Double prosthetic replacement of pulmonary artery and superior vena cava and sleeve lobectomy for lung cancer

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.

Surgical outcome of pulmonary artery reconstruction using the expanded polytetrafluoroethylene patch in patients with lung cancer

PURPOSE

Pulmonary artery reconstruction is sometimes utilized as an alternative to pneumonectomy in lung cancer surgery. We herein report our experience of pulmonary artery reconstruction using an expanded polytetrafluoroethylene (ePTFE) patch based on the surgical results and long-term outcome.

METHODS

Clinical records of lung cancer patients who underwent patch plasty were reviewed retrospectively.

RESULTS

Between 2003 and 2017, pulmonary artery patch plasty were performed in 21 patients [18 males, 3 females; mean age 65 (range 47-79) years]. Induction chemoradiotherapy was performed in three patients. Bronchoplasty was performed in five patients. The pathologic stages were stage I in 3 patients, stage II in 6 and stage III in 12. Pneumonectomy, lobectomy and segmentectomy were performed in 2, 18 and 1 patient, respectively. The left upper lobe was the most frequent origin of lung cancer (15 patients). There was no reconstruction-related morbidity or mortality. The overall survival rate at 5 years was 64.1% with a mean follow-up of 39.5 months, and the survival rates for N0-1 and N2-3 were 80.8% and 28.6%, respectively.

CONCLUSION

Patch angioplasty using the ePTFE sheet is a reliable procedure in radical surgery for lung cancer.

Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion

Video assisted thoracic surgery (VATS) has become a routinely utilized approach to complex procedures of the chest, such as pulmonary resection. It has been associated with decreased postoperative pain, shorter length of stay and lower incidence of complications such as pneumonia. Limitations to this modality may include limited exposure, lack of tactile feedback, and a two-dimensional view of the surgical field. Furthermore, the lack of an open incision may incur technical challenges in preventing and controlling operative misadventures leading to major hemorrhage or other intraoperative emergencies. While these events may occur in the best of circumstances, prevention strategies are the primary means of avoiding these injuries. Unplanned conversions for major intraoperative bleeding or airway injury during general thoracic surgical procedures are relatively rare and often can be avoided with careful preoperative planning, review of relevant imaging, and meticulous surgical technique. When these events occur, a pre-planned, methodical response with initial control of bleeding, assessment of injury, and appropriate repair and/or salvage procedures are necessary to maximize outcomes. The surgeon should be well versed in injury-specific incisions and approaches to maximize adequate exposure and when feasible, allow completion of the index operation. Decisions to continue with a minimally invasive approach should consider the comfort and experience level of the surgeon with these techniques, and the relative benefit gained against the risk incurred to the patient. These algorithms may be expected to shift in the future with increasing sophistication and capabilities of minimally invasive technologies and approaches.

Lung resections combined with vena cava replacement

Resection and reconstruction of the superior vena cava in patients with lung cancer is still considered a surgical challenge; the numerous problems related to patient selection, the choice of the most appropriate surgical strategy and technique, the most suitable material for replacement, and the number of potential complications definitively show an impact on short-term outcome and long-term prognosis. However, with the appropriate indications and surgical technique, a clear benefit has been documented in a select group of patients with lung cancer.

Combined Double Sleeve Lobectomy and Superior Vena Cava Resection for Non-small Cell Lung Cancer with Persistent Left Superior Vena Cava

A 65-year-old man with right central type of lung squamous carcinoma was admitted to our department. Bronchoscopy displayed complete obstruction of right upper lobe bronchus and infiltration of the bronchus intermedius with tumor. Chest contrast computed tomography revealed the tumor invaded right pulmonary artery, superior vena cava, and the persistant left superior vena cava flowed into the coronary sinus. The tumor was successfully removed by means of bronchial and pulmonary artery sleeve resection of the right upper and middle lobes combined with resection and reconstruction of superior vena cava (SVC) utilizing ringed polytetrafluoroethylene graft. To the best of our knowledge, this was the first report of complete resection of locally advanced lung cancer involving superior vena cava, right pulmonary artery trunk and main bronchus with persistant left superior vena cava.

Translocation of left inferior lobe pulmonary artery to the pulmonary artery trunk for central type non-small cell lung cancers

BACKGROUND

The purpose of this study was to report on a technique for translocation of the left inferior lobar pulmonary artery (PA) to the PA trunk associated with bronchial sleeve resection of the left superior lobe in the treatment of bronchogenic cancer.

METHODS

The clinical data of four non-small-cell lung cancer (NSCLC) patients with translocation of the left inferior lobar PA to the PA trunk associated with bronchial sleeve resection of the left superior lobe was retrospectively reviewed between June 13, 2014 and June 8, 2015. A reconstruction of the left pulmonary arteries was performed by translocating the left inferior lobar PA to the PA trunk with end-to-side anastomosis, sleeve resection of bronchus, and systemic lymphadenectomy.

RESULTS

Histology confirmed squamous carcinoma in these four cases. Stage pT3N2M0-IIIA was confirmed in 2 cases, pT3N1M0-IIIA in 1 case, and pT3N0M0-IIB in 1 case. No perioperative deaths or complications were observed. Four patients underwent postoperative chemotherapies, and the end of follow-ups date was Oct. 21, 2015.

CONCLUSIONS

Translocation of the left inferior lobar PA to the PA trunk is practicable as a lung-sparing procedure, despite being technically challenging.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

Pulmonary artery reconstruction with a prosthetic conduit in lung cancer

In radical pulmonary resection for advanced lung cancer, reconstruction of the pulmonary artery (PA) can preserve the lung parenchyma. Reconstruction techniques have gained acceptance because they enable the surgeon to avoid pneumonectomy. Various techniques have been documented, such as direct suturing, end-to-end anastomosis, and a patch or conduit reconstruction. We present two lobectomy cases in which the patients underwent PA reconstruction with prosthetic conduits because they were unfit for other procedures. In both cases, the conduits showed good postoperative patency. When interposition of a conduit is required for PA reconstruction, the use of a prosthetic conduit should be considered in selected cases.

Pulmonary sleeve resection in locally advanced lung cancer using cryopreserved allograft for pulmonary artery replacement

BACKGROUND

During lobectomy, resection of pulmonary artery, followed by reconstruction or replacement with or without concomitant sleeve bronchial resection, is feasible in selected cases. We report morbidity, mortality, and technical issues in pulmonary artery replacement using a cryopreserved arterial allograft after sleeve resection for centrally located non-small cell lung carcinoma (NSCLC).

METHODS

We reviewed clinical and pathologic data of patients who underwent arterial sleeve lobectomy with pulmonary artery replacement in our institution from 2007 to 2012.

RESULTS

Of 178 centrally located NSCLCs, sleeve resections were performed in 92 (51%), pneumonectomies in 33 (18%), and lobectomies in 53 (31%). Of the 32 (34.7%) pulmonary) reconstructions (excluding tangential suture), 20 (21.7%) were end-to-end anastomosis, 2 (2.1%) were pericardial patch reconstructions, and 10 (11%) were PA replacements. Clinical T staging was cT2a in 4 patients, cT2b in 3, cT3 in 2, and cT4 in 1. Four patients received concurrent induction chemoradiotherapy. Three patients underwent a double-sleeve right lobectomy. Cryopreserved allografts used were descending thoracic aorta (n = 3) and pulmonary arteries (n = 7). Complete resection (R0) was achieved in all patients. Final N staging was pN0 (n = 4), pN1 (n = 5), and pN2 (n = 1). There was no operative mortality. Four patients had major morbidity, including 1 early conduit thrombosis treated by pneumonectomy completion. Graft patency, assessed by contrast-enhanced computed tomography scan, was 90%. Mean follow-up was 25 ± 14 (range, 8-47) months (30% for >36 months). Overall 5-year survival was 66.7%, and the estimated median disease-free survival was 42 months.

CONCLUSIONS

In central NSCLCs, conservative surgery using a cryopreserved arterial allograft to replace the pulmonary artery after extended segmental resection could avoid pneumonectomy in selected patients.

Triple plasty of bronchus, pulmonary artery, and superior vena cava for non-small cell lung cancer

BACKGROUND

It has been technically challenging to perform simultaneous triple plasty on the superior vena cava (SVC), pulmonary artery (PA), and main bronchus for central-type lung cancers. In the present study, the authors describe a corresponding technique and clinical outcomes of this surgical manipulation.

METHODS

Clinical data from 4 patients with non-small cell lung cancer (NSCLC) who underwent triple plastic resections and reconstructions were retrospectively reviewed. Three patients received neoadjuvant chemotherapy for pathologically proven locally advanced disease. For pulmonary arteries, sleeve resection with end-to-end anastomosis was performed in 2 patients; tangential resection was used in the other 2 patients. SVC resection with ringed polytetrafluoroethylene (PTFE) graft interposition was performed in 1 patient; the other 3 patients underwent tangential SVC resection. Sleeve resection of the bronchus was performed in all 4 patients. Systemic lymphadenectomy was accomplished in all patients.

RESULTS

There was histologic confirmation of large cell carcinoma, adenocarcinoma, squamous cancer, and adenosquamous cancer, respectively, in these 4 patients. Stage pT4N2M0-IIIB was confirmed in 2 patients, and stage T4N1M0-IIIA and stage T2aN2M0-IIIA were confirmed in the other 2 patients. There were no perioperative deaths. Postoperative atrial fibrillation and prolonged air leakage occurred in 2 patients, respectively. Four patients underwent postoperative chemotherapy and 2 patients were administered radiotherapy. Patients were followed for 21 to 38 months: Two patients had disease-free survival at their 32-month and 38-month follow-ups, and the other 2 patients died 21 and 22 months, respectively, after operation because of remote metastasis.

CONCLUSIONS

Triple plasty of bronchus, PA, and SVC is both practical and safe for patients with locally advanced NSCLC. For patients with strict indications, the long-term survival is favorable.

Reconstruction of the Pulmonary Artery

Sleeve resection and prosthetic reconstruction of the pulmonary artery have progressively gained acceptance as an alternative to pneumonectomy in lung cancer surgery. Previous concern was mainly related to technical difficulties, intraoperative and postoperative complications, lack of long-term survival, and impact on cardiopulmonary function. For this reason it was not until very recently that lobectomy associated with resection and reconstruction of the pulmonary artery, associated or not to a sleeve resection of the bronchus, has been demonstrated to be an advantageous alternative. The concern about an increased complication rate has been proven to be excessive; in fact, pulmonary artery reconstruction can be performed safely and effectively with the correct indications and technique. We hereby report our experience, along with a review of the indications, the surgical technique, and outcome of pulmonary artery reconstruction.