Initial experience of video-assisted thoracic surgery lobectomy with partial removal of the pulmonary artery

A lobectomy with a resection of the pulmonary artery is less invasive than a pneumonectomy. However, it seems to be extremely difficult to perform this technique using video-assisted thoracic surgery with technical limitations because this technique is associated with an increased operative risk even in an open thoracotomy. Between April 2002 and December 2006, a curative video-assisted thoracic surgery lobectomy including a mediastinal lymphadenectomy was performed in 121 patients with primary non-small cell lung cancer. Five of those patients underwent a thoracoscopic lobectomy with the partial removal and reconstruction of the pulmonary artery. The causes of the pulmonary artery resection included two direct invasions of the artery, two invasions of the arterial branch, and one calcified lymphadenopathy involving the branch. No patients required a blood transfusion. No complications attributable to the technique or mortality were seen. No patients showed an abnormal blood flow through the reconstructed vessel. There were no local recurrences on the pulmonary artery. A video-assisted thoracic surgery lobectomy including a partial resection and reconstruction of the pulmonary artery is a complex procedure for patients with non-small cell lung cancer. It is feasible when all associated technical issues are properly addressed.     

Pulmonary artery reconstruction using a great saphenous vein autograft in the treatment of bronchogenic cancer

Sleeve resection of the pulmonary artery, followed by reconstruction with or without bronchoplasty, for bronchogenic carcinoma located at a major lobar orifice has been reported as an alternative to pneumonectomy in patients with poor respiratory functional reserve. We describe herein what is, to our knowledge, the first, report of a successful pulmonary arterial reconstruction using a saphenous vein autograft. This operation was performed in a 63-year-old man with poor pulmonary functional reserve who was diagnosed as having a large bronchogenic cancer in the left lower lobe of the lung, located close to the pulmonary hilum. First, a left lower lobectomy was performed with segmental resection of the pulmonary artery, from the basal artery to the lingular artery, after which pulmonary arterial continuity was reconstructed using a saphenous vein autograft. The patient had an uneventful recovery and remains well without any sign of recurrence 4 months after his operation.Presented at the Ninth Meeting of Ibaraki Prefectural Vascular Surgical Society, Hitachi, Ibaraki January 23, 1993.     

Cardiopulmonary bypass assisted resection of mediastinal masses

We report a recurrent solitary fibrous tumor of the mediastinum that was encircling the right pulmonary artery. The resection of the tumor with the involved right pulmonary artery segment and sequential graft reconstruction of the vessel was facilitated by the use of cardiopulmonary bypass. We review the indications, management, and outcomes of cardiopulmonary bypass for the resection of mediastinal masses.     

A Benign Pulmonary Artery Mass

Abstract   We present a case of a benign pulmonary artery mass leading to pulmonary artery stenosis. A 39-year-old male patient had a dyspnea on exertion and chest discomfort four months before admission. Computerized tomographic scan revealed a mass extending 2.1 cm in the right pulmonary artery resulting in pulmonary artery stenosis. He underwent a mass resection and pulmonary artery reconstruction under cardiopulmonary bypass. His symptoms improved postoperatively. Histology revealed it was a reactive lymph node. It is recommended that surgical resection should be the only alternative for complete relief of the symptoms in such patients.     

Carinal reconstruction with wide airway resection by a new technique

Carinal reconstruction with wide airway resection by a new technique was conducted in two cases. A 61-year man with tracheal stenosis by tracheal cancer, 6 tracheal rings, 2 left bronchial rings, total right main bronchus, for which carina was resected and reconstructed by a new technique and for a 69 year man with lung cancer in right upper lobe, for which right upper-middle bilobectomy, S6 segmental resection and circumferential pulmonary artery resection were performed. The tracea, left main bronchus, and right basal segment bronchus were anastomosed by new technique and the right main pulmonary artery and basal segment artery was anastomosed subsequent to chemotherapy. Both patients discharged within seventeen postoperative days in consideration of the absence of postoperative complication. Bronchoscopic findings after reconstruction indicated neither stenosis nor dehiscence at the site of anastomosis. The new reconstructive method of carina permits simple anastomosis, the possibility of carina reconstruction even in the case of wide airway resection and loss tension at the site of anastomosis.     

Problematic vascular reconstruction in liver transplantation. Part I. Arterial

Arterial inflow is essential for graft function after liver transplantation. Sometimes the recipient celiac axis is not suitable for anastomosis, and in these cases a conduit from either the aorta or iliac artery is an alternative. We retrospectively reviewed 32 patients who required arterial conduits and compared them with a matched control group who underwent standard arterial reconstruction (donor celiac artery to recipient celiac artery). The indications and surgical technique for arterial conduits are presented. There were no differences in intraoperative vascular flow studies, postoperative liver function, or incidence of rejection in the two groups. There were, however, more deaths in the conduit group, two of which are related to the retropancreatic conduit technique, with the others caused by the patients' underlying condition at transplantation. There was no morbidity or death associated with the antepancreatic conduit techniques. We therefore believe the use of arterial conduits from the aorta or iliac artery, when placed antepancreatically, are safe and should be used without reservation when indicated.     

Debanding and repair of ventricular septal defect: a new technique for older patients.

Between October 1972 and April 1977 15 patients underwent definitive repair of a ventricular septal defect (VSD) and reconstruction of the pulmonary artery at the banding site. This report presents pre- and post-operative haemodynamic data in 12 patients, seven to 22 years after banding (mean 13.4). Banding of the pulmonary artery was performed before the age of 6 months (mean 4). The indications were increased pulmonary blood flow and intractable heart failure. As we had previously become dissatisfied with patch angioplasty of the main pulmonary artery, we introduced a new technique in this group of excising the site of the band and anastomosing the pulmonary artery end-to-end. The gradient between the right ventricle and pulmonary artery was abolished completely in nine cases and reduced to below 30 mmHg in the remaining three patients. This technique is used only in older patients in whom the banding has persisted for a long time. In children under 2 years of age we usually remove the band and dilate the pulmonary artery.     

Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection

BACKGROUND: Portal vein and hepatic artery resection and reconstruction may be required in radical surgery for biliary cancer. Microvascular reconstruction requires special equipment and training, and may be difficult to accomplish when the arterial stump is small, when there are multiple vessels or when the stump lies deep within the wound. This study examined the feasibility and safety of arterioportal shunting as an alternative to arterial reconstruction. METHODS: Over 30 months, ten patients with biliary cancer (six bile duct and four gallbladder carcinomas) underwent radical surgery with en bloc resection of the hepatic artery and end-to-side arterioportal reconstruction between the common hepatic or gastroduodenal artery and the portal trunk. RESULTS: No patient died. Complications included bile leakage in two patients and liver abscess in one. Routine angiography performed 1 month after surgery revealed shunt occlusion in three patients. Once the existence of hepatopetal arterial collaterals had been confirmed in the remaining patients, the shunt was occluded by coil embolization. CONCLUSION: Arterioportal shunting appears to be a safe alternative to microvascular reconstruction after hepatic artery resection. However, the safety of the procedure and its potential to increase the cure rate require further assessment in a larger series with a longer follow-up.     

Isolated internal iliac artery aneurysm resection and reconstruction: operative planning and technical considerations

Isolated iliac artery aneurysms are rare but dangerous aneurysms associated with a high incidence of rupture (between 14 and 70%). Rupture is frequently associated with an exceedingly high mortality primarily because of the elusive nature of the presenting symptoms and the resulting major delays in treatment. Accordingly these aneurysms are best managed aggressively. Although emerging endovascular techniques show promise surgical resection and reconstruction remains the gold standard for definitive management and has withstood the test of time with excellent durable and unparalleled results. That said, from an operative perspective these aneurysms are technically demanding and remain one of the more formidable technical challenges in vascular surgery. To highlight the key elements involved in a successful repair we present a right internal iliac artery aneurysm with an associated contralateral common iliac artery occlusion, review the necessary preoperative planning and the available surgical treatment options, and detail the technical steps leading to a successful reconstruction. Careful operative planning is critical. Inadequate preoperative studies, inadequate preoperative decision making, and a poorly formulated operative strategy can lead to catastrophic results. Some of the most feared complications include pelvic venous injury with resulting massive hemorrhage and postoperative pelvic ischemia (with resulting rectal and/or spinal cord ischemia) which occurs as a result of inadequate contralateral collateral pelvic blood flow when the internal iliac artery is not reimplanted. Accordingly the preoperative workup must include a careful analysis of the adequacy of the contralateral pelvic blood flow to supply collateral flow in the event that the internal iliac is not reimplanted. In the presence of compromised contralateral internal iliac perfusion, resection and reconstruction or an alternative form of pelvic revascularization is mandatory. Excellent and unencumbered exposure is mandatory for a safe and successful repair. The retroperitoneal approach as illustrated in this case is strongly recommended. Although it is challenging excellent results can be achieved by resection of the aneurysm and reconstruction.     

Side-to-end colorectal anastomosis with monofilament stainless steel wire.

Anastomotic separation after anterior resection of the rectum remains a major problem, although the frequency of anastomotic dehiscence after anterior resection varies. Monofilament stainless steel wire suture is an inert suture, has excellent holding power, and is associated with a low probability of wound infection. Side-to-end coloproctostomy for anastomotic reconstruction after anterior resection has proved to be a satisfactory alternative to the usual end-to-end anastomosis. A combination of wire suture with side-to-end coloproctostomy was performed in 60 consecutive anterior resections in which there were two clinical anastomotic leaks and no deaths attributable to anastomotic dehiscence. Simultaneous loop transverse colostomy was performed in 13 cases (22%), and all colostomies were subsequently closed without difficulty. This technique is recommended for reconstruction of bowel continuity after anterior resection of the rectum.     

Anaesthetic problems during resection of the carina (author's transl)]

Benigne tracheo-bronchial constriction is an infrequent indications for resection of the bifurcation of the trachea. In former times resection and reconstruction of the bifurcation have been performed using extracorporal oxygenation. Nowadays, the method of separate ventilation of both lungs is used more frequently. Pathophysiological variations should be taken into consideration, which may occur during interruption of the ventilation of one side of lung caused by operating procedures. Rapidly developing atelectasis of the non-ventilated but perfused lung endangers the patient, as a result of an increased intrapulmonary right-to-left-shunt. Hypoxaemia can be prevented by temporary occlusion of the pulmonary artery of the nonventilated lung. This procedure is to be recommended in view of the fact that there is no prompt constriction of the vessels. Investigations with dogs show that a slightly developing accommodation of the perfusion can be disturbed by variations of cardiac output or mean pressure of ventilation.     

A twenty-year analysis of the results of sleeve resection for primary bronchogenic carcinoma.

Ninety-six patients with primary bronchogenic carcinoma were treated by lobectomy with sleeve resection of the bronchus, over a 20 year period (1958 through 1977). In 80 resections undertaken prior to 1973, a 5 year survival rate of 34 percent was realized, with an operative mortality rate of 7.5 percent.Survival at 10 and 15 years has been assessed. A review of factors influencing survival has been undertaken and the biologic behavior of these pulmonary neoplasms, modified by sleeve resection, has been outlined. Of interest is the high rate of local recurrence accounting for death within 5 years postoperatively and the late incidence in the survivors of second malignancies and other diseases of surgical interest. Sleeve resection represents a surgical alternative in selected cases of bronchogenic carcinoma in which wider resection may be hazardous, and the indications should be extended to include some lesions commonly managed by pneumonectomy.     

Management of Type 9 Hepatic Arterial Anatomy at the time of Pancreaticoduodenectomy: Considerations for Preservation and Reconstruction of a Completely Replaced Common Hepatic Artery

Recognition and management of aberrant hepatic arterial anatomy for patients undergoing pancreaticoduodenectomy (PD) are critical to ensure safe completion of the operation. When the common hepatic artery (CHA) is noted to emanate from the superior mesenteric artery (Michels’ type 9 variant), it is vulnerable to injury during the dissection required for PD. While this anatomy does not preclude an operation, care must be taken to avoid injury, often by identifying the CHA throughout its entire course before beginning the dissection of the portal venous structures. The oncologic principle that cautions against resection of a pancreatic cancer when it involves the CHA in its standard position may not universally apply to tumors that focally involve the CHA in the type 9 anatomic variant. In highly selected patients, surgical resection may be entertained as disease biology may be analogous to local involvement of the gastroduodenal artery in a patient with standard anatomy. Here, we review the indications, techniques, and outcomes associated with arterial resection and reconstruction during pancreatectomy among patients with a pancreatic tumor involving a common hepatic artery arising from the superior mesenteric artery.     

Non steroidal anti-inflammatory drug-based pain control for minimally invasive direct coronary artery bypass surgery

Minimally invasive direct coronary artery bypass (MIDCAB) surgery has become an attractive alternative technique to treat coronary artery insufficiency. Changes in surgical and anesthesia techniques have led to reduced pulmonary morbidity associated with the operation. Early extubation is typically expected. However, postoperative pain management becomes even more important with early extubation. We describe our technique of a NSAID-based protocol with indomethicin and Torodal that has been safe and effective in over 175 patients following MIDCAB.     

Reconstruction of hand soft-tissue defects: alternatives to the radial forearm fasciocutaneous flap

Soft-tissue defects of the hand and wrist are not an uncommon problem confronting the hand surgeon. Over the past 20 years the retrograde radial forearm fasciocutaneous flap has gained widespread acceptance in reconstruction of these defects. Appreciation of the inherent limitations of this workhorse flap and increased understanding of the blood supply of the upper extremity have prompted the development of several alternative pedicled forearm flaps. Aspects of surgical technique, specific limitations, and indications for the radial forearm fascial flap, the posterior interosseous artery flap, the retrograde radial artery perforator flap, and the dorsal ulnar artery flap are discussed and a reconstructive algorithm for flap selection is presented.     

Staged reconstruction for hypoplastic left heart syndrome. Contemporary results.

OBJECTIVE: The authors review their experience with staged reconstructive surgery for hypoplastic left heart syndrome (HLHS) and assess current outcome for this condition. SUMMARY BACKGROUND DATA: Once considered a uniformly fatal condition, the outlook for newborns with HLHS has been altered dramatically with staged reconstructive procedures. Refinements in operative technique and perioperative management have been largely responsible for this improved outlook. METHODS: The authors reviewed their experience with 158 consecutive patients undergoing stage 1 reconstruction with a Norwood procedure from January 1990 to August 1995. All patients had classic HLHS, defined as a right ventricular dependent circulation in association with atresia or severe hypoplasia of the aortic valve. RESULTS: There were 120 hospital survivors. Among the 127 patients considered at standard risk, survival was significantly higher than that for the 31 patients with important risk factors. Adverse survival was associated most strongly with significant associated noncardiac congenital conditions and severe preoperative obstruction to pulmonary venous return. Second-stage reconstruction with the hemi-Fontan procedure was performed in 106 patients, with 103 hospital survivors and one late death. Three of the late survivors were not considered candidates for the Fontan procedure. To date, the Fontan procedure has been completed in 62 patients, with 53 survivors. Deaths after the Fontan procedure occurred early in our experience and were mostly secondary to left pulmonary artery stenosis or hypoplasia. Significant or potentially significant morbid conditions were noted in 25 of the 120 hospital survivors. Neurologic conditions were found in 6% and cardiovascular conditions in 10%, including dysrhythmia, left pulmonary artery thrombosis, and chronic pleural effusions. Among the patients considered at standard risk with typical anatomy, actuarial survival was 69 +/- 8% at 5 years. Survival was 71 +/- 17% at 5 years for standard risk patients with variant anatomy and 58 +/- 9% for the entire cohort of 158 patients. The largest decrease in survival occurred in the first month of life and late deaths primarily affected those patients in the high-risk group. CONCLUSIONS: Staged reconstruction has significantly improved the intermediate-term outlook for patients with HLHS. Factors addressing improvements in early (< 1 month) first-stage survival would be expected to add significantly to an overall improved late outcome. Currently employed refinements in operative technique are associated with eliminating or reducing pulmonary artery distortion and dysrhythmia.     

Complete transposition of the great arteries with intact ventricular septum and left ventricular outflow tract obstruction. Surgical management and anatomic considerations.

Surgical management of patients with complete transposition and intact ventricular septum may become difficult in the presence of left ventricular outflow tract obstruction. A Mustard operation and direct resection of the obstruction through the pulmonary artery has been the treatment of choice for this combination. Our study of the structure of the left ventricular outflow tract in four specimens with the anatomic findings of complete transposition, intact ventricular septum, and subpulmonary stenosis suggests that direct resection of the stenosis through the pulmonary artery can seldom be adequate without major risk of damaging either the mitral valve or the conduction tissue. An alternative procedure, namely, a combined Mustard operation and insertion of an external conduit from the left ventricle to the main pulmonary artery, has been employed in the management of six patients with this combination of lesions. One early and one late death occurred. Postoperative cardiac catheterization performed in all of the survivors before discharge from the hospital showed good relief of the stenosis and no significant gradient across the conduit.     

胸部肿瘤侵及大血管时的手术处理

目的 总结64例胸部肿瘤浸润大血管手术时的处理经验，分析上腔静脉（SVC）手术技术及指征以及肺动脉袖状切除的适应证。方法 回顾性分析1991年1月至1999年6月64例胸内大血管受到肿瘤浸润患者的手术经验。受侵血管包括肺动脉根部和（或）肺动脉干、上静脉和（或）下肺静脉根部、SVC和（或）无名静脉。结果 24例接受了不同类型的SVC手术，包括左及右无名静脉分别与右心房人工血管搭桥术1例、左无名静脉与右心房人工血管搭桥4例、右无名静脉与右心房搭桥3例、奇青脉切除并SVC部分切除11例、单纯SVC部分切除5例。SVC置换或搭桥除1例应用涤纶血管者外，其余均是Gore-Tex人工血管，5例部分切除者使用了缝合器，41例肺动脉部分或袖状切除（肺动脉袖状并支气管袖状成形4例）、左心房部分切除13例，应用肺血管阻断或临时架桥术，所有手术均成功进行，无手术死亡，无严重并发症。SVC切除后生存时间最长者已达15年，为1例恶性畸胎瘤患者，肺癌切除SVC、无名静脉搭桥患者术后生存最长者已达5年。结论 大血管包括SVC及肺血管阻断与成形技术以及SVC置换术，是根治性切除浸润大血管的胸部肿瘤的关键性技术，正确及时地应用可以提高根治性切除率和安全性，减少探查率。     

Resection of high-cervical paraganglioma with cervical-to-petrous internal carotid artery saphenous vein bypass. Report of two cases

Two patients with large high-cervical paragangliomas were treated with radical resection and placement of a cervical-to-petrous internal carotid artery saphenous vein bypass. The high-cervical and infratemporal segments of the internal carotid artery engulfed within the tumor were resected and successfully replaced with a saphenous vein interposition graft. The postoperative course was uneventful in both cases and follow-up angiography revealed satisfactory reconstruction of the high-cervical and infratemporal skull base carotid artery. The operative technique, indications, and potential future applications of this newly developed skull base bypass procedure are discussed.     

Long-term survival of a pulmonary artery sarcoma produced by aggressive surgical resection and adjuvant chemoradiotherapy.

Malignant pulmonary artery tumors represented by sarcomas are rare, but fatal. Early diagnosis and radical surgical resection offer the only chance for survival. However, surgical intervention has some challenging aspects, and prognosis is poor even after tumor resection. We report a case of a pulmonary artery sarcoma between the right ventricular outflow tract and the pulmonary artery branches. The tumor was aggressively extracted with reconstruction using a cryopreserved pulmonary valved allograft, followed by adjuvant chemoradiotherapy. At 56 months after surgery, the patient is well without any evidence of recurrence, demonstrating that aggressive surgical resection with adjuvant chemoradiotherapy can prolong survival.