1
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Wu WK, Guenthart BA, O’Neill JD, Hozain AE, Tipograf Y, Ukita R, Stokes JW, Patel YJ, Pinezich M, Talackine JR, Cardwell NL, Fung K, Vunjak-Novakovic G, Bacchetta M. Technique for xenogeneic cross-circulation to support human donor lungs ex vivo. J Heart Lung Transplant 2023; 42:335-344. [PMID: 36456408 PMCID: PMC9985920 DOI: 10.1016/j.healun.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/30/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Xenogeneic cross-circulation (XC) is an experimental method for ex vivo organ support and recovery that could expand the pool of donor lungs suitable for transplantation. The objective of this study was to establish and validate a standardized, reproducible, and broadly applicable technique for performing xenogeneic XC to support and recover injured human donor lungs ex vivo. METHODS Human donor lungs (n = 9) declined for transplantation were procured, cannulated, and subjected to 24 hours of xenogeneic XC with anesthetized xeno-support swine (Yorkshire/Landrace) treated with standard immunosuppression (methylprednisolone, mycophenolate mofetil, tacrolimus) and complement-depleting cobra venom factor. Standard lung-protective perfusion and ventilation strategies, including periodic lung recruitment maneuvers, were used throughout xenogeneic XC. Every 6 hours, ex vivo donor lung function (gas exchange, compliance, airway pressures, pulmonary vascular dynamics, lung weight) was evaluated. At the experimental endpoint, comprehensive assessments of the lungs were performed by bronchoscopy, histology, and electron microscopy. Student's t-test and 1-way analysis of variance with Dunnett's post-hoc test was performed, and p < 0.05 was considered significant. RESULTS After 24 hours of xenogeneic XC, gas exchange (PaO2/FiO2) increased by 158% (endpoint: 364 ± 142 mm Hg; p = 0.06), and dynamic compliance increased by 127% (endpoint: 46 ± 20 ml/cmH2O; p = 0.04). Airway pressures, pulmonary vascular pressures, and lung weight remained stable (p > 0.05) and within normal ranges. Over 24 hours of xenogeneic XC, gross and microscopic lung architecture were preserved: airway bronchoscopy and parenchymal histomorphology appeared normal, with intact blood-gas barrier. CONCLUSIONS Xenogeneic cross-circulation is a robust method for ex vivo support, evaluation, and improvement of injured human donor lungs declined for transplantation.
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Affiliation(s)
- W. Kelly Wu
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brandon A. Guenthart
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - John D. O’Neill
- Xylyx Bio, Inc., Brooklyn, New York;,Department of Cell Biology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Ahmed E. Hozain
- Department of Surgery, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Yuliya Tipograf
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rei Ukita
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W. Stokes
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yatrik J. Patel
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghan Pinezich
- Department of Biomedical Engineering, Columbia University, New York, New York
| | - Jennifer R. Talackine
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nancy L. Cardwell
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenmond Fung
- Perfusion Services, New York – Presbyterian Hospital, New York, New York
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, New York;,Department of Medicine, Columbia University Medical Center, New York, New York
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.
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2
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Kosaka R, Sakota D, Niikawa H, Ohuchi K, Arai H, McCurry KR, Okamoto T. Lung thermography during the initial reperfusion period to assess pulmonary function in cellular ex vivo lung perfusion. Artif Organs 2022; 46:1522-1532. [PMID: 35230734 DOI: 10.1111/aor.14219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thermography is a non-invasive technology to detect low temperatures in poorly circulated areas. In ex vivo lung perfusion (EVLP), lungs are rewarmed to body temperature during the initial 1 h. Currently, the effect of graft thermal changes during the rewarming phase on pulmonary function is unknown. In this study, we evaluated the correlation of lung surface temperature with physiological parameters, wet/dry ratio, and transplant suitability in Lund-type EVLP. METHODS Fifteen pigs were divided into three groups: control group (no warm ischemia) or donation after circulatory death groups with 60 or 90 min of warm ischemia (n = 5, each). Thermal images of the lower lobes were continuously collected from the bottom of organ chamber using infrared thermography throughout EVLP. RESULTS At 8 min, lung surface temperatures of non-suitable cases were significantly lower than in suitable cases (25.1 ± 0.6 vs. 27.8 ± 1.2°C, P < 0.001), while there was no difference in lung surface temperature between the two groups at 0-4 min and 12-120 min. There was a significant negative correlation between lung surface temperature at 8 min and wet/dry ratio at 2 h in the lower lobes (R = -0.769, P < 0.001, cut-off = 26°C, Area under the curve = 1.0). A lung surface temperature of < 26°C was significantly correlated with poor pulmonary function and transplant non-suitability. CONCLUSION A lung surface temperature of ≥ 26°C at 8 min is a good early predictor of transplant suitability in cellular EVLP and might be applicable in clinical EVLP.
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Affiliation(s)
- Ryo Kosaka
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Daisuke Sakota
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki, Japan
| | - Hiromichi Niikawa
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Katsuhiro Ohuchi
- Department of Advanced Surgical Technology Research and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Chiyoda-ku, Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Transplant Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Toshihiro Okamoto
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Transplant Center, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Detecting intersegmental plane in thoracoscopic segmentectomy using infrared thermography. Chin Med J (Engl) 2021; 135:119-120. [PMID: 34759221 PMCID: PMC8850828 DOI: 10.1097/cm9.0000000000001806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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4
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Magnin M, Junot S, Cardinali M, Ayoub JY, Paquet C, Louzier V, Garin JMB, Allaouchiche B. Use of infrared thermography to detect early alterations of peripheral perfusion: evaluation in a porcine model. BIOMEDICAL OPTICS EXPRESS 2020; 11:2431-2446. [PMID: 32499935 PMCID: PMC7249846 DOI: 10.1364/boe.387481] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/10/2020] [Accepted: 03/18/2020] [Indexed: 05/08/2023]
Abstract
This study aimed to evaluate the variations of infrared thermography according to rapid hemodynamic changes, by measuring the peripheral skin temperature in a porcine model. Eight healthy piglets were anesthetized and exposed to different levels of arterial pressure. Thermography was performed on the left forelimb to measure carpus and elbow skin temperature and their associated gradient with the core temperature. Changes in skin temperature in response to variations of blood pressure were observed. A negative correlation between arterial pressure and temperature gradients between peripheral and core temperature and a negative correlation between cardiac index and these temperature gradients were observed. Thermography may serve as a tool to detect early changes in peripheral perfusion.
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Affiliation(s)
- Mathieu Magnin
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, F-69280 Marcy l’Etoile, France
- Université de Lyon, Vetagro Sup, Campus Vétérinaire de Lyon, Unité de Physiologie, Pharmacodynamie et Thérapeutique, F-69280 Marcy l’Etoile, France
| | - Stephane Junot
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, F-69280 Marcy l’Etoile, France
- Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, Anesthésiologie, F-69280 Marcy l’Etoile, France
| | - Martina Cardinali
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, F-69280 Marcy l’Etoile, France
- Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, Anesthésiologie, F-69280 Marcy l’Etoile, France
| | - Jean Yves Ayoub
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, F-69280 Marcy l’Etoile, France
- Université de Lyon, Vetagro Sup, Campus Vétérinaire de Lyon, Unité de Physiologie, Pharmacodynamie et Thérapeutique, F-69280 Marcy l’Etoile, France
| | - Christian Paquet
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, F-69280 Marcy l’Etoile, France
- Université de Lyon, Vetagro Sup, Campus Vétérinaire de Lyon, Unité de Physiologie, Pharmacodynamie et Thérapeutique, F-69280 Marcy l’Etoile, France
| | - Vanessa Louzier
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, F-69280 Marcy l’Etoile, France
- Université de Lyon, Vetagro Sup, Campus Vétérinaire de Lyon, Unité de Physiologie, Pharmacodynamie et Thérapeutique, F-69280 Marcy l’Etoile, France
| | - Jeanne Marie Bonnet Garin
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, F-69280 Marcy l’Etoile, France
- Université de Lyon, Vetagro Sup, Campus Vétérinaire de Lyon, Unité de Physiologie, Pharmacodynamie et Thérapeutique, F-69280 Marcy l’Etoile, France
| | - Bernard Allaouchiche
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, F-69280 Marcy l’Etoile, France
- Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Réanimation Médicale, Unité APCSE, Pierre-Bénite, France
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5
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Hozain AE, Tipograf Y, Pinezich MR, Cunningham KM, Donocoff R, Queen D, Fung K, Marboe CC, Guenthart BA, O'Neill JD, Vunjak-Novakovic G, Bacchetta M. Multiday maintenance of extracorporeal lungs using cross-circulation with conscious swine. J Thorac Cardiovasc Surg 2019; 159:1640-1653.e18. [PMID: 31761338 PMCID: PMC7094131 DOI: 10.1016/j.jtcvs.2019.09.121] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022]
Abstract
Objectives Lung remains the least-utilized solid organ for transplantation. Efforts to recover donor lungs with reversible injuries using ex vivo perfusion systems are limited to <24 hours of support. Here, we demonstrate the feasibility of extending normothermic extracorporeal lung support to 4 days using cross-circulation with conscious swine. Methods A swine behavioral training program and custom enclosure were developed to enable multiday cross-circulation between extracorporeal lungs and recipient swine. Lungs were ventilated and perfused in a normothermic chamber for 4 days. Longitudinal analyses of extracorporeal lungs (ie, functional assessments, multiscale imaging, cytokine quantification, and cellular assays) and recipient swine (eg, vital signs and blood and tissue analyses) were performed. Results Throughout 4 days of normothermic support, extracorporeal lung function was maintained (arterial oxygen tension/inspired oxygen fraction >400 mm Hg; compliance >20 mL/cm H2O), and recipient swine were hemodynamically stable (lactate <3 mmol/L; pH, 7.42 ± 0.05). Radiography revealed well-aerated lower lobes and consolidation in upper lobes of extracorporeal lungs, and bronchoscopy showed healthy airways without edema or secretions. In bronchoalveolar lavage fluid, granulocyte-macrophage colony-stimulating factor, interleukin (IL) 4, IL-6, and IL-10 levels increased less than 6-fold, whereas interferon gamma, IL-1α, IL-1β, IL-1ra, IL-2, IL-8, IL-12, IL-18, and tumor necrosis factor alpha levels decreased from baseline to day 4. Histologic evaluations confirmed an intact blood–gas barrier and outstanding preservation of airway and alveolar architecture. Cellular viability and metabolism in extracorporeal lungs were confirmed after 4 days. Conclusions We demonstrate feasibility of normothermic maintenance of extracorporeal lungs for 4 days by cross-circulation with conscious swine. Cross-circulation approaches could support the recovery of damaged lungs and enable organ bioengineering to improve transplant outcomes.
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Affiliation(s)
- Ahmed E Hozain
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY; Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY
| | - Yuliya Tipograf
- Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY; Departments of Thoracic and Cardiac Surgery, Vanderbilt University, Nashville, Tenn
| | - Meghan R Pinezich
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - Katherine M Cunningham
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - Rachel Donocoff
- Institute of Comparative Medicine, Columbia University Medical Center, Columbia University, New York, NY
| | - Dawn Queen
- Vagelos College of Physicians and Surgeons, Columbia University Medical Center, Columbia University, New York, NY
| | - Kenmond Fung
- Department of Clinical Perfusion, Columbia University Medical Center, Columbia University, New York, NY
| | - Charles C Marboe
- Department of Pathology and Cell Biology, Columbia University Medical Center, Columbia University, New York, NY
| | - Brandon A Guenthart
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - John D O'Neill
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY; Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY.
| | - Matthew Bacchetta
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY; Departments of Thoracic and Cardiac Surgery, Vanderbilt University, Nashville, Tenn.
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6
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Guenthart BA, O'Neill JD, Kim J, Queen D, Chicotka S, Fung K, Simpson M, Donocoff R, Salna M, Marboe CC, Cunningham K, Halligan SP, Wobma HM, Hozain AE, Romanov A, Vunjak-Novakovic G, Bacchetta M. Regeneration of severely damaged lungs using an interventional cross-circulation platform. Nat Commun 2019; 10:1985. [PMID: 31064987 PMCID: PMC6504972 DOI: 10.1038/s41467-019-09908-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 04/01/2019] [Indexed: 12/13/2022] Open
Abstract
The number of available donor organs limits lung transplantation, the only lifesaving therapy for the increasing population of patients with end-stage lung disease. A prevalent etiology of injury that renders lungs unacceptable for transplantation is gastric aspiration, a deleterious insult to the pulmonary epithelium. Currently, severely damaged donor lungs cannot be salvaged with existing devices or methods. Here we report the regeneration of severely damaged lungs repaired to meet transplantation criteria by utilizing an interventional cross-circulation platform in a clinically relevant swine model of gastric aspiration injury. Enabled by cross-circulation with a living swine, prolonged extracorporeal support of damaged lungs results in significant improvements in lung function, cellular regeneration, and the development of diagnostic tools for non-invasive organ evaluation and repair. We therefore propose that the use of an interventional cross-circulation platform could enable recovery of otherwise unsalvageable lungs and thus expand the donor organ pool.
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Affiliation(s)
- Brandon A Guenthart
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA.,Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - John D O'Neill
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Jinho Kim
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA.,Department of Biomedical Engineering, Stevens Institute of Technology, Hoboken, NJ, 07030, USA
| | - Dawn Queen
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Scott Chicotka
- Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Kenmond Fung
- Department of Clinical Perfusion, Columbia University Medical Center, Columbia University, New York, NY, 1003, USA
| | - Michael Simpson
- Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Rachel Donocoff
- Institute of Comparative Medicine, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Michael Salna
- Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Charles C Marboe
- Department of Pathology and Cell Biology, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Katherine Cunningham
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Susan P Halligan
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Holly M Wobma
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Ahmed E Hozain
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA.,Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Alexander Romanov
- Institute of Comparative Medicine, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA. .,Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA.
| | - Matthew Bacchetta
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY, 10032, USA. .,Department of Thoracic and Cardiovascular Surgery, Vanderbilt University, Nashville, TN, 37232, USA.
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7
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Niikawa H, Okamoto T, Ayyat KS, Itoda Y, Farver CF, McCurry KR. The protective effect of prone lung position on ischemia–reperfusion injury and lung function in an ex vivo porcine lung model. J Thorac Cardiovasc Surg 2019; 157:425-433. [DOI: 10.1016/j.jtcvs.2018.08.101] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/24/2018] [Accepted: 08/11/2018] [Indexed: 12/15/2022]
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8
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Clamping improves your judgment. J Thorac Cardiovasc Surg 2017; 154:e93. [PMID: 28888376 DOI: 10.1016/j.jtcvs.2017.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/25/2017] [Indexed: 11/20/2022]
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9
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Sakamoto K, Kanzaki M, Mitsuboshi S, Maeda H, Kikkawa T, Isaka T, Murasugi M, Onuki T. A novel and simple method for identifying the lung intersegmental plane using thermography. Interact Cardiovasc Thorac Surg 2016; 23:171-3. [PMID: 27030684 DOI: 10.1093/icvts/ivw076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/18/2016] [Indexed: 11/14/2022] Open
Abstract
Identifying the intersegmental plane is very important for successful lung segmentectomy. Although several methods are available, they require specialized skills and pose a potential risk of losing sight of the correct intersegmental planes. Therefore, easier and more reliable methods are required. In this study, we hypothesized that surface temperatures of resecting segments or lobes decrease because of blood flow suppression after the ligation of target arteries and veins, and intersegmental planes can be visualized using a thermography. To test this hypothesis, we performed six lung resections (two lobectomies and four segmentectomies) on three pigs and, using a handheld thermography, we monitored the lung surface temperatures to identify intersegmental planes. We demonstrated that thermal imaging sharply demarcated intersegmental planes soon after the ligation of vessels in all procedures. Compared with other methods, thermography requires no special technical skills, drug injection and lung inflation. Therefore, we believe that the thermographic method described in this study will be a powerful option to identify intersegmental planes during anatomical lung segmentectomy.
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Affiliation(s)
- Kei Sakamoto
- Department of Surgery I, Tokyo Women's Medical University, Tokyo, Japan
| | - Masato Kanzaki
- Department of Surgery I, Tokyo Women's Medical University, Tokyo, Japan
| | - Shota Mitsuboshi
- Department of Surgery I, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideyuki Maeda
- Department of Surgery I, Tokyo Women's Medical University, Tokyo, Japan
| | - Takuma Kikkawa
- Department of Surgery I, Tokyo Women's Medical University, Tokyo, Japan
| | - Tamami Isaka
- Department of Surgery I, Tokyo Women's Medical University, Tokyo, Japan
| | - Masahide Murasugi
- Department of Surgery I, Tokyo Women's Medical University, Tokyo, Japan
| | - Takamasa Onuki
- Department of Surgery I, Tokyo Women's Medical University, Tokyo, Japan
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