was 62.8% with 3-year recurrence-free survival of 43.5%.

Surgical Outcome After Extended Sleeve Lobectomy in Centrally Located Non-small Cell Lung Cancer

BackgroundWe primarily aimed to evaluate the operative techniques, clinicopathologic characteristics, and surgical outcomes after extended sleeve lobectomy (ESL). Additionally, we evaluated the feasibility of ESL for centrally located non-small cell lung cancer (NSCLC) compared with pneumonectomy (PN). MethodsA retrospective review identified 119 patients who underwent pulmonary resections for centrally located NSCLC; of whom, 43 underwent ESLs and 76 underwent PNs. Perioperative morbidity and oncologic outcomes of ESL were analyzed. Postoperative morbidity was evaluated according to the Common Terminology Criteria for Adverse Events version 5.0. Overall survival was evaluated using a Cox proportional hazard model. ResultsAccording to the classifications of ESL, 10 patients comprised type A, 8 (19%) type B, 16 (37%) type C, and 9 (21%) type D. Pulmonary artery reconstructions were performed in 5 of type A, 8 of type B, 1 of type C, and 1 of type D, and pulmonary vein reconstructions occurred in 3 of type A and 2 of type C. After ESL, 30-day hospital mortality occurred in 1 patient (2.3%), and grade ≥3 morbidities occurred in 13 patients (30%). In particular, bronchial anastomosis/stump fistula was seen in 4 patients (9.3%) after ESL, and blood perfusion disorders due to the presence of thrombi were seen in 4 (9.3%). The 3-year overall survival was significantly better after ESL compared with that after PN (62.8% vs 45.2%, P = .047). ConclusionsESLs to preserve lung parenchyma will likely become a promising operative strategy in appropriately selected patients with centrally located NSCLC.

Computed tomography in cystic fibrosis lung disease: a focus on radiation exposure.

Thoracic computed tomography (CT) is the imaging reference method in the diagnosis, assessment and management of lung disease. In the setting of cystic fibrosis (CF), CT demonstrates increased sensitivity compared with pulmonary function tests and chest radiography, and findings correlate with clinical outcomes. Better understanding of the aetiology of CF lung disease indicates that even asymptomatic infants with CF can have irreversible pulmonary pathology. Surveillance and early diagnosis of lung disease in CF are important to preserve lung parenchyma and to optimise long-term outcomes. CF is associated with increased cumulative radiation exposure due to the requirement for repeated imaging from a young age. Radiation dose optimisation, important for the safe use of CT in children with CF, is best achieved in a team environment where paediatric radiologists work closely with paediatric respiratory physicians, physicists and radiography technicians to achieve the best patient outcomes. Despite the radiation doses incurred, CT remains a vital imaging tool in children with CF. Radiologists with special interests in CT dose optimisation and respiratory disease are key to the appropriate use of CT in paediatric imaging. Paediatric radiologists strive to minimise radiation dose to children whilst providing the best possible assessment of lung disease.

Locally advanced non-small cell lung cancer: the place of specialist thoracic surgery in the multidisciplinary team

One reason that lung cancer is the leading cause of cancer mortality worldwide, is that surgical intervention is highly dependent on earlier tumor stage and good patient condition. As large proportion of cases are already metastatic at presentation and many are locally advanced, curative surgery is only possible in a minority of fit patients. Increasing the number of patients achieving complete resection is one of the avenues to increase overall survival using our existing technology. In the past, complex cases may have been sporadically discussed between various specialists in order to achieve better outcomes. More recently, the idea of discussing those cases on a routine basis, rather than an accident of geography or referral pattern, gave rise to the multidisciplinary team. Lung cancer management is now increasingly complex, especially with novel modalities such as targeted therapies, immune checkpoint inhibitors and stereotactic body radiotherapy delivery. Likewise, in thoracic surgery, minimally invasive techniques, early recovery after surgery protocols and complex techniques for resecting locally advanced tumours or preserving lung parenchyma must all be deployed appropriately to continue our incremental gains in survival and quality of life. To highlight the role of specialist thoracic surgeon in the multidisciplinary care of locally advanced non-small cell lung cancer, we conducted a search of English language publications for its multidisciplinary-based surgical management. We limited our search to the last decade, then hand-searched relevant references. In addition, we used our large prospective database as a team-oriented specialized thoracic surgical service to benchmark and demonstrate the benefits of specialist surgeons in the modern multidisciplinary team. In conclusion, patients with locally advanced non-small cell lung cancer should have any surgical option withheld without a specialist thoracic surgical opinion as part of the multidisciplinary team discussion.

Thoracoscopic posterobasal segmentectomy, right lower lobe

Minimally invasive pulmonary segmentectomy allows adequate oncologic treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay. Most lung segments may be resected as segmentectomies or as part of bisegmentectomies (as is the case for the lingula). However, the resection of individual basal segments may be particularly challenging. Although several variations of minimally invasive pulmonary segmentectomy have been described, I favor a fully thoracoscopic multiport approach that allows direct access to the segmental structures, and is straightforward and versatile enough to allow for adaptation in case of unexpected intraoperative findings (such as conversion to lobectomy in the case of positive margins). Key aspects of posterobasal segmentectomy include proper patient positioning, appropriate positioning of operating trocars, standardized technique to expose and dissect the segmental vein, bronchus, and artery, and accurate division of the intersegmental plane.

Thoracoscopic superior segmentectomy, left lower lobe

Minimally invasive pulmonary segmentectomy allows adequate oncologic treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay. Although several variations of minimally invasive pulmonary segmentectomy have been described, I favor a fully thoracoscopic multiport approach that allows direct access to the segmental structures, is straightforward, and is versatile enough to allow adaptation in case of unexpected intraoperative findings (such as conversion to lobectomy in the case of positive margins). Key aspects of the procedure include proper patient positioning, appropriate positioning of operating trocars, standardized technique to expose and dissect of the segmental vein, bronchus, and artery, and accurate division of the intersegmental plane and fissure.

Left main bronchial sleeve resection with total lung parenchymal preservation: a tailored surgical approach.

Bronchial sleeve resection is an uncommon thoracic surgical procedure. Under specific conditions, patients can be selected to undergo a sleeve resection of the main bronchus with complete parenchymal preservation. The left main bronchus is longer than the contralateral bronchus, therefore left endobronchial tumours can be localized at the proximal end of the bronchus or distally, near the secondary carina. Bronchial anastomosis in these 2 situations requires different approaches. We present the surgical technique of left main bronchus resection with complete preservation of lung parenchyma through a hemi-clamshell incision (proximal tumour) or posterolateral thoracotomy (distal tumour).

Video-assisted thoracoscopic surgery (VATS) lower lobe bisegmentectomy (S7/8) for a central pulmonary metastasis.

Surgery for pulmonary metastasis is performed heterogeneously with regard to surgical approach [open vs. video-assisted thoracoscopic surgery (VATS)] and resection techniques (e.g., laser enucleation, electro-cautery resection, stapling). Complete tumor resection and preservation of lung parenchyma are of upmost importance. This is technically challenging, especially for central lesions close to vascular and bronchial segmental structures. Thus, simple thoracoscopic wedge resections are often not feasible. A VATS lower lobe bisegmentectomy (S7/8) was performed on a 62-year-old patient with a suspicious pulmonary nodule and a history of hemicolectomy for colorectal carcinoma. Different VATS techniques of vessel dissection and parenchymal control were applied. VATS anatomic segmental resections represent a helpful tool in surgical therapy of central pulmonary metastasis.

P1.08-049 CT Guided Labeling with Indocyanine Green of Small Lung Nodules for Sublobar Resection Utilizing Robotic Assisted Thorascopic Surgery (RATS)

Localization of deep and small pulmonary lung nodules undergoing a wedge or sublobar resection may be challenging during thoracoscopy, and may necessitate greater resection or conversion to thoracotomy. Particularly in robotic surgery, with the absence of tactile feedback. Percutaneous CT guided Indocyanine Green injection provides a means to pinpoint these nodules. A retrospective study of 40 consecutive patients who underwent preoperative CT-guided localization of solitary pulmonary nodules with ICG. Nodules ≤ 15mm were 21/40 (52.5%), ≤ 20mm 30/40 (75%), and ≤ 30mm 38/40 (95%). A 22-gauge spinal needle (BD, NJ) or Chiba needle (Cook, IA) was positioned into or adjacent to the nodule. 0.4cc Indocyanine Green was injected and the inner stylet withdrawn. The Xi daVinci robot (Intuitive Surgery, CA) was docked and the firefly filter of the 8mm camera was activated, and the nodule illuminates in a fluorescence green color. A wedge or sublobar resection was performed, with progression to lobectomy when indicated. CT guidance successfully localized the nodules in 100% of 40 patients employing this technique. Success was measured in nodule illumination as seen by the surgeon upon activation of the camera filter and confirmed on frozen and permanent section by pathology. Initial wedge resection for diagnosis prior to lobectomy and sublobar resection for decreased PFTs or decrease cardiac function were performed by Robotic Assisted Thoracoscopy (RATS). There were no conversions to thoracotomy. Diagnosis were adenocarcinoma in 18 patients (45%), squamous cell carcinoma in 7 patients (17.5%), carcinoid in 1 patient (2.5%), metastatic in 8 patients (20%), and benign in 6 patients (15%). There were no 30 or 90 day mortalities. A chest tube reinsertion in one patient for pneumothorax. Economically the cost for the vial of ICG is $79.56 compared to a fiducil marker at a cost of $128.00. Thoracic Surgery has access to CT scanners, without an extra cost, electromagnetic navigation systems come with significant added costs. Percutaneous CT guided labeling with ICG is quick and economical for the localization of small and deep nodules undergoing RATS wedge or sublobar resection. This technique may be supportive in preserving lung parenchyma and reduce the need for conversion to thoracotomy, maintaining minimal invasive thoracic surgery, especially where palpation or tactile feedback is absent.

Bronchial Foreign Body Alerting of a Bronchial Tumor: The Need of a Follow-Up Radiography.

Lung tumors are extremely rare in the pediatric population, comprising only 0.2% of all malignancies in children. Among them, mucoepidermoid carcinoma (MEC) is even rarer with a reported frequency of 0.1% to 0.2%. MEC is defined by the World Health Organization as a tumor characterized by a combination of mucus-secreting, squamous, and intermediate cell types. We describe the case of a 4-year-old girl who presented with a history of intermittent fever and nonproductive cough of 1-month duration after foreign body aspiration. The chest X-ray showed complete collapse of the left lung. After removal of the foreign body, the lung expanded well after. However, the control chest X-ray done after 5 days showed again complete collapse of the left lung. The biopsy specimen taken during bronchoscopy confirmed the diagnosis of low-grade MEC. Fluorescence in situ hybridization (FISH) confirmed the presence of MAML2 rearrangement. Complete surgical resection with preservation of lung parenchyma was performed. No adjuvant therapy was needed. Repeat bronchoscopy was performed 2 months after surgery and showed no recurrence of the tumor. In conclusion, a remote chest X-ray after removal of a foreign body is necessary to avoid missing a rare serious underlying disease such as MEC. According to the size and the location of the tumor, complete surgical removal is sufficient without additional treatment in case of low-grade tumor. The presence of MAML2 rearrangement confers a favorable outcome and may have long-term implications for the clinical management.

Augmentation treatment for α1 antitrypsin deficiency

α1 antitrypsin is a serine antiprotease secreted by the liver. 1 Stoller JK Aboussouan LS A review of alpha1-antitrypsin deficiency. Am J Respir Crit Care Med. 2012; 185: 246-259 Crossref PubMed Scopus (313) Google Scholar , 2 Wewers MD Crystal RG Alpha-1 antitrypsin augmentation therapy. COPD. 2013; 10: 64-67 Crossref PubMed Scopus (32) Google Scholar Its main function is inhibition of neutrophil elastase, a non-specific protease released by activated or dying neutrophils. In individuals with healthy concentrations of α1 antitrypsin, the fragile alveolar structures of the lung parenchyma are protected from this protease (figure). (A) α1 antitrypsin produced in the liver functions to protect the lungs from the burden of neutrophil elastase. (B) With the Z mutation in the α1 antitrypsin gene, the α1 antitrypsin Z protein aggregates in the liver, resulting in low α1 antitrypsin concentrations in the lungs. (C) The effect is progressive lung destruction, resulting in emphysema (scanning electron microscopy). Intravenous augmentation treatment and lung density in severe α1 antitrypsin deficiency (RAPID): a randomised, double-blind, placebo-controlled trialMeasurement of lung density with CT at TLC alone provides evidence that purified A1PI augmentation slows progression of emphysema, a finding that could not be substantiated by lung density measurement at FRC alone or by the two measurements combined. These findings should prompt consideration of augmentation treatment to preserve lung parenchyma in individuals with emphysema secondary to severe α1 antitrypsin deficiency. Full-Text PDF

Intravenous augmentation treatment and lung density in severe α1 antitrypsin deficiency (RAPID): a randomised, double-blind, placebo-controlled trial

The efficacy of α1 proteinase inhibitor (A1PI) augmentation treatment for α1 antitrypsin deficiency has not been substantiated by a randomised, placebo-controlled trial. CT-measured lung density is a more sensitive measure of disease progression in α1 antitrypsin deficiency emphysema than spirometry is, so we aimed to assess the efficacy of augmentation treatment with this measure. The RAPID study was a multicentre, double-blind, randomised, parallel-group, placebo-controlled trial of A1PI treatment in patients with α1 antitrypsin deficiency. We recruited eligible non-smokers (aged 18-65 years) in 28 international study centres in 13 countries if they had severe α1 antitrypsin deficiency (serum concentration <11 μM) with a forced expiratory volume in 1 s of 35-70% (predicted). We excluded patients if they had undergone, or were on the waiting list to undergo, lung transplantation, lobectomy, or lung volume-reduction surgery, or had selective IgA deficiency. We randomly assigned patients (1:1; done by Accovion) using a computerised pseudorandom number generator (block size of four) with centre stratification to receive A1PI intravenously 60 mg/kg per week or placebo for 24 months. All patients and study investigators (including those assessing outcomes) were unaware of treatment allocation throughout the study. Primary endpoints were CT lung density at total lung capacity (TLC) and functional residual capacity (FRC) combined, and the two separately, at 0, 3, 12, 21, and 24 months, analysed by modified intention to treat (patients needed at least one evaluable lung density measurement). This study is registered with ClinicalTrials.gov, number NCT00261833. A 2-year open-label extension study was also completed (NCT00670007). Between March 1, 2006, and Nov 3, 2010, we randomly allocated 93 (52%) patients A1PI and 87 (48%) placebo, analysing 92 in the A1PI group and 85 in the placebo group. The annual rate of lung density loss at TLC and FRC combined did not differ between groups (A1PI -1·50 g/L per year [SE 0·22]; placebo -2·12 g/L per year [0·24]; difference 0·62 g/L per year [95% CI -0·02 to 1·26], p=0·06). However, the annual rate of lung density loss at TLC alone was significantly less in patients in the A1PI group (-1·45 g/L per year [SE 0·23]) than in the placebo group (-2·19 g/L per year [0·25]; difference 0·74 g/L per year [95% CI 0·06-1·42], p=0·03), but was not at FRC alone (A1PI -1·54 g/L per year [0·24]; placebo -2·02 g/L per year [0·26]; difference 0·48 g/L per year [-0·22 to 1·18], p=0·18). Treatment-emergent adverse events were similar between groups, with 1298 occurring in 92 (99%) patients in the A1PI group and 1068 occuring in 86 (99%) in the placebo group. 71 severe treatment-emergent adverse events occurred in 25 (27%) patients in the A1PI group and 58 occurred in 27 (31%) in the placebo group. One treatment-emergent adverse event leading to withdrawal from the study occurred in one patient (1%) in the A1PI group and ten occurred in four (5%) in the placebo group. One death occurred in the A1PI group (respiratory failure) and three occurred in the placebo group (sepsis, pneumonia, and metastatic breast cancer). Measurement of lung density with CT at TLC alone provides evidence that purified A1PI augmentation slows progression of emphysema, a finding that could not be substantiated by lung density measurement at FRC alone or by the two measurements combined. These findings should prompt consideration of augmentation treatment to preserve lung parenchyma in individuals with emphysema secondary to severe α1 antitrypsin deficiency. CSL Behring.

Evaluation of the effect of pulmonary hydatid cyst location on the surgical technique approaches.

Purpose:A hydatid cyst is the most common lung parasitic disease and is endemic in Iran. A hydatid cyst is more common in the right lung and lower lobes.Objective:The aim of this study was to assess surgical treatment of pulmonary hydatid cysts and whether the location of cyst affects surgical technique approaches.Materials and Methods:This study was performed on 87 patients with a pulmonary hydatid cyst who were referred to Qaem Hospital from 2010 to 2012. Selection of surgical technique was according to size, location, and the number of cysts. Patients were divided into two groups: (1) surgery with preserving lung parenchyma and (2) lobectomy. Afterward, the relationship between the location of cyst and surgical technique approaches was evaluated. Data was analyzed by Chi-square and Fisher exact tests.Results:In this study, no significant relation was found between the size (P = 0.682) and number (P = 0.344) of cysts and lobectomy necessity. But, there was a significant relation between the occurrence of cyst in middle lobe and lobectomy necessity (P = 0.016).Conclusions:According to the results, type of surgical technique does not depend on the size and number of cysts, but it may be related to the location of the cyst and the ratio of lung destruction.

Traumatic Tracheobronchial Injury: Delayed Diagnosis and Treatment Outcome

BackgroundMost traumatic tracheobronchial injuries are fatal and result in death. Some milder cases are not life threatening and are often missed at the initial presentation. Tracheobronchial rupture is difficult to diagnose in the evaluation of severe multiple trauma patients. We reviewed the traumatic tracheobronchial injuries at Konyang University and Eulji University Hospital and analyzed the clinical results.Materials and MethodsFrom January 2001 to December 2011, 23 consecutive cases of traumatic tracheobronchial injury after blunt trauma were reviewed retrospectively. We divided them into two groups by the time to diagnosis: group I was defined as the patients who were diagnosed within 48 hours from trauma and group II was the patients who diagnosed 48 hours after trauma. We compared the clinical parameters of the two groups.ResultsThere was no difference in the age and gender between the two groups. The most common cause was traffic accidents (56.5%). The Injury Severity Score (ISS) was 19.6 in group I and 27.5 in group II (p=0.06), respectively. Although the difference in the ISS was not statistically significant, group II tended toward more severe injuries than group I. Computed tomography was performed in 22 cases and tracheobronchial injury was diagnosed in 5 in group I and 6 in group II, respectively (p=0.09). Eighteen patients underwent surgical treatment and all four cases of lung resection were exclusively performed in group II (p=0.03). There were two mortality cases, and the cause of death was shock and sepsis.ConclusionWe believe that close clinical observation with suspicion and rigorous bronchoscopic evaluation are necessary to perform diagnosis earlier and preserve lung parenchyma in tracheobronchial injuries from blunt trauma.

CURRENT ROLE OF BRONCHOPLASTIC PROCEDURE FOR LUNG CANCER

The indication for a sleeve resection is well established: a tumor arising at the origin of a lobar bronchus but not infiltrating as far as to require pneumonectomy. In addition, a sleeve resection may be indicated when N1 nodes infiltrate the bronchus from the outside, as is often the case in the left upper lobe tumors. From a functional point of view, sleeve lobectomy is strictly indicated in patients who cannot withstand pneumonectomy, but recent experiences have shown that the advantages of sparing lung parenchyma are evident also in patients without cardio-pulmonary impairment. Most studies show similar or better survival results for parenchymal sparing resections if compared with pneumonectomy. Moreover, in the analysis of 5-year survival according to stage, sleeve lobectomy results in higher survival rates for stage I, II. The survival advantage in stage III appears to be limited and the benefit is not always confirmed for stage III-N2 patients. Postoperative morbidity and mortality data reveal overall better results for patients undergoing sleeve lobectomy with respect to pneumonectomy. The preservation of lung parenchyma has been indicated by some authors as the possible cause of a theoretical increased risk for locoregional recurrence after sleeve lobectomy. However, although in some experiences a higher local recurrence rate is reported for sleeve resection with advanced nodal status (N2), the few studies analysing risk factors for recurrence, show that the tumor stage and the nodal status are the only negative predictive factors, rather than the type of operation performed.

Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy

Video-assisted thoracoscopic surgery (VATS) segmentectomies are usually more complex procedures than lobectomies. With the gained experience in the field of thoracoscopic surgery, many thoracic surgery departments have progressively adopted this technique to preserve lung parenchyma, especially in cases of metastasis or benign conditions. The majority of surgeons use three incisions but the procedure can be performed by only one port. We report the first anatomic segmentectomy performed by uniportal VATS with no rib spreading.

Segmental Bronchial Sleeve Resection: Preserving All Lung Parenchyma for Benign/Low-Grade Neoplasms

Bronchoplastic techniques are used commonly for the surgical treatment of benign or low-grade malignant neoplasms as a means of sparing healthy lung parenchyma. Because of technical difficulties, however, standard lobectomy or segmentectomy procedures are performed for the neoplasms localized in distally located tumors. We present the clinical and surgical data of 12 patients who underwent a unique surgical procedure, called by the authors of this article "segmental bronchial sleeve resection," without any pulmonary resection. Twelve patients with benign or low-grade malignant neoplasms who underwent segmental bronchial sleeve resection to totally preserve lung parenchyma between the years 1979 and 2008 were included in the study. Data were gathered from patient records retrospectively. The postoperative course was uneventful for 10 patients. One of the remaining 2 patients underwent rethoracotomy because of hemorrhage, and tracheostomy was performed for the other patient because of persistent atelectasis. There was no mortality for any of the patients. Segmental bronchial sleeve resection is complex in technique and may have an increased risk of complications compared to a standard sleeve resection, but it is an effective and safe bronchoplastic technique for selected patients with benign or low-grade malignant bronchial tumors when performed carefully by an experienced surgeon.

Severe Refractory Hypoxemia 16 Years After a Gunshot Injury

A 53-year-old man presented with a history of depressant syndrome. He had been hospitalized 16 years previously because of penetrating traumatic injury of the left hemithorax by bullet secondary to a suicide attempt. Recently, he came to the emergency department for an illness leading to the discovery of severe hypoxemia refractory to nasal oxygen therapy. The arterial blood gas measurements revealed a pH of 7.41, a Paco2 of 41 mm Hg, a Pao2 of 45 mm Hg, and O2 saturation of 83% on ambient air; the Pao2 increased to 85 mm Hg on inspired oxygen of 100%. resulting in a shunt of 30%. Multidetector computed tomography–angiography of the chest showed clearly a giant proximal pulmonary arteriovenous fistula (Figure 1A and B and …

New technique for pulmonary artery reconstruction

Bronchial and vascular reconstructive procedures are a technically feasible alternative to pneumonectomy in lung cancer and have the advantage of preserving lung parenchyma function. Sleeve resection and prosthetic reconstruction of the pulmonary artery (PA) have progressively gained acceptance as an alternative to pneumonectomy in lung cancer surgery. To spare the lung parenchyma, angioplastic procedures involving removal of a portion of the arterial wall or a circumferential resection with arterial reconstruction have been used. Several techniques of pulmonary arterioplasty have been documented, such as patch reconstruction, end-to-end anastomosis, synthetic prosthesis, biological prosthesis, prosthetic or pericardial conduit. We present the first case reported in the literature of PA reconstruction with a pulmonary vein graft.