~ ET AL CASE REPORT CEREZO MADUENO PERIAREOLAR APPROACH FOR VATS LOBECTOMY
Ann Thorac Surg 2014;97:1427–9
References 1. Takanami I. Tracheal laceration: A rare complication of median sternotomy. J Thorac Cardiovasc Surg 2001;122:184. 2. Choudhury A, Makhija N, Kiran U. Tracheal injury causing massive air leak during mitral valve replacement surgery. Ann Card Anaesth 2012;15:171–2. 3. Cardillo G, Carbone L, Carleo F, et al. Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment. Eur J Cardiothorac Surg 2010;37:581–7. 4. Lehr EJ, van Wagenberg FS, Haque R, et al. Robotic total endoscopic coronary artery bypass hybrid revascularization in a patient with a preoperative tracheostoma. Interac Cardiovasc Thorac Surg 2011;12:878–80. 5. Ngaage DL, Cale AR, Griffin S, et al. Is post-sternotomy percutaneous dilatational tracheostomy a predictor for sternal wound infections? Eur J Cardiothorac Surg 2008;33: 1076–81. 6. Cassada DC, Munyikwa MP, Moniz MP, et al. Acute injuries of the trachea and major bronchi: importance of early diagnosis. Ann Thorac Surg 2000;69:1563–7. 7. Carretta A, Melloni G, Bandiera A, et al. Conservative and surgical treatment of acute posttraumatic tracheobronchial injuries. World J Surg 2011;35:2568–74. 8. Creagh-Brown B, Sheath A, Crerar-Gilbert A, et al. A novel approach to the management of acute tracheal tear. J Laryngol Otol 2008;122:1392–3. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Periareolar Approach for Thoracoscopic Lobectomy Francisco Cerezo Madue~ no, MD, Elisabet Arango Tom as, MD, Francisco Javier Algar Algar, MD, and Angel Salvatierra Vel azquez, PhD General Thoracic Surgery and Lung Transplantation Unit, Reina Sofía University Hospital, C ordoba, Spain
In recent years advances in video-assisted thoracoscopic surgery have been aimed at reducing the number of video surgery ports, and especially major lung resections pose the greatest challenge. We describe a new minimally invasive as well as aesthetic approach for thoracoscopic lobectomy. The technique poses no difficulty for the surgeon and has certain advantages over other videothoracoscopic approaches. (Ann Thorac Surg 2014;97:1427–9) Ó 2014 by The Society of Thoracic Surgeons
M
inimally invasive surgical techniques are gaining ground over conventional open thoracic surgery. Major lung resections pose the greatest challenge, and in recent years advances in video-assisted thoracoscopic surgery have been aimed at reducing the number of video surgery ports. We describe a new minimally invasive as well as aesthetic approach for thoracoscopic lobectomy. The technique poses no difficulty for the surgeon and has certain advantages over other videothoracoscopic approaches. A 53-year-old former smoker with a 60-pack-year history was studied for an incidental finding of a pulmonary nodule in the left lower lobe when he was screened for a chest pain episode. Computed tomography of the brain showed a lacunar infarct in the lenticular nucleus and right periventricular white matter hypoattenuation related to possible ischemic disease. A thoracoabdominal computed tomographic scan showed an air cavity in the right lung apex, left apical pleural thickening, and a 1.1-cm nodule with homogeneous attenuation in the apical segment of the left lower lobe with spiculated margins and adhesions to adjacent pleura. There was no evidence of pleural effusion, the upper abdomen was unremarkable, and no notable mediastinal lymphadenopathy was detected. Spirometry showed a predicted forced expiratory volume in 1 second of 84% (2,250 mL/s), and a predicted forced vital capacity of 105% (3,740 mL). Positron emission tomography showed an apparently malignant pulmonary
Accepted for publication June 3, 2013. Address correspondence to Dr Arango Tom as, Division of Thoracic Surgery and Lung Transplantation, Reina Sofía University Hospital, Avda Menendez Pidal s/n, 14004 C ordoba, Spain; e-mail: eli_piano@hotmail. com.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.129
FEATURE ARTICLES
contamination; only sparse air bubbles were seen, which alerted us to the injury. Lessons can be learned from the management of acute tracheal injury secondary to trauma. Operative management with direct suture repair has been recommended [6]. However, more recent reports show that conservative treatment is an acceptable alternative in selected cases; this approach consists of broad-spectrum antibiotics with clinical observation [7]. We elected to wait 4 days to extubate primarily and allow more time for healing. The trachea was not directly repaired because it was very fragile and calcified and could not hold sutures to approximate the defect. Whether we could have extubated successfully on the day of the operation is unclear, but we thought it was best to wait several days for healing to occur. Creagh-Brown and coworkers [8] showed that tracheal stenting can be used to repair a tracheal tear. We were prepared to proceed with this option in our patient as an alternative to open surgical repair, which could have resulted in significant morbidity and mortality. Although stenting would not have prevented bacterial contamination that could have already occurred, because the small defect was similar to a small lung injury we believe that preventing any additional tearing and sealing the defect with a stent would have been sufficient. Our case report demonstrates that a small iatrogenic tracheal injury during a cardiac surgical procedure can be successfully managed with soft tissue coverage alone. The original planned cardiac operation can then be performed because of minimal potential contamination of the operative field. It is unclear if extended intubation was necessary. Having a backup plan for tracheal stenting was imperative in case signs of a persistent tracheal defect developed.
1427
1428
~ ET AL CASE REPORT CEREZO MADUENO PERIAREOLAR APPROACH FOR VATS LOBECTOMY
Ann Thorac Surg 2014;97:1427–9
FEATURE ARTICLES
Fig 1. (A) Patient positioning. (B) External periareolar incision closed with interrupted Ethibond 5-0 sutures and drainage through the camera port.
lesion in the upper segment of the left lower lobe, but no other pathologic findings. A bronchogenic carcinoma was suspected, but as it was not possible to rule out an inflammatory infectious disease we elected to perform diagnostic therapeutic surgery. The procedure was performed under general anesthesia with selective endotracheal intubation, with the patient in the right lateral decubitus position to enable a video-assisted thoracoscopic surgery approach using a left external periareolar incision encompassing 50% of the circumference of the areola (superolateral and inferolateral quadrants). A camera port was placed at the seventh intercostal space in the anterior axillary line (Fig 1). We introduced a 10-mm, 120-degree angle thoracoscope through this port, and the instruments were inserted through the periareolar incision. Posterior
pleuropulmonary adhesions at the level of segment six were separated. After palpation of segment six, the presence of a nodule was confirmed, and a wedge resection was performed for intraoperative biopsy. The pathologist diagnosed adenocarcinoma of the lung, and we therefore proceeded to perform a lobectomy. After releasing the pulmonary ligament, we dissected and divided the structures of the left lower lobe. The resection was performed through the periareolar port using the following instruments: ring forceps for retraction of the parenchyma; Ligasure (Covidien, Mansfield, MA), dissector, swabs, and device suction probe for dissection; curved hemostatic forceps to pass sutures; and an intestinal clamp to flatten and define the parenchyma to be stapled. We began with the left inferior pulmonary vein, which was directly visualized after cranial lobe retraction and release of the pulmonary ligament. Dissection in the upper part was from anterior to posterior, fixing with 2-0 thread, and division was completed with a vascular endostapler. We continued with the left lower lobe bronchus, which after dissection and subsequent release we transected with an endostapler. We then opened the fissure with a parenchymal endostapler, the artery with a vascular endostapler, and completed the rest of the fissure with a parenchymal endostapler. The Ligasure and suction device were used for the lymphadenectomy. The lobe was extracted after expanding the camera port, through which a single 28F chest drain was placed. The areola was closed using interrupted U-shaped Ethibond 5-0 sutures (Ethicon, Somerville, NJ). The chest tube was removed at 72 hours. The postoperative course was uneventful, and the patient was discharged on the third postoperative day. Definitive histologic examination confirmed pulmonary adenocarcinoma.
Comment Currently no standard technique exists for the videothoracoscopic approach, and the trend is toward smaller incisions and fewer ports. Periareolar incisions are commonly used by general surgeons for breast tumor biopsies and by plastic surgeons for extensive subcutaneous dissection to access most of the anterior chest wall, with excellent tissue healing and minimal scarring [1, 2]. Reports exist of some thoracic surgeons using this approach to perform sympathectomies [3], mediastinoscopies [4], and
Table 1. Initial Experience With Periareolar Approach
Type of Resection
N
Sex
Specimen Removed Through Periareolar Wound
Lobectomy
3
Males
1/3
Sublobar resection Bullectomy and pleurodesis Mediastinal tumors resection
2 3 3
Males Males Males
All All All
Complications
Mean Stay (days)
Subcutaneous emphysema No No No
2 1 1 1
recently to correct pectus [5]. In our department we have used this approach for mediastinal tumors, and others have performed minor pulmonary resections with excellent results (Table 1). However, this technique has not been previously reported as an option for major pulmonary resections. As described in this paper, a periareolar incision up to 60% of the circumference of the areola can be made without damaging the tissues. This method provides a direct approach to the pulmonary hilum and easy access owing to the elasticity of the skin covering the chest and the motility of the gland. Furthermore, access through the anterior thorax enables wide separation and distensibility of the rib arches, whereas in the posterior thorax the ribs are more horizontal, rigid, and closer together. Thus, the mammary approach allows insertion of several instruments without discomfort to the surgeon and with no intercostal neurovascular compression in comparison with other minimally invasive techniques. In some cases, we used the main periareolar wound to remove the resected lobe, but our experience is only when we performed an intraoperative biopsy of the nodule and then we resected the remaining lobe. The sensitivity of the nipple and areola is preserved, usually transmitted through the fourth intercostal nerve with lateral extension to the breast, and in our technique, originally designed for men, the skin incision in the lateral quadrant of the areola gives access to the third intercostal space without affecting breast innervation. A reported disadvantage in plastic surgery is the increased risk of infection of breast implants as a result of the number of bacteria that colonize the area, although in our case there was no infection or other complication. Our experience on this approach is only for male patients up to now. For women we prefer to use a perimammary approach, and we are collecting these cases, too. The periareolar incision for major lung resection not only offers easy access and satisfactory aesthetic results with respect to classical incisions but is also a technique without difficulty for the surgeon. The wider breadth and greater elasticity of the costal arches in the anterior thoracic region permit insertion of instruments into the chest in a manner that is not uncomfortable or limited, as in other minimally invasive techniques.
References 1. Salgado CJ, Mardini S. Periareolar approach for the correction of congenital symmastia. Plast Reconstr Surg 2004;113:992–4. 2. Amanti C, Regolo L, Moscaroli A, Lo Russo M, Catracchia V. Total periareolar approach in breast-conserving surgery [in Italian] Tumori 2003;89(4 Suppl):169–72. 3. Kesler KA, Brooks-Brunn JA, Campbell RL, Brown JW. Thoracoscopic sympathectomy for hyperhidrosis palmaris: a periareolar approach. Ann Thorac Surg 2000;70:314–7. 4. Tabet GS, Kassabian EB, Rohayem JN, Jebara VA. Periareolar mediastinoscopy: a new technique. Ann Thorac Surg 2002;73: 1335–6. 5. P erez D, Cano JR, Quevedo S, L opez L. New minimally invasive technique for correction of pectus carinatum. Eur J Cardiothorac Surg 2011;39:271–3. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
CASE REPORT WATANABE ET AL LOBAR TRANSPLANT AND PULMONARY ARTERY BANDING
1429
Contralateral Pulmonary Artery Banding After Single Lobar Lung Transplantation Tatsuaki Watanabe, MD, Yoshinori Okada, MD, Osamu Adachi, MD, Tetsu Sado, MD, Hiroaki Toyama, MD, Masafumi Noda, MD, Yasushi Hoshikawa, MD, Hisashi Oishi, MD, Yoji Sasahara, MD, Yoshikatsu Saiki, MD, and Takashi Kondo, MD Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Departments of Cardiovascular Surgery and Pediatrics, Tohoku University Graduate School of Medicine, and Department of Anesthesiology, Tohoku University Hospital, Sendai, Japan
A 14-year-old female patient underwent right single living-donor lobar lung transplantation for bronchiolitis obliterans after bone marrow transplantation. The patient experienced a complication with severe hypoxemia requiring venovenous extracorporeal membrane oxygenation, which appeared to result from significant ventilation–perfusion mismatch caused by preferential ventilation of the transplanted lobe and relatively preserved perfusion to the native lung. On day 2, we performed left pulmonary artery banding, which significantly improved oxygenation leading to weaning from extracorporeal membrane oxygenation. Our experience indicates that contralateral pulmonary artery banding may be a feasible option to rescue patients from hypoxemia resulting from ventilation–perfusion mismatch after single living-donor lobar lung transplantation. (Ann Thorac Surg 2014;97:1429–31) Ó 2014 by The Society of Thoracic Surgeons
L
ung transplantation has been established as a lifesaving treatment for adult and pediatric patients with end-stage lung diseases. Bilateral [1] or single [2] living-donor lobar lung transplantation (LDLLT) is an alternative to lung transplantation with cadaveric donors, especially for patients with rapidly deteriorating respiratory dysfunction. The present report illustrates a unique postoperative course of a pediatric patient who showed severe hypoxemia on the basis of ventilation–perfusion mismatch after single LDLLT. The patient required venovenous extracorporeal membrane oxygenation (ECMO) after the operation, and was successfully weaned off ECMO by contralateral pulmonary artery banding (PAB). A 4-month-old female patient was diagnosed with Diamond-Blackfan anemia. She underwent bone marrow Accepted for publication July 1, 2013. Address correspondence to Dr Okada, Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryomachi, Aoba-ku, Sendai, 980-8575, Japan; e-mail: yokada@idac. tohoku.ac.jp.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.07.030
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1429–31
Ann Thorac Surg 2014;97:1427–9
References 1. Takanami I. Tracheal laceration: A rare complication of median sternotomy. J Thorac Cardiovasc Surg 2001;122:184. 2. Choudhury A, Makhija N, Kiran U. Tracheal injury causing massive air leak during mitral valve replacement surgery. Ann Card Anaesth 2012;15:171–2. 3. Cardillo G, Carbone L, Carleo F, et al. Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment. Eur J Cardiothorac Surg 2010;37:581–7. 4. Lehr EJ, van Wagenberg FS, Haque R, et al. Robotic total endoscopic coronary artery bypass hybrid revascularization in a patient with a preoperative tracheostoma. Interac Cardiovasc Thorac Surg 2011;12:878–80. 5. Ngaage DL, Cale AR, Griffin S, et al. Is post-sternotomy percutaneous dilatational tracheostomy a predictor for sternal wound infections? Eur J Cardiothorac Surg 2008;33: 1076–81. 6. Cassada DC, Munyikwa MP, Moniz MP, et al. Acute injuries of the trachea and major bronchi: importance of early diagnosis. Ann Thorac Surg 2000;69:1563–7. 7. Carretta A, Melloni G, Bandiera A, et al. Conservative and surgical treatment of acute posttraumatic tracheobronchial injuries. World J Surg 2011;35:2568–74. 8. Creagh-Brown B, Sheath A, Crerar-Gilbert A, et al. A novel approach to the management of acute tracheal tear. J Laryngol Otol 2008;122:1392–3. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Periareolar Approach for Thoracoscopic Lobectomy Francisco Cerezo Madue~ no, MD, Elisabet Arango Tom as, MD, Francisco Javier Algar Algar, MD, and Angel Salvatierra Vel azquez, PhD General Thoracic Surgery and Lung Transplantation Unit, Reina Sofía University Hospital, C ordoba, Spain
In recent years advances in video-assisted thoracoscopic surgery have been aimed at reducing the number of video surgery ports, and especially major lung resections pose the greatest challenge. We describe a new minimally invasive as well as aesthetic approach for thoracoscopic lobectomy. The technique poses no difficulty for the surgeon and has certain advantages over other videothoracoscopic approaches. (Ann Thorac Surg 2014;97:1427–9) Ó 2014 by The Society of Thoracic Surgeons
M
inimally invasive surgical techniques are gaining ground over conventional open thoracic surgery. Major lung resections pose the greatest challenge, and in recent years advances in video-assisted thoracoscopic surgery have been aimed at reducing the number of video surgery ports. We describe a new minimally invasive as well as aesthetic approach for thoracoscopic lobectomy. The technique poses no difficulty for the surgeon and has certain advantages over other videothoracoscopic approaches. A 53-year-old former smoker with a 60-pack-year history was studied for an incidental finding of a pulmonary nodule in the left lower lobe when he was screened for a chest pain episode. Computed tomography of the brain showed a lacunar infarct in the lenticular nucleus and right periventricular white matter hypoattenuation related to possible ischemic disease. A thoracoabdominal computed tomographic scan showed an air cavity in the right lung apex, left apical pleural thickening, and a 1.1-cm nodule with homogeneous attenuation in the apical segment of the left lower lobe with spiculated margins and adhesions to adjacent pleura. There was no evidence of pleural effusion, the upper abdomen was unremarkable, and no notable mediastinal lymphadenopathy was detected. Spirometry showed a predicted forced expiratory volume in 1 second of 84% (2,250 mL/s), and a predicted forced vital capacity of 105% (3,740 mL). Positron emission tomography showed an apparently malignant pulmonary
Accepted for publication June 3, 2013. Address correspondence to Dr Arango Tom as, Division of Thoracic Surgery and Lung Transplantation, Reina Sofía University Hospital, Avda Menendez Pidal s/n, 14004 C ordoba, Spain; e-mail: eli_piano@hotmail. com.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.129
FEATURE ARTICLES
contamination; only sparse air bubbles were seen, which alerted us to the injury. Lessons can be learned from the management of acute tracheal injury secondary to trauma. Operative management with direct suture repair has been recommended [6]. However, more recent reports show that conservative treatment is an acceptable alternative in selected cases; this approach consists of broad-spectrum antibiotics with clinical observation [7]. We elected to wait 4 days to extubate primarily and allow more time for healing. The trachea was not directly repaired because it was very fragile and calcified and could not hold sutures to approximate the defect. Whether we could have extubated successfully on the day of the operation is unclear, but we thought it was best to wait several days for healing to occur. Creagh-Brown and coworkers [8] showed that tracheal stenting can be used to repair a tracheal tear. We were prepared to proceed with this option in our patient as an alternative to open surgical repair, which could have resulted in significant morbidity and mortality. Although stenting would not have prevented bacterial contamination that could have already occurred, because the small defect was similar to a small lung injury we believe that preventing any additional tearing and sealing the defect with a stent would have been sufficient. Our case report demonstrates that a small iatrogenic tracheal injury during a cardiac surgical procedure can be successfully managed with soft tissue coverage alone. The original planned cardiac operation can then be performed because of minimal potential contamination of the operative field. It is unclear if extended intubation was necessary. Having a backup plan for tracheal stenting was imperative in case signs of a persistent tracheal defect developed.
1427
1428
~ ET AL CASE REPORT CEREZO MADUENO PERIAREOLAR APPROACH FOR VATS LOBECTOMY
Ann Thorac Surg 2014;97:1427–9
FEATURE ARTICLES
Fig 1. (A) Patient positioning. (B) External periareolar incision closed with interrupted Ethibond 5-0 sutures and drainage through the camera port.
lesion in the upper segment of the left lower lobe, but no other pathologic findings. A bronchogenic carcinoma was suspected, but as it was not possible to rule out an inflammatory infectious disease we elected to perform diagnostic therapeutic surgery. The procedure was performed under general anesthesia with selective endotracheal intubation, with the patient in the right lateral decubitus position to enable a video-assisted thoracoscopic surgery approach using a left external periareolar incision encompassing 50% of the circumference of the areola (superolateral and inferolateral quadrants). A camera port was placed at the seventh intercostal space in the anterior axillary line (Fig 1). We introduced a 10-mm, 120-degree angle thoracoscope through this port, and the instruments were inserted through the periareolar incision. Posterior
pleuropulmonary adhesions at the level of segment six were separated. After palpation of segment six, the presence of a nodule was confirmed, and a wedge resection was performed for intraoperative biopsy. The pathologist diagnosed adenocarcinoma of the lung, and we therefore proceeded to perform a lobectomy. After releasing the pulmonary ligament, we dissected and divided the structures of the left lower lobe. The resection was performed through the periareolar port using the following instruments: ring forceps for retraction of the parenchyma; Ligasure (Covidien, Mansfield, MA), dissector, swabs, and device suction probe for dissection; curved hemostatic forceps to pass sutures; and an intestinal clamp to flatten and define the parenchyma to be stapled. We began with the left inferior pulmonary vein, which was directly visualized after cranial lobe retraction and release of the pulmonary ligament. Dissection in the upper part was from anterior to posterior, fixing with 2-0 thread, and division was completed with a vascular endostapler. We continued with the left lower lobe bronchus, which after dissection and subsequent release we transected with an endostapler. We then opened the fissure with a parenchymal endostapler, the artery with a vascular endostapler, and completed the rest of the fissure with a parenchymal endostapler. The Ligasure and suction device were used for the lymphadenectomy. The lobe was extracted after expanding the camera port, through which a single 28F chest drain was placed. The areola was closed using interrupted U-shaped Ethibond 5-0 sutures (Ethicon, Somerville, NJ). The chest tube was removed at 72 hours. The postoperative course was uneventful, and the patient was discharged on the third postoperative day. Definitive histologic examination confirmed pulmonary adenocarcinoma.
Comment Currently no standard technique exists for the videothoracoscopic approach, and the trend is toward smaller incisions and fewer ports. Periareolar incisions are commonly used by general surgeons for breast tumor biopsies and by plastic surgeons for extensive subcutaneous dissection to access most of the anterior chest wall, with excellent tissue healing and minimal scarring [1, 2]. Reports exist of some thoracic surgeons using this approach to perform sympathectomies [3], mediastinoscopies [4], and
Table 1. Initial Experience With Periareolar Approach
Type of Resection
N
Sex
Specimen Removed Through Periareolar Wound
Lobectomy
3
Males
1/3
Sublobar resection Bullectomy and pleurodesis Mediastinal tumors resection
2 3 3
Males Males Males
All All All
Complications
Mean Stay (days)
Subcutaneous emphysema No No No
2 1 1 1
recently to correct pectus [5]. In our department we have used this approach for mediastinal tumors, and others have performed minor pulmonary resections with excellent results (Table 1). However, this technique has not been previously reported as an option for major pulmonary resections. As described in this paper, a periareolar incision up to 60% of the circumference of the areola can be made without damaging the tissues. This method provides a direct approach to the pulmonary hilum and easy access owing to the elasticity of the skin covering the chest and the motility of the gland. Furthermore, access through the anterior thorax enables wide separation and distensibility of the rib arches, whereas in the posterior thorax the ribs are more horizontal, rigid, and closer together. Thus, the mammary approach allows insertion of several instruments without discomfort to the surgeon and with no intercostal neurovascular compression in comparison with other minimally invasive techniques. In some cases, we used the main periareolar wound to remove the resected lobe, but our experience is only when we performed an intraoperative biopsy of the nodule and then we resected the remaining lobe. The sensitivity of the nipple and areola is preserved, usually transmitted through the fourth intercostal nerve with lateral extension to the breast, and in our technique, originally designed for men, the skin incision in the lateral quadrant of the areola gives access to the third intercostal space without affecting breast innervation. A reported disadvantage in plastic surgery is the increased risk of infection of breast implants as a result of the number of bacteria that colonize the area, although in our case there was no infection or other complication. Our experience on this approach is only for male patients up to now. For women we prefer to use a perimammary approach, and we are collecting these cases, too. The periareolar incision for major lung resection not only offers easy access and satisfactory aesthetic results with respect to classical incisions but is also a technique without difficulty for the surgeon. The wider breadth and greater elasticity of the costal arches in the anterior thoracic region permit insertion of instruments into the chest in a manner that is not uncomfortable or limited, as in other minimally invasive techniques.
References 1. Salgado CJ, Mardini S. Periareolar approach for the correction of congenital symmastia. Plast Reconstr Surg 2004;113:992–4. 2. Amanti C, Regolo L, Moscaroli A, Lo Russo M, Catracchia V. Total periareolar approach in breast-conserving surgery [in Italian] Tumori 2003;89(4 Suppl):169–72. 3. Kesler KA, Brooks-Brunn JA, Campbell RL, Brown JW. Thoracoscopic sympathectomy for hyperhidrosis palmaris: a periareolar approach. Ann Thorac Surg 2000;70:314–7. 4. Tabet GS, Kassabian EB, Rohayem JN, Jebara VA. Periareolar mediastinoscopy: a new technique. Ann Thorac Surg 2002;73: 1335–6. 5. P erez D, Cano JR, Quevedo S, L opez L. New minimally invasive technique for correction of pectus carinatum. Eur J Cardiothorac Surg 2011;39:271–3. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
CASE REPORT WATANABE ET AL LOBAR TRANSPLANT AND PULMONARY ARTERY BANDING
1429
Contralateral Pulmonary Artery Banding After Single Lobar Lung Transplantation Tatsuaki Watanabe, MD, Yoshinori Okada, MD, Osamu Adachi, MD, Tetsu Sado, MD, Hiroaki Toyama, MD, Masafumi Noda, MD, Yasushi Hoshikawa, MD, Hisashi Oishi, MD, Yoji Sasahara, MD, Yoshikatsu Saiki, MD, and Takashi Kondo, MD Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Departments of Cardiovascular Surgery and Pediatrics, Tohoku University Graduate School of Medicine, and Department of Anesthesiology, Tohoku University Hospital, Sendai, Japan
A 14-year-old female patient underwent right single living-donor lobar lung transplantation for bronchiolitis obliterans after bone marrow transplantation. The patient experienced a complication with severe hypoxemia requiring venovenous extracorporeal membrane oxygenation, which appeared to result from significant ventilation–perfusion mismatch caused by preferential ventilation of the transplanted lobe and relatively preserved perfusion to the native lung. On day 2, we performed left pulmonary artery banding, which significantly improved oxygenation leading to weaning from extracorporeal membrane oxygenation. Our experience indicates that contralateral pulmonary artery banding may be a feasible option to rescue patients from hypoxemia resulting from ventilation–perfusion mismatch after single living-donor lobar lung transplantation. (Ann Thorac Surg 2014;97:1429–31) Ó 2014 by The Society of Thoracic Surgeons
L
ung transplantation has been established as a lifesaving treatment for adult and pediatric patients with end-stage lung diseases. Bilateral [1] or single [2] living-donor lobar lung transplantation (LDLLT) is an alternative to lung transplantation with cadaveric donors, especially for patients with rapidly deteriorating respiratory dysfunction. The present report illustrates a unique postoperative course of a pediatric patient who showed severe hypoxemia on the basis of ventilation–perfusion mismatch after single LDLLT. The patient required venovenous extracorporeal membrane oxygenation (ECMO) after the operation, and was successfully weaned off ECMO by contralateral pulmonary artery banding (PAB). A 4-month-old female patient was diagnosed with Diamond-Blackfan anemia. She underwent bone marrow Accepted for publication July 1, 2013. Address correspondence to Dr Okada, Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryomachi, Aoba-ku, Sendai, 980-8575, Japan; e-mail: yokada@idac. tohoku.ac.jp.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.07.030
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1429–31
