Chimeric ALT Perforator-Free Flap with Vastus Lateralis Muscle for the Obliteration of the Intrathoracic Dead Space Post-Pneumonectomy: A Case Report

Chest wall reconstruction is a surgical procedure aimed at restoring the integrity and function of the chest wall, which may be damaged due to trauma, cancer, infection, or congenital defects. The chest wall plays a vital role in protecting the thoracic organs, supporting the respiratory system, and maintaining the shape of the chest. Therefore, any defect or deformity of the chest wall can have significant functional and aesthetic consequences for the patient. The authors present a case report at Kenyatta National Hospital (KNH) of a dyspneic 47-year-old male patient with a right anterolateral chest wall defect post-pneumonectomy previously complicated by bronchopleural fistula. Past attempts at the chest wall reconstruction had utilized the ipsilateral latissimus dorsi muscle, pectoralis major muscle, and the omental pedicled flaps with limited success. A chimeric anterolateral thigh (ALT) perforator-free flap with vastus lateralis (VL) muscle was used to obliterate the post-pneumonectomy intrathoracic dead space and to provide a cutaneous paddle. This case report aims to show the versatility of the ALT flap for chest wall reconstruction to prevent the post-pneumonectomy syndrome associated with tracheal deviation, inspiratory stridor, and exertional dyspnea. In conclusion, chest wall reconstruction with obliteration of intrathoracic dead space post-pneumonectomy is challenging and needs careful planning and execution.

VATS Right Upper Lobe Anterior Segmentectomy in Post Left Pneumonectomy: Technique

Lung resection following pneumonectomy for recurrent lung cancer is a challenging scenario.Peri-operative airway management and choice of surgical procedure are issues to be addressed by both the anesthesiologists and thoracic surgeons.We hereby report a case of anterior segmentectomy of the right upper for recurrent lung cancer,in a patient who had previously underwent pneumonectomy for primary lung cancer one year earlier.A modified conventional tracheal intubation and unique surgical techniques were applied for video-assisted thoracoscopic surgery(VATS)anterior segmentectomy of the right upper lobe in a patient with a notable mediastinal shift(following contralateral pneumonectomy),resulting in a good recovery and clinical outcome.The clinical experience is summarized in detail in this article.

Limited thoracoplasty and free musculocutaneous flap transposition for postpneumonectomy empyema: A case report

BACKGROUND Empyema is a severe complication following pneumonectomy that is associated with high morbidity and mortality rates.Although there are a wide variety of treatment options,successful management remains challenging when this condition is combined with a large cavity in very thin patients who had previously undergone a posterolateral thoracotomy.CASE SUMMARY We reported the case of a thin,63-year-old man with a progressive pulmonary cyst who underwent left pneumonectomy via posterolateral thoracotomy 23 years ago.After an initially uneventful postoperative course,he was readmitted with empyema and a large cavity 21 years after surgery.He was successfully treated with limited thoracoplasty,followed by free vastus lateralis musculocutaneous flap transposition.CONCLUSION This case highlights that the treatment mode of limited thoracoplasty and free vastus lateralis musculocutaneous flap transposition is safe and effective for the management of postpneumonectomy empyema with a large cavity in thin patients who had previously undergone a posterolateral thoracotomy.

Pulmonary artery sarcoma successfully treated by right pneumonectomy after definitive diagnosis

Pulmonary artery sarcoma(PAS)is a rare and lethal neoplasm that is usually diagnosed during surgery or autopsy.Early diagnosis and radical surgical resection offer the only chance for survival.However,making a preoperative histopathological diagnosis is quite difficult.We encountered a 57-year-old woman presenting a PAS that mimicked a pulmonary thromboembolism.After confirming a definitive diagnosis using a catheter suction biopsy,we successfully performed a right pneumonectomy via a median sternotomy without cardiopulmonary bypass.Eighteen months after surgery,no recurrence was observed.

Pneumonectomy of Primary Pulmonary Angiosarcoma with Malignant Effusion and Intrapleural Hypotonic Hyperthermic Chemotherapy: Case Report and Review of the Literature

Background: Primary pulmonary angiosarcoma is extremely rare and the prognosis is very poor. We report a combination therapy of pneumonectomy and intrapleural hypotonic hyperthermic chemotherapy (IPHHC). Case report: A 48-year-old male with exertional dyspnea was found to have a left massive pleural effusion. Bronchoscopic examination displayed endobronchial stenosis of the left lower bronchus B8,9,10?and diagnosed with pulmonary angiosarcoma. Chest computed-tomographic scanning revealed a 5-cm mass in the left inferior lobe, which invaded the left upperbronchus. Intrapleural dissemination and malignant pleural effusion were also suspected (cT3N1M1a,?c-stage IV). As a palliative initial therapy, we performed a pneumonectomy. On the 7th?postoperative day, under general anesthesia, we performed video-assisted IPHHC (43°C, 60 min, 200 mg/m2?of CDDP). After the IPHHC, there was no major adverse event (more than Grade 3) during the postoperative course. Histological examination of the resected specimen revealed a highly-cellular growth of atypical spindle cells with a storiform pattern. By immunohistochemical testing, the tumor cells stained positive for markers including CD31 and the factor VIII related antigen, and the diagnosis of pulmonary angiosarcoma was made. No adjuvant chemoradiotherapy was given, and the postoperative clinical course was uneventful. Although there had been a recurrence in the chest wall, the patient eventually died twenty-one months later. Conclusion: As a new therapeutic option, we performed IPHHC after the pneumonectomy for an advanced pulmonary angiosarcoma with malignant pleural effusion. Although the patient had a recurrence in the chest wall, he had a reasonable postoperative outcome, that is, he returned to a work, retained a good quality of life and had a longer survival in spite of the poor prognosis of the pulmonary angiosarcoma.

Role of Completion Pneumonectomy in the Treatment of Lung Cancer

Objective To analyze the experience of completion pneumonectomy for lung cancer at a single institution in China.Methods From January 1988 to December 2007,92 patients underwent completion pneumonectomy for the treatment of lung cancer. The indications were second primary lung cancer (n=51),Local recurrence (n=37) and Lung metastasis (n=4).The median interval between the primary operation and completion pneumonectomy was 24 months ( 2~145 months ).Results There was no intraoperative deaths. The median duration of the surgical procedure was 4 hours and 18 minutes (2~6 hours). Blood loss in this performance was 1 854.5 ml (200~9 100 ml). Nine (9.78%) patients died in the postoperative period:pulmonary embolism(n=2) ,diffuse intravascular clotting(DIC) after multisystem failure (n=1) ,respiratory failure after contralateral pneumonia(n=5),and bronchopleural fistula(BPF) with acute respiratory distress syndrome( ARDS) (n=1). Thirty-one(33.7%) patients had at least one major nonfatal complication.1,3 and 5 year survival rates were 81%,26% and 14%,respectively.Conclusion Completion pneumonectomy for lung cancer is a safe surgical procedure for skilled surgeon though it has relatively more complications.

RISK FACTORS ASSOCIATED WITH MORBIDITY AND OPERATIVEMORTALITY OF PNEUMONECTOMY

Objective: Identifying and evaluation of the predictors of outcome of pneumonectomy for lung cancer. Methods: 123 patients undergoing pneumonectomy from June 1984 to June 2000 were reviewed retrospectively. Results: The operative mortality was 7.3% (9/123). The most significant predictors of operative mortality were presence of coexisting medical conditions, respiratory tract infection, bronchopleural fistula, arrhythmias, myocardial infarction, pulmonary edema and renal failure. There were 76 postoperative complications presenting in 123 patients. The most significant predictors of postoperative morbidity were continued cigarette smoking up to the time of operation and fluid infusion of more than 3L in the first 24-hours. Conclusion: This study has identified preoperative and perioperative factors associated with operative mortality and morbidity after pneumonectomy.

Safety and efficacy of trimodality therapy in patients undergoing extrapleural pneumonectomy

Malignant pleural mesothelioma （MPM） is a rare but rapidly deadly disease （1）. Macroscopic complete resection （MCR） is the goal of surgery （2）. MCR seems to have the most significant impact on survival in patients undergoing multimodality treatment for MPM. The role of surgical resection in the management of MPM remains controversial. The selection criterion to perform either extrapleural pneumonectomy （EPP） or extended/radical pleurectomy/ decortication （PD） rely not only on the cardio-pulmonary status of the patient, tumor stage and intraoperative findings but is strongly dependent also on surgeons＇ decision and philosophy. This is reflected by a recent survey of opinions and beliefs among 802 thoracic surgeons, in which EPP was believed to be more effective than PD （3）. Nonetheless, either surgery might achieve MCR.

Thoracoscopic Pneumonectomy for Non-Small Cell Lung Cancer (NSCLC): A Case Report and Review of the Literature

Minimally invasive resection of lung cancer remains surprisingly uncommon in comparison to the adoption of similar techniques in other surgical disciplines. The reported use of video-assisted thoracic surgery (VATS) lobectomy for anatomic resections in comparison to open lobectomy ranges from 10% -40% even though it has been demonstrated to be equivalent in safety and accomplishes the same oncologic goals. Further, it may provide improved survival outcomes as others have reported benefits in perioperative recovery and patient satisfaction. VATS pneumonectomy has been far less commonly described despite the physiologic advantages such as less blood loss, shorter intensive care stay, and less respiratory compromise. This report specifically addresses this lacuna by drawing upon the successful case of a VATS pneumonectomy with fissure invasion and then considering why minimally invasive VATS techniques remain underutilized. In conclusion, we suggest that focused thoracic surgery fellowship training in VATS techniques will make thoracoscopic surgery a more conventional technique rather than a challenging procedure.

Pneumonectomy in a Patient with Swyer-James-MacLeod Syndrome

Swyer-James-MacLeod syndrome is a rare disease that results in parenchymal damage believed to be caused by recurrent lung infections in childhood. We report a case of a previously healthy young woman that presented with insidious progression of exertional dyspnea with restrictive lung physiology. Axial imaging demonstrated a hyperinflated emphysematous right lung with lower lobe fibrosis, nodules and air-fluid filled cysts, with a small right pulmonary artery and contralateral shifting of the mediastinum. She underwent right pneumonectomy ultimately resulting in improvement of her symptoms, with surgical pathology indicating extensive emphysema, bronchiec- tasis, fibrosis with osseous metaplasia, and placental transmogrification of alveolar septa, being consistent with a diagnosis of SJMS.

Coronary surgery following prior pneumonectomy —A challenging clinical scenario with excellent results

Coronary artery bypass grafting (CABG) in patients with prior pneumonectomy is challenging because of the decreased pulmonary function and the anatomical alterations of the thoracic cavity. Due to extended morbidity and mortality in this special patient cohort, only very few reports in the world literature focus on this topic. Overall, no general recommendations exist with regard to the optimal management of this continuously growing patient cohort. We present our experience with another successful case.

Intercostal Muscle Flap in Post Tuberculous Pneumonectomy: A New Technique

Objective: There are many risk factors for postoperative bronchopleural fistula (BPF), including extensive resection, diabetes, chronic infection, perioperative steroid therapy, preoperative chemotherapy, and radiotherapy, the risk of bronchopleural fistula increases with resection for inflammatory diseases, especially Mycobacterium tuberculosis (MTB). The aim of this study is to evaluate the efficacy and safety of using double pedicled intercostal muscle flaps with dual blood supply to buttress the bronchial stump after pneumonectomy for tuberculous lesions as a prophylactic new technique from post-pneumonectomy BPF. Methods: Between 2007 and 2011, 47 patients with pneumonectomy for post tuberculous lesions in the department of cardiothoracic surgery, Zagazig University Hospital were divided into two groups. Group A: 28 patients with single pedicled intercostal muscle flap used and applied on the bronchial stump after pneumonectomy. Group B: 19 patients with double pedicled intercostal muscle flaps used and applied on the bronchial stump. The mean age of the patients was 42.9 years (range 27 - 67 years) in Group A, 44.8 years (range 36 - 71 years) in Group B. Results: Bleeding in one patient in Group A (3.5%) and two patients in Group B (10.5%);empyema in two patients (7.1%) in Group A only one of them developed bronchopleural fistula;arrhythmias in one patients (3.5%) in Group A and one patient in Group B (5.2%);chylothorax in one patients (3.5%);Chronic chest pain in one patient in Group A (3.5%) and two patients in Group B (10.5%). The mean follow up period was 32.7 ± 12.9 months (range between 3 and 48 months). All patients remained symptom free with no evidence of late bronchopleural fistula in Group B. Conclusions: Double pedicled intercostal muscle flaps with dual blood supply buttressing the bronchial stump is new prophylactic technique from BPF after pneumonectomy for pulmonary tuberculous lesions in high risk patients.

Failed Completion Pneumonectomy for Early Recurrent Pleomorphic Carcinoma: A Case Report

We report a patient with a large pulmonary pleomorphic carcinoma (PPC) in the left upper lobe greater than 10 cm in diameter. She underwent left upper lobectomy with mediastinal lymph node dissection and concomitant resection of the left phrenic nerve, vagus nerve and pericardium. She received adjuvant chemotherapy, but had tumor recurrence. We then performed left completion pneumonectomy, but could not remove the tumor completely because of rapid tumor invasion to the left atrium. Urgent surgery should be considered for recurrent resectable PPC.

Extra-pleural pneumonectomy in the setting of tri-modality therapy for patients with malignant pleural mesothelioma

Although declining in the US due to restrictions of asbestos exposure, malignant pleura/mesothelioma （MPP） remains a very serious thoracic malignancy that is rising in incidence worldwide （1）. Trirnodality therapy with chemotherapy and radiotherapy combined with extrapleural pneumonectomy （EPP） has gained acceptance given the acceptable mortality rate （〈5%） and long term survival reported in patients with epithelial histology, negative margins, and no extrapleural lymph node involvement after trimodalitv treatment （2）.

A Case Report of Right Pneumonectomy with a Focus on the Right Ventricular Function and Hemodynamic Management

Background: In patients undergoing pneumonectomy, intraoperative pulmonary and cardiac complications are the major cause of morbidity and mortality. Protective lung ventilation strategies may decrease the overall lung injury. Right, ventricular dysfunction may occur during the surgery and after the pneumonectomy, in the early postoperative period, with reduced RV ejection fraction and increased RV end-diastolic volume index, caused by increased RV afterload. Case report: We describe the case of a 28-year-old non-smoker female who underwent to a right pneumonectomy. The patient presented intraoperative hemodynamic instability and signs of RV dysfunction, requiring vasoactive amines and nitric oxide. Discussion: This article is intended to provide an overview of the anesthetic management for pneumonectomy including the hemodynamic management and considerations of the causes and management of right ventricular dysfunction.

Perioperative Nursing Care for Patients with Lung Cancer Undergoing Total Pneumonectomy

Objectives: To explore the perioperative nursing care for lung cancer patients undergoing total pneumonectomy, and to promote their rehabilitation. Methods: We will provide preoperative assessment and education in the aspects of respiratory function, diet, and psychology to patients undergoing total pneumonectomy, and provide continuous postoperative management about posture, fluid, and respiratory to help patients diagnosed with lung squamous cell carcinoma and underwent total pneumonectomy to reduce their postoperative complications and improve their overall quality of life. Results: 78.9% of lung cancer patients who underwent total pneumonectomy achieved a better outcome and prognosis by receiving the above nursing program. Conclusion: With large lung cancer tumors, the surgical trauma is highly invasive and the resection is extensive. Management of the patient’s respiratory tract is the focus of perioperative nursing and the key to preventing the development of related postoperative complications.

Unexpected Intraoperative Resecting of Common Trunk of Pulmonary Vein Resulted in an Incidental Pneumonectomy from Left Upper Lobectomy

There is a wide range of anatomical variations in the pulmonary vessels. Some of these variations may cause surgical morbidity during general thoracic surgery. We intended to perform a left upper lobectomy for a 73-year-old male with suspected left lung cancer (lt.U, S3, 20 × 20 mm, P0, E0, D0, PM0, N0, T1aN0M0, c-stage IA). Preoperatively, we did not recognize the existence of the common trunk of the left pulmonary vein. After the open thoracotomy, due to a severe intrathoracic adhesion, we omitted releasing the adhesion of the lower lobe. We did not exactly confirm the location of the inferior pulmonary vein (IPV). After cutting the interlobular pulmonary arterial branchies, we resected the superior pulmonary vein (SPV) using auto sutures. After division of the lung parenchyma and incomplete fissures using auto sutures, we intended to resect the upper bronchus. However, we could not find an IPV at the normal IPV site. A thin IPV was found to be returned to the peripheral site of the resected SPV. The SPV and IPV formed a common trunk at the normal site of the SPV. Although we considered reconstructing the resected common trunk, we finally made a decision of performing an incidental pneumonectomy in order to prevent any postoperative complications on the reconstruction of the IPV such as thrombus occlusion at the anastomosis site and venous return congestion. Retrospectively, we confirmed the preoperative images of the computed tomographic scanning, which showed a narrow IPV that returned to the peripheral site of the SPV. It is important to confirm both accurate locations of the SPV and IPV when performing a lobectomy.

The history of acupuncture anesthesia for pneumonectomy in Shanghai during the 1960s

The success of acupuncture anesthesia （AA） for pneumonectomy in Shanghai in 1960 was a key event for AA gaining practical clinical application. The effort was a close collaboration between the Shanghai First Tuberculosis Hospital and the Shanghai Institute of Acupuncture and Moxibustion. One of the most important factors of AA success was the great financial and political support provided by the Chinese central government and Shanghai local government. In December 1965 the State Science and Technology Commission of China issued a formal document acknowledging AA as an important first-leve national achievement of the integration of Chinese and Western medicine, and a collaborative effort of the whole scientific community in China. AA was an important influential factor that helped acupuncture spread across the world.

Pneumonectomy for chronic inflammatory lung disease： indications and complications

Chronic inflammatory lung disease is a common ,health problem and often treated with potent antibiotics, anti-tuberculosis drugs, and antifungal agents. However, in case of medical therapy failure, surgical treatment has been often considered as an effective procedure. Indications for surgical procedure mainly include recurrent infection, acute suppurative complications including lung abscess and empyema, and often chronic, intermittent, or massive hemoptysis.1 Segmentectomy or lobectomy is considered as an ＂ideal＂ procedure when the disease is localized to one lung and single segment or lobe.

Effect of Yiqi Bufei Recipe （益气补肺方） on Patients with Pulmonary Incompetence after Pneumonectomy

Objective： To study the effect of Yiqi Bufei Recipe （益气补肺方, YBR） on surgical tolerability, pulmonary compensatory function and post-operation rehabilitation in patients with pulmonary incompetence （PI） after pneumonectomy. Methods： YBR intervention was applied to 60 patients with PI after pneumonectomy （as test group）, the pulmonary and cardiac functions changes before and after operation, occurrence of postoperative complications, mortality, and the number of hospitalization days and intensive care unit （ICU） confinement period were observed. Meantime, for the negative and positive controls, the same parameters were observed comparatively in 60 patients with normal lung function, and in 60 patients with PI undergoing a similar operation but untreated with Chinese herbs. Results： Lung function in the test group showed insignificant change before and after operation （P〉0.05）, while significant decrease was seen in the two control groups （P〈0.05）. Furthermore, the incidences of post-operation complications and mortality as well as the number of hospitalization days and the ICU confinement period in the test group were significantly lower than those in the positive control group respectively （P〈0.05）. Conclusion： YBR could relieve lung injury after pneumonectomy, improve surgical tolerability, reduce the length of postoperative hospitalization days and ICU confinement period, and lower the incidence of postoperative complications and mortality in patients with PI after pneumonectomy.