One hundred and one cases of bronchoplasty for primary lung cancer

The results of 101 consecutive bronchoplasties performed between 1979 and 1993, including 8 cases of pneumonectomy, 88 cases of lobectomy, 3 cases of segmentectomy, and 2 cases of bronchial resection, are herein reported. Squamous cell carcinoma was the most common disease (59%) followed by adenocarcinoma (30%) and other diseases (11%). Anastomosis was satisfactory in 96 cases. Among the five stenosed cases, local recurrence was found in two cases, and there were three benign strictures. Two of the three benign strictures were treated with bouginage. The pulmonary artery was concomitantly reconstructed in seven cases with satisfactory results. Preoperative chemoradiotherapy was performed in 15 advanced cases and was followed by acceptable surgical results. The 5-year survival rate, according to the post-operative staging of the 86 patients without induction therapy, was 86% in stage I (19 patients), 49% in stage II (21 patients), and 27% in stage IIIA (40 patients). The overall survival rate was 46% at 5 years. There were two indications for this procedure i.e., a positive resection margin in 59 cases and positive hilar nodes in 42 cases. Better survival was noted in patients with squamous cell carcinoma, stage I, and surgery was thus selected for a positive resection margin, and not for a positive node.     

Video-assisted thoracoscopic lobectomy with bronchoplasty for lung cancer: tip regarding bronchial anastomosis

No study has discussed the application of video-assisted thoracoscopic surgery (VATS) to bronchoplasty or the handling of a needle and forceps in a bronchial anastomosis. We use the following steps for bronchial anastomosis: Insert the needle and forceps vertical to the bronchial wall, move them in such way as to scoop something up, rotate and turn around, repeat the second step, and pull from the bronchial wall along the curvature of the needle. Handling the needle forceps along the curvature of the needle is critically important.     

Consecutive left lower sleeve lobectomy and left S3 segmentectomy for a patient with node-negative double lung cancer

A 74-year-old-man visited our hospital because of a dry cough. A chest radiograph showed a nodular shadow measuring 2.0 cm diameter in the left S3 segment and a tumor shadow measuring 3.5 cm diameter in the left S6 segment; no mediastinal lymph node enlargement was observed. The bronchoscopic findings revealed direct invasion of the tumor into the spur of the left B6 branch, but no abnormal findings were found in the upper bronchus. An endobronchial biopsy revealed squamous cell carcinoma in a left B6 biopsy specimen and adenocarcinoma in the left S3 lung biopsy specimen. The patient's lung function was not good, and an arterial blood gas analysis was Po2 69.3mmHg and PCO2 48.5 mmHg. We performed left lower sleeve lobectomy and left S3 segmentectomy simultaneously. He was discharged uneventfully on the 14th day after the operation, and he has since been doing fine without lung caner recurrence for 3 years after surgery.     

VATS right apical segmentectomy for lung cancer in a patient with tracheal bronchus

IntroductionA tracheal bronchus is rarely observed, occurring in only 1% of all patients who undergo thoracic surgeries. We rarely encounter lung cancer in a patient with a tracheal bronchus; however, it is essential to know the distinctive perioperative management strategy for patients with a tracheal bronchus.Case presentationWe report a 72-year-old man with lung cancer located in the right apical segment supplied by a tracheal bronchus. Annual chest computed tomography performed as follow-up after colon cancer resection showed an enlarging pulmonary nodule with pure ground-glass opacity, which was suspected to be lung adenocarcinoma. The nodule was located in the right apical segment. The apical segment was independently supplied by a single pulmonary artery superior trunk and a tracheal bronchus that branched directly from the trachea at 1.2 cm above the carina. The pulmonary vein branching pattern was uncommon in that the central vein that usually runs through B2 (posterior bronchus) and B3 (anterior bronchus) was missing. The patient underwent video-assisted thoracoscopic apical segmentectomy under one-lung ventilation using a left-sided double-lumen tube.DiscussionAnomalous venous return accompanied with tracheal bronchus has been described in some reports. Since pulmonary vein is important during segmentectomy, the surgeon should pay particular attention to the venous return.ConclusionPreoperative three-dimensional graphic imagery helped us accurately identify the anatomical anomaly to enable the successful segmentectomy in a patient with a tracheal bronchus. We review the relevant literature regarding the perioperative management of patients with a tracheal bronchus.     

加压吻合环：一项结直肠吻合新技术

目的 评价用一种新型镍钛记忆合金加压吻合环（CAR27）进行结直肠吻合的安全性和有效性.方法 2009年11月12日,采用镍钛记忆合金加压吻合环（CAR27）对1例行直肠高位切除术的乙状结肠癌患者进行结直肠端端吻合.结果 本例手术时间42 min,其中吻合时间11 min,术后第1天肛门即排气,术后第2天开始进食.CAR27吻合环于术后第10天随粪便中排出.患者术后随访1个月,无感染、肠梗阻、吻合口狭窄或瘘等并发症发生.结论 本例研究初步提示,采用镍钛记忆合金加压吻合环进行结直肠吻合安全、可行.     

极量肝切除治疗肝细胞癌的适应证与疗效

临床对原发性肝细胞癌(HCC)的手术治疗已取得了长足进步,其中极量肝切除是高难度手术的典型代表。极量肝切除术疗效显著,但必须严格掌握适应证。笔者分别从极量肝切除术治疗HCC的适应证、术前评估、提高手术疗效和减少手术并发症、争议与建议等方面就其治疗现状与进展作一总结。     

One-lung high-frequency ventilation for tracheoplasty and bronchoplasty: a new technique

Major airway surgery requires the maintenance of adequate ventilation and oxygenation during the period of resection and reconstruction, as well as an unobstructed surgical field and optimal access to the airway's circumference. High-frequency positive-pressure ventilation (HFPPV) at a frequency of 1 Hz (60 breaths/min) or more, along with a small tidal volume (50 to 250 cc), provides adequate ventilation and oxygenation with minimal impairment of pulmonic and systemic circulatory functions. We have used HFPPV of one lung through a 2 mm internal diameter catheter in six patients (three undergoing right sleeve pneumonectomies, two having carinal tumor resections, and one having tracheal resection). High-frequency positive-pressure ventilation of the left lung provided continuous and adequate ventilation and oxygenation during the period of resection and reconstruction of the airways, while the small catheter permitted unimpaired visualization and adequate access to the operative site.     

Extended resection for unexpected invasion of the left sided lung cancer into the liver: combined lung,diaphragm, and liver resection

Complete anatomic lung resection remains the best curative option in patients with early-stage lung cancer. In some cases, extended lung resections are required to achieve R0 resection. Although diaphragmatic invasion and resection is a well-known condition in lung cancer, direct invasion of the diaphragm and liver in lung cancer is rare. We report a 66-year-old man with left-sided lung cancer. Preoperative evaluation revealed the risk of diaphragm invasion, but the liver invasion was detected intraoperatively. In addition to left pneumonectomy, left-sided partial liver and diaphragm resection was performed. At 24 months from the operation, the patient is alive without any disease progression. We believe that combined resection including lung, diaphragm, and liver may have survival benefits in selected cases.     

Microsurgical technique used in right anterior segmentectomy and pancreatoduodenectomy with reconstruction of the right posterior hepatic artery for widespread bile duct cancer involving the hepatic hilus

A microsurgical technique was used in performing anterior hepatic segmentectomy and pancreatoduodenectomy with reconstruction of the posterior hepatic artery in a 64-year-old man with widespread bile duct cancer from the intrapancreatic bile duct over the hepatic hilus. The anterior hepatic artery was obviously involved and the posterior hepatic artery just behind common hepatic duct was very close to the cancer. Microsurgical anastomosis between the remnant gastroduodenal artery and the posterior hepatic artery at the hepatic hilus made it possible to preserve the posterior segment of the liver and to perform a curative resection of the cancer. The patient had pyrexia because of suprahepatic abscess after the operation, but the abscess drained spontaneously. Postoperative arteriogram showed neither obstruction nor kinking of the reconstructed artery. He was discharged 2 months after surgery and has been enjoying a normal quality of life for 10 months since, with no signs of recurrence. It is suggested that a microsurgical technique is useful for performing an accurate anastomosis with good patency that allows not only a safe but also a highly curative operation for advanced bile duct cancer.     

Partial anomalous pulmonary venous connection in right lung cancer: Report of a case

A partial anomalous pulmonary venous connection (PAPVC) is an uncommon congenital anomaly which is frequently associated with congenital heart disease such as an atrial-level shunt. This report documents the case of an 81-year-old man with PAPVC which was incidentally discovered during a right upper lobectomy for lung cancer. Surgery was performed through a minithoracotomy of an auscultatory triangle using a video-assisted procedure (video-assisted thoracic surgery: VATS). Although the ramus lobi medii was connected normally, the right superior lobe vein was found to drain into the superior vena cava. The surgery was successful, and the patient had an uneventful postoperative course. Asymptomatic PAPVC without an atrial septal defect (ASD) is extremely rare. If the PAPVC is located in a different lobe, a pulmonary resection for lung cancer would precipitate an adverse outcome without a correction of the PAPVC. Surgeons should therefore be cautious regarding the potential existence of a PAPVC when a patient undergoes surgical procedures, especially VATS, for lung cancer.     

A novel technique for hepaticojejunostomy for nondilated bile ducts: a purse-string anastomosis with an intra-anastomotic biodegradable biliary stent

In non-dilated bile ducts, performing a well-functioning hepaticojejunal anastomosis (HJ) may be challenging. We investigated a novel technique for small-caliber HJ: a purse-string anastomosis with an intra-anastomotic biodegradable stent. HJ was performed randomly either conventionally with interrupted sutures without any stent (n = 5; conventional) or using the novel purse-string technique with a 4-mm caliber polylactide-barium sulfate biodegradable biliary stent (n = 4; pursestring + stent) in minipigs with bile ducts 3.5-4.0 mm in caliber. The anastomosis creation time was not different in the groups. In the conventional group 2 complications occurred: 1 early anastomotic leakage, and 1 late anastomotic stricture. The remaining animals (3/5 in conventional, and 4/4 in purse-string + stent group) had normal liver histology and function, and developed no signs of complications during the 6-month follow-up. All biodegradable stents disappeared by 3 months. At 6 months, the HJ caliber was smaller in the conventional (5 [1-9] mm) than in the purse-string + stent group (12 [4-15] mm; P < .05). We conclude that this novel HJ technique is easy and safe to perform, and ensures a well-functioning anastomosis in nondilated bile ducts.     

Video-assisted thoracic surgery lobectomy for right lung cancer in a patient with right aortic arch: report of a case

A 57-year-old man with an anomalous right aortic arch presented with cancer of the right lung. The right recurrent laryngeal nerve was found to be hooked around the right aortic arch. Right lower lobectomy with systematic mediastinal lymph node dissection was successfully performed using video-assisted thoracic surgery to provide close intraoperative attention to the branching of recurrent laryngeal nerve.     

手术机器人系统直肠癌切除术——经肛门拖出标本及手术机器人行吻合重建

目的总结对直肠癌施行经肛门拖出标本及达芬奇手术机器人系统下进行直肠重建的临床经验。方法回顾性分析2012年2-5月间15例在南京军区南京总医院接受机器人系统施行直肠癌根治术患者的临床资料。结果15例患者中男9例．女6例,年龄（61．5±9．2）岁。所有病例均顺利完成机器人手术．手术时间（154．7±10．6）min,术中出血量（17．3±6．5）ml,术后肛门排气时间（2.3±0．8）d．术后住院时间（3．3±0．6）d。标本内获取的淋巴结（15．0±1．2）枚／例,切缘均为阴性。术后所有患者均接受了4-8周的随访．无术后感染、吻合口瘘及切口疝等并发症,无近期死亡病例。结论达芬奇手术机器人系统以其独特的光源系统及灵活的器械操作．极大地降低了直肠癌手术的难度。     

Video-assisted thoracic surgery for left lung cancer in a patient with a right aortic arch

We report a rare case of left lung cancer in a patient with a right aortic arch. A 65-year-old woman was diagnosed to have an adenocarcinoma in the left upper lobe (S3) in addition to a right aortic arch (type II), with the left subclavian artery originating from the descending aorta. Left upper lobectomy and lymph node dissection was performed by video-assisted thoracic surgery (VATS). For the mediastinal dissection, the upper mediastinal lymph nodes were easily resected after verifying the location of the arterial ligament and the recurrent laryngeal nerve (RLN). This is the first report of using VATS to remove a lung cancer from a patient with a right aortic arch.     

Superior vena cava resection with prosthetic replacement for non-small cell lung cancer: long-term results of a multicentric study

Objectives: Superior vena cava (SVC) resection with prosthetic replacement for non-small cell lung cancer (NSCLC) is infrequently performed and oncological results are unclear. To establish a historical benchmark for this extended surgery, we have updated and reviewed data from four international centers. Methods: Data were obtained through retrospective chart review. Prognostic factors were analyzed using first univariate techniques and subsequently multiple regression (logistic regression). Kaplan–Meier overall survival was calculated and prognostic factors examined by log–rank test and the estimation of hazard ratios using Cox regression. Results: From 1985 to 2000, 28 patients underwent SVC resection with prosthetic replacement for NSCLC. During the same period, 65 patients underwent partial SVC resection. Induction treatment was performed in 25% of patients. The resection was done for T involvement in 22 patients (79%), and for N2 involvement in the remaining. There were 12 tracheal sleeve resections, four pneumonectomies, and 12 lobar or sublobar resections with or without bronchoplasty. The median clamping time was 40 min. The median diameter of the prosthesis used was No. 14. Pathological examination showed direct SVC invasion (T4) in 79% of patients, whereas N2 disease was present in 50% of patients. Median intensive care unit and hospital stay were 3 and 20 days, respectively. The postoperative morbidity and mortality were 39 and 14%, respectively. The overall 5-year probability of survival was 15% (median of 9 months, range 0–105 months). Patients who underwent partial SVC resection during the same period had a significantly higher probability of survival (P=0.03). Induction chemotherapy was associated with a significant increase of postoperative morbidity in multivariate analysis. None of the potential prognostic factors analyzed in multivariate analysis were associated with survival, but the type of resection (sleeve pneumonectomy/pneumonectomy) were borderline significant. Conclusions: SVC resection with prosthetic replacement should not be considered an absolute contraindication in patients with NSCLC; however, the poor oncological results suggest more restrictive and severe criteria of patient selection (mediastinoscopy, induction treatment, no pneumonectomy, no N2 disease).