A completion sleeve bilobectomy for nonstump postlobectomy bronchopleural fistula

We present a novel approach for treatment of nonstump postlobectomy bronchial fistula. Our patient had right lower lobectomy for T3 N2 M0 adenocarcinoma. An increased air leak developed 8 days later, and bronchoscopy revealed the presence of a bronchial fistula. On reexploration, the bronchial stump was intact, and the membranous part of the bronchus intermedius was sloughed up to the opening of the upper lobe bronchus. A middle lobectomy with sleeve resection of the bronchus intermedius and part of the right main bronchus was performed, and the upper lobe was reanastomosed to the right main bronchus. The patient's postoperative course was uneventful, and follow-up bronchoscopy showed an intact healed anastomosis.     

Intraoperative bronchial blood flow evaluation using indocyanine green fluorescence for bronchoplasty: A case report

Introduction and importanceBlood flow evaluation of bronchial arteries using indocyanine green fluorescence (ICG-FL) is rarely reported during pulmonary resection. We present the case of a patient with bronchiectasis and a history of bronchial artery embolization (BAE) for hemoptysis. Bronchial artery blood flow was evaluated using ICG-FL during lobectomy with bronchoplasty.Case presentationA 63-year-old woman presented with right middle lobe bronchiectasis (due to nontuberculous mycobacteriosis) and repeated hemoptysis, which had previously been corrected each time with hemostasis by BAE. Bronchoscopy revealed a swollen blood vessel proximal to the right middle lobe bronchus that was suspected of being the origin of bleeding. Right middle lobectomy with bronchoplasty was performed to prevent hemoptysis. ICG-FL was used to detect the patency of the right bronchial arteries, and the arteries surrounding the right middle lobe bronchus were ligated. The proximal side of the right middle lobe bronchus was cut in a deep wedge shape, and the bronchus was anastomosed. ICG-FL revealed that the blood supply was maintained at the bronchial anastomosis. No bronchial anastomotic leakage was observed after the surgery.Clinical discussionThe key to successful bronchoplasty is the maintenance of blood flow. Bronchial artery blood flow theoretically decreases after BAE. In this case, ICG-FL was able to detect bronchial artery patency before cutting the bronchus as well as the maintenance of blood flow at the bronchial anastomosis after bronchoplasty.ConclusionIntraoperative blood flow evaluation of the bronchus using ICG-FL may reduce the risk of bronchial anastomotic leakage caused by ischemia after bronchoplasty.     

Bilateral sleeve lobectomy for metachronous multiple primary lung cancer

In a patient with metachronous multiple primary lung cancer, bilateral lobectomy was performed, using bronchoplastic procedures. This case may be one of very few such cases reported in the literature. A 56-year-old man with squamous cell carcinoma was surgically treated for lung cancer. At the first operation, right upper lobectomy with wedge resection of the right main bronchus was performed, as the tumor occupied the orifice of the right main bronchus. Six months later, re-operation for stricture at the anastomotic line was done because of granulation. By means of sleeve resection of the strictured right main bronchus, the airway was reconstructed. The patient remained well for five years, then a similar cancer at the orifice of the left lower lobe and bulging into the left main bronchus became evident. Left lower sleeve lobectomy was done for the second primary cancer. The postoperative course was uneventful and he is well with no signs of recurrence 6 years and 10 months after the first operation and 19 months after the second sleeve lobectomy.     

Bilateral sleeve lobectomy for metachronous multiple primary lung cancer

In a patient with metachronous multiple primary lung cancer, bilateral lobectomy was performed, using bronchoplastic procedures. This case may be one of very few such cases reported in the literature. A 56-year-old man with squamous cell carcinoma was surgically treated for lung cancer. At the first operation, right upper lobectomy with wedge resection of the right main bronchus was performed, as the tumor occupied the orifice of the right main bronchus. Six months later, re-operation for stricture at the anastomotic line was done because of granulation. By means of sleeve resection of the strictured right main bronchus, the airway was reconstructed. The patient remained well for five years, then a similar cancer at the orifice of the left lower lobe and bulging into the left main bronchus became evident. Left lower sleeve lobectomy was done for the second primary cancer. The postoperative course was uneventful and he is well with no signs of recurrence 6 years and 10 months after the first operation and 19 months after the second sleeve lobectomy     

A case of lung cancer underwent carinal resection with right upper lobectomy and carinal reconstruction with double-barreled anastomosis

A 70-year-old male complaining cough was admitted to our hospital. Bronchoscopic examination revealed a tumor mass which occluded the orifice of the right upper lobe. Chest computed tomographic (CT) scans gave the image of tumor invasion at the carina. The pathological diagnosis of the tumor was squamous cell carcinoma. Operation was accomplished by right posterolateral thoracotomy approach through the fifth rib bed. The carinal resection with right upper lobectomy was followed by a double-barreled anastomosis of the right intermediate trunk and left main-stem bronchus into the carina. The operation was successfully performed and was considered curative. The length of resected airway measured 4.0 cm from tracheal line of resection to the divided the right intermediate trunk. Reinforcement of the anastomosis was not performed in this case. No postoperative complication occurred but mild ischemia of the anastomosis. The patient died of recurrent tumor in a year and 2 months after operation.     

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.     

Coexistent lung carcinoma and active pulmonary tuberculosis in the same lobe.

We observed a rare case of lung carcinoma accompanied by active pulmonary tuberculosis in the same lobe. The chest x-ray of a 49-year-old man revealed an abnormal shadow in the right upper field and a giant bulla in the left upper field. Chest computed tomography (CT) revealed a nodule with consolidation, which was not continuous in the right S3. Bronchoscopically, epidermoid carcinoma existed in the proximal right upper bronchus. In the sputum specimens, the smear was negative, but the polymerase chain reaction of Mycobacterium tuberculosis and culture was positive. Anti-tuberculosis treatments were administered for approximately 4 weeks, but the chest x-ray remained unchanged. Right upper lobectomy with bronchoplasty (wedge resection of the right upper bronchus) was performed, and the anastomosis was covered with an intercostal muscle flap. Lymphadenectomy of the right hilum and mediastum was also performed. Microscopy revealed epidermoid carcinoma in the proximal tumor (pT3N0M0-stage IIB) and epithelioid granuloma with caseous necrosis, granulomatous pneumonia, exudative lesions, and fibrocaseous nodules in the distal lung. After surgery, anti-tuberculosis treatment was resumed.     

Endobronchial histoplasmosis: a masquerade of primary endobronchial neoplasia--a clinical study of four cases

Background

Histoplasma capsulatum is a dimorphic fungus with both hyphal and microconidial elements and is endemic in certain areas of the central United States. Most clinically recognized syndromes are self-limited, presenting in more than 80% of cases as an influenza-like acute pulmonary illness. We encountered four patients with an endobronchial presentation of histoplasmosis masquerading as a bronchogenic malignancy.

Methods

The patient files from one of the authors (PR) uncovered four patients diagnosed with, and treated for, endobronchial histoplasmosis; all cases were referred for a presumptive diagnosis of endobronchial neoplasia.

Results

The case study group comprised three women, ages 52, 68, and 81 years, respectively, and one man age 29 years, all presenting with recurrent hemoptysis. An obstructing adherent lesion was apparent on bronchoscopy in three, involving the right upper lobe bronchus in two, and right mainstem bronchus in one. In one patient, blood was observed in the bronchus intermedius; there was no gross lesion. Recurrent hemoptysis necessitated a right upper sleeve lobectomy in one, a right upper lobe lobectomy and right lower wedge resection in one, a right middle lobectomy in one, and wedge resection of the right upper lobe in one.

Conclusions

Endobronchial histoplasmosis may mimic primary bronchogenic carcinoma, presenting as a fixed obstructing endobronchial lesion associated with hemoptysis; the latter potentially necessitating surgical intervention. Endobronchial histoplasmosis should be considered in the differential diagnosis of obstructing endobronchial lesions associated with hemoptysis, especially when prior and(or) concurrent biopsies fail to disclose malignancy.     

Management of acute empyema with leakage of bronchial anastomosis after right sleeve upper lobectomy--a case report

Bronchopleural fistula developing empyema after pulmonary resection is a fatal complication. But we have successfully treated this complication after right sleeve upper lobectomy. The patient was a 61-year-old male, who has a squamous cell carcinoma originating in the right upper lobe of the lung in the clinical stage of IIIa. Right sleeve upper lobectomy with pericardiotomy to reduce the tension of bronchial anastomosis and R2a lymph node dissection. The leakage of bronchial anastomosis was complicated on 5th postoperative day and developed aspiration pneumonia of right middle and lower lobe and empyema. Reoperation was done on 7POD and completion pneumonectomy, omentopexy and open window thoracotomy were performed. Then endotracheal tube had been inserted into the left main bronchus and he controlled under respirator. Six weeks after that fistula was cured. Empyema, which caused by methicillin resistant staphylococcus aureus, was cured by open drainage for 2 weeks and closed drainage and irrigation for 14 weeks. He discharged 16 weeks after reoperation.     

Radical resection of a pleomorphic carcinoma after relieving airway obstruction by the endobronchial snare method

A 69-year-old man was hospitalized for fever and cough. He was diagnosed with and treated for an abscess in the left lower jaw and pneumonia by an otolaryngologist, but the pneumonia persisted with no improvement. Chest computed tomography revealed the presence of a heterogeneous torose lesion in the inlet of the left upper bronchus, and bronchoscopy revealed an endobronchial tumor with a smooth surface. An episode of sudden dyspnea occurred and was resolved after the patient changed his sitting position. We concluded that this symptom occurred because the tumor was incarcerated in the left lower lobe bronchus. The tumor was excised by bronchofi berscopic snare resection under tracheal intubation. It was found to be a pleomorphic carcinoma, and left upper lobectomy was performed. There has been no recurrence during the 3 years since the operation.     

Carinal resection and reconstruction for recurrent lung cancer

A patient with a recurrent tumor in the trachea adjacent to the right main bronchus was treated by surgical resection 19 months after undergoing surgery for the primary cancer. The patient had previously undergone right upper lobectomy for T1N0M0 stage I squamous cell carcinoma. A carinal resection was performed which included 4 rings of the trachea, 2 rings of the righ main bronchus, and 1 ring of the left main bronchus. Reconstruction consisted of an end-to-end anastomosis of the trachea and left main bronchus, and an end-to-side anastomosis of the right and left main bronchi. The postoperative course was uneventful, and at present the patient is healthy 12 months following reoperation.     

Three cases of endobronchial hamartoma

We reported three cases of endobronchial hamartoma. There were some difficulties in diagnosis of the disease by bronchoscopic examination, because the tumors were covered with normal bronchial epithelium. But X ray film and CT film contributed to the diagnosis when calcification of intra-bronchial tumor was observed. Three different modes of operation were performed as extirpation of tumor by wedge resection of upper lobe bronchus, sleeve resection of left S6 segmental bronchus, and right middle lobectomy.     

Successful treatment of bronchial mucoepidermoid carcinoma in an 11-year-old boy by bronchoplasty: Report of a case

We report herein the rare case of an 11-year-old boy in whom mucoepidermoid carcinoma of the right upper lobe bronchus was successfully treated by bronchoplasty. The patient underwent bronchoscopy to investigate the cause of relapsing respiratory infections over the past 2 years, which revealed a tumor at the orifice of the right upper lobe bronchus. Thus, a right upper sleeve lobectomy was effectively carried out, preserving right pulmonary function. The tumor was observed to partially invade the bronchial wall, but not the lung parenchyma. Histological examination confirmed a diagnosis of mucoepidermoid carcinoma, classified as grade 2 by Conlan's classification. The patient has been well and free of recurrence for 3 years postoperatively.     

Bronchial carcinoid of an accessory tracheal bronchus

We present a rare case of bronchial carcinoid tumor arising in an accessory right tracheal bronchus and involving the associated tracheal lobe in a 48-year-old man, who presented with a history of recurrent respiratory infections and recent onset of hemoptysis. Diagnosis was established on preoperative bronchoscopy and biopsy. The tumor was completely removed by right upper lobectomy with the tracheal bronchus resected flush to its origin from the right lower tracheal wall. Final histology revealed a typical carcinoid tumor.     

Treatment of endoscopic laser therapy for obstruction due to granulation at the anastomosis site after right sleeve lobectomy

A case treated with endoscopic laser therapy for obstruction due to granulation at the anastomosis site after sleeve lobectomy was reported. A 57-year-old male was admitted to our hospital with complaint of dyspnea four months after right sleeve upper lobectomy for long cancer. Chest roentgenogram showed complete atelectasis of the right lung and bronchoscopy revealed obstruction at the anastomotic site. The biopsy of the site showed granulation tissue. Pulmonary angiography immediately after bronchography yielded 3 to 4 mm obstruction in length and no particular vascular communication between the obstruction site and pulmonary vessel. Nd-YAG Laser irradiation of 774 Joules gave complete reopening. Good patency has been maintained one month since the laser therapy. It is important to recognized bronchus peripheral to the obstructive site and to identify the correlation between the anastomotic site and vascular system preoperatively. Pulmonary angiography combined with bronchography examination could be very useful to obtain these information.     

Torsion of the middle lobe after right upper lobectomy of the lung; report of a case and the review of the Japanese literatures

We report a case of torsion of the residual right middle lobe of the lung, following right upper lobectomy for lung cancer. A 71-year-old man who had medical treatment for emphysema was admitted with a lung tumor on chest computed tomography. The tumor was diagnosed as pulmonary adenocarcinoma by transbronchial biopsy. Right upper lobectomy with mediastinal lymph node dissection, and partial resection of the right lower lobe were performed. On the following day, chest X-ray showed an opacification in the right upper lung field, which gradually increased. Bronchoscopic examination revealed a stenotic middle lobe bronchus. Torsion of the middle lobe was suspected, and rethoracotomy was performed on the second postoperative day. The middle lobe was torsed 90-degree counterclockwise around its bronchovascular pedicle. A middle lobectomy was performed secondary to severe congestion. The patient was discharged in good condition on the 11th postoperative day. In reviewing the literatures including this case, 13 of 16 torsions occurred after right upper lobectomy of the lung. Thirteen patients had rethoracotomy, 10 of them underwent resection of the rotated lung. Simple detorsion was carried out in 3 patients, and 1 of them developed cerebral infarction. Lung torsion was reported to be potentially life-threatening. Therefore, fixation of a remaining lobe should be performed. Exploratory thoracotomy should be performed without delay, if lung torsion is suspected.     

Bilateral lung transplantation using a donor with a tracheal right upper lobe bronchus

We report on a case of successful bilateral sequential lung transplantation using a donor with the right upper lobe bronchus arising from the trachea. After en-bloc donor lung retrieval, the right bronchial stump was fashioned to create one lumen including the bronchus intermedius and the aberrant right upper lobe bronchus. A carinoplasty was performed in the recipient with resection of a portion of the lateral wall of trachea. The anastomosis was completed using a telescoping technique without any complication. This case demonstrates the possibility of successfully using donor lungs with such anatomic abnormality for transplantation.     

An operated case of traumatic intrapulmonary foreign body persisting for 45 years]

A case with a bronchial foreign body which had an uncommon way of entry through a wound in the chest wall was described. A 70-year-old man was admitted to our hospital because of productive cough and weight loss. He had been injured by a fragment of a hand grenade which penetrated his anterior chest wall at the front in China 45 years ago. A chest x-ray film revealed a metallic foreign body, measuring 1.3 by 0.9 cm, in the upper lobe of the right lung. Computed tomography of the chest and bronchoscopy demonstrated a steel fragment lodging beside and in the right upper lobe bronchus. Right upper lobectomy was performed, and the patient remains well without any thoracic symptoms one and a half years after the operation. Problems in the treatment of traumatic intrapulmonary foreign bodies were discussed.     

Lobar torsion after pulmonary resection; report of two cases.

Lobar torsion is a rare complication after pulmonary resection. We report a case of right middle lobe torsion following a right upper lobectomy, and left lower lobe torsion following a left upper lobectomy. Careful postoperative clinical observation, chest radiography, fiberoptic bronchoscopy (FOB), and computed tomography (CT) are crucial for precise diagnosis of lobar torsion following pulmonary resection. Both patients underwent re-thoracotomy; a middle lobectomy and completion pneumonectomy were performed. In the clinical management of lobar torsion urgent diagnosis and conclusive surgical resection is needed to avoid mortality and morbidity.     

Sleeve resection of a transcarinal bronchial carcinoid after laser debulking

We report a case of a bronchial carcinoid tumor extending from the right upper lobe into the left mainstem bronchus in a 30-year-old woman. Diagnosis was established by preoperative bronchoscopy and biopsy. After extensive debulking with seven sessions of bronchoscopic neodymium:yttrium-aluminum-garnet laser therapy, the tumor was resected by right upper-lobe sleeve lobectomy. Final pathology revealed a typical carcinoid tumor with surgical margins and all lymph nodes free of tumor.