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References

the lymphadenectomy sample (ypT2a N2 M0, stage IIIA non-small cell lung carcinoma, squamous cell carcinoma). All margins were uninvolved by tumor (R0 resection). He subsequently completed adjuvant chemotherapy and radiotherapy.

Comment Secondary spontaneous pneumothorax has been previously described as an initial presentation of lung cancer [1, 2] and is, unfortunately, associated with poor survival [3]. Current treatment options for persistent air leaks often involve prolonged tube thoracostomy drainage, pleurodesis, and surgical repair; however, these may preclude or complicate subsequent potentially curative surgical resection [4, 5] as well as significantly delay initiation of oncologic care. We present the first reported use of endobronchial valves in the setting of pneumothorax related to primary lung carcinoma used as a means to avoid pleurodesis and prolonged hospitalization. Endobronchial valves are currently approved by the United States Food and Drug Administration as a humanitarian use device in the setting of persistent air leak after pulmonary resection. In addition, numerous case reports exist for their use in etiologies of persistent air leak, including bronchopleural fistula causing empyema [6], spontaneous pneumothorax [7], and as a bridge for lung transplantation [8]. Our multidisciplinary thoracic oncology team pursued endobronchial valve placement in this patient with secondary spontaneous pneumothorax from stage IIIA nonsmall cell lung carcinoma and a prolonged air leak. This strategy allowed for a minimally invasive method to expedite resolution of his air leak, permit earlier hospital discharge, and preserve the integrity of the pleural space in anticipation of providing a safer surgical resection after neoadjuvant therapy. Ó 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc

Right Lower Lobectomy With Middle Lobe Preservation After Right Upper Lobectomy in Lung Cancer of the Right Lower Lobe Naohiro Taira, MD, Tsutomu Kawabata, MD, PhD, Atsushi Gabe, MD, Takaharu Ichi, MD, Kazuaki Kushi, MD, Tomofumi Yohena, MD, PhD, Hidenori Kawasaki, MD, PhD, and Kiyoshi Ishikawa, MD, PhD Department of General Surgery, National Hospital Organization, Okinawa Hospital, and Department of General Surgery, Okinawa Hokubu Hospital, Okinawa, Japan

A 73-year-old woman who underwent right upper lobectomy for tuberculosis 40 years earlier was diagnosed with adenocarcinoma, clinical stage IIA (T2bN0M0), in the right lower lobe of her lung. A lower lobectomy with preservation of the middle lobe was performed. The patient had an uneventful recovery. She is alive without signs of recurrence or requirement for additional oxygen support 6 years after the operation. (Ann Thorac Surg 2013;96:2227–30) Ó 2013 by The Society of Thoracic Surgeons

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eports of right upper and lower lobectomy with preservation of the middle lobe are rare because of the risk of middle lobe torsion or emphysematous change. We describe a good outcome in a case of

Accepted for publication Jan 28, 2013. Address correspondence to Dr Taira, Department of General Surgery, National Health Organization, Okinawa Hospital, Ganeko, Ginowan City, Okinawa 9012214, Japan; e-mail: [email protected].

0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.01.100

FEATURE ARTICLES

Fig 3. Bronchoscopic view shows the anterior segment of the right upper lobe at time of removal. Endobronchial valves are identified occluding the subsegment orifices of the right upper lobe (arrows).

1. Mawatari T, Watanabe A, Ohsawa H, Fujisawa Y, Abe T. Multiple pleural destruction due to pleural dissemination of pulmonary carcinoma originating from pneumothorax. Ann Thorac Surg 2005;79:716. 2. Vencevicius V, Cicenas S. Spontaneous pneumothorax as a first sign of pulmonary carcinoma. World J Surg Oncol 2009; 7:57. 3. Steinhauslin CA, Cuttat JF. Spontaneous pneumothorax. A complication of lung cancer? Chest 1985;88:709–13. 4. Brunelli A, Monteverde M, Borri A, Salati M, Marasco RD, Fianchini A. Predictors of prolonged air leak after pulmonary lobectomy. Ann Thorac Surg 2004;77:1205–10. 5. Yim AP, Liu HP, Hazelrigg SR, et al. Thoracoscopic operations on reoperated chests. Ann Thorac Surg 1998;65:328–30. 6. Feller-Kopman D, Bechara R, Garland R, Ernst A, Ashiku S. Use of a removable endobronchial valve for the treatment of bronchopleural fistula. Chest 2006;130:273–5. 7. Travaline JM, McKenna RJ Jr, De Giacomo T, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest 2009;136:355–60. 8. Fischer W, Feller-Kopman D, Shah A, Orens J, Illei P, Yarmus L. Endobronchial valve therapy for pneumothorax as a bridge to lung transplantation. J Heart Lung Transplant 2012;31:334–6.

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Ann Thorac Surg 2013;96:2227–30

Fig 1. (A) Roentgenogram shows an abnormal shadow in right lower lobe. (B) Chest computed tomographic scan shows solid mass in right lower lobe with no significant mediastinal lymphadenopathy.

lobectomy with preservation of the middle lobe for lung adenocarcinoma in the right lower lobe after initial right upper lobectomy. FEATURE ARTICLES

Fig 2. Preserved forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and percent vital capacity (VC) after right upper and lower lobectomy were 1770 mL, 1390 mL, and 89%, respectively. They were more than quantitative predictions of the preoperative respiratory function. Perfusion scintigraphy of preserved middle lobe showed 12.1% of residual respiratory function.

A 73-year-old woman who underwent right upper lobectomy for lung tuberculosis 40 years earlier was referred to our hospital for an abnormal shadow on chest

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roentgenography (Fig 1A). Contrast media–enhanced computed tomography revealed an 80-  72-mm mass in the right lower lobe with no significant mediastinal lymphadenopathy (Fig 1B). Adenocarcinoma was diagnosed by transbronchial lung biopsy results. The clinical stage was determined as stage IIA T2bN0M0. Preoperative forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were 2620 mL and 1980 mL, respectively. We evaluated predicted respiratory function after completion pneumonectomy by using perfusion scintigraphy . Predicted FVC and FEV1 after completion pneumonectomy were 1640 mL and 950 mL, respectively. We planned the operation (pneumonectomy or lower lobectomy) based on intraoperative findings. Intraoperatively, adhesion of the lower lobe to the chest wall was easily detached. The compensatory hypertrophy of the middle lobe was seen, and it was also adherent to the chest wall and served to prevent middle lobe torsion. Therefore, lower lobectomy with preservation of the middle lobe was performed. There were no intraoperative problems, and the patient had an uneventful recovery. The final staging of the tumor was stage IIA T2N0M0. Postoperative FVC and FEV1 were 1770 mL and 1390 mL, respectively. Perfusion scintigraphy showed 12.1% for the preserved middle lobe (Fig 2) and no ventilationperfusion mismatch. Respiratory function after right upper and lower lobectomies was preserved more than we predicted. Chest roentgenography and chest computed tomographic imaging after the preservation of the middle lobe showed adequate volume without emphysematous change (Fig 3). The patient is alive uneventfully without signs of recurrence or requirement for additional oxygen support 6 years after the operation.

Comment When an operable lung cancer in the right lower lobe is identified in a patient who has undergone previous

right upper lobectomy, the operative method consists of 2 options: pneumonectomy or lobectomy with middle lobe preservation. Pneumonectomy is associated with a number of potential complications that involve the respiratory and cardiovascular systems. Gugginoa and colleagues [1] described postoperative respiratory insufficiency after completion pneumonectomy in 26.3% of patients with lung cancer and reported operative mor-tality rates of 0% to 17.6% for cancer from several institutions. On the other hand, preservation of the middle lobe in the absence of the upper and lower lobes may produce torsion [2]. Also, emphysematous changes in the residual middle lobe may be induced because of volume mismatch in the middle lobe and thoracic cavity during follow-up. However, preserving the middle lobe contributes to postoperative lung function [3, 4]. Therefore, the treatment of choice depends on the intraoperative findings. In our patient, the middle lobe adhesions to the chest wall were not removed to prevent torsion. Furthermore, the postoperative shift of the mediastinum to the right occurred because fortunately there was sufficient elasticity of the chest wall and mobility within the mediastinum to allow for the shift to the right after right upper lobectomy for tuberculosis. This eliminated a persistent pleural space and sequelae such as empyema. We believe that this led to the good outcome of our case. In conclusion, right lower lobectomy after right upper lobectomy with preservation of the middle lobe is possible. It is worth preserving the middle lobe.

References 1. Gugginoa G, Doddolia C, Barlesi F, et al. Completion pneumonectomy in cancer patients: experience with 55 cases. Eur J Cardiothorac Surg 2004;25:449–55. 2. Cable D, Deschamps C, Allen M, et al. Lobar torsion after pulmonary resection: presentation and outcome. J Thorac Cardiovasc Surg 2001;122:1091–3. 3. Iwata H, Kiryu T, Shirahashi K, Matsumoto S, Matsui M, Takemura H. Right lower lobectomy after right upper lobectomy for multiple metastases in lung cancer of the right lower

FEATURE ARTICLES

Fig 3. (A) Chest roentgenogram and (B) chest computed tomographic image taken 6 years after middle lobe preservation showed adequate volume without emphysematous change in middle lobe and shift of mediastinum to right.

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lobe: benefit of middle lobe preservation. J Thorac Cardiovasc Surg 2007;134:1078–80. 4. Kataoka K, Fujiwara T, Matsuura M, Seno N. An octogenarian case of multiple primary lung cancers undergoing right upper lobectomy after right lower lobectomy with preservation of the middle lobe. Jpn J Lung Cancer 2009;49:472–6.

Semiautologous Repair for Congenital Discontinuous Right Pulmonary Artery Ahmad Y. El-Hattab, BS, Domenico Calcaterra, MD, PhD, Kalpaj R. Parekh, MD, Nicholas P. Rossi, MD, James E. Davis, MD, and Joseph W. Turek, MD, PhD Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and Department of Cardiovascular Surgery, Indiana University Health, Indianapolis, Indiana

FEATURE ARTICLES

Unilateral absence of a proximal pulmonary artery (UAPA) is rare and occurs in an isolated form or in the presence of other cardiovascular anomalies. There is a paucity of literature describing surgical correction of this anomaly. Most commonly, a primary anastomosis between the main and proximal right pulmonary arteries has been described. However, in cases of long-gap discontinuity, this can be difficult and may result in excess tension on the anastomosis, predisposing to decreased patency. We present a novel technique by which discontinuity in the right pulmonary artery (RPA) is surgically corrected in a semiautologous fashion using a main pulmonary artery (MPA) flap. (Ann Thorac Surg 2013;96:2230–1) Ó 2013 by The Society of Thoracic Surgeons

U

nilateral absence of a proximal pulmonary artery (UAPA) is rare and occurs in an isolated form or in the presence of other cardiovascular anomalies [1–4]. There is a paucity of literature describing surgical correction of this anomaly. Most commonly, a primary anastomosis between the main pulmonary artery (MPA) and the right pulmonary artery (RPA) has been described. However, in cases of long-gap discontinuity, this can be difficult and may result in excess tension on the anastomosis, predisposing to decreased patency. We present a novel technique by which discontinuity in the RPA is surgically corrected in a semiautologous fashion using an MPA flap. A newborn boy born at 34 weeks’ gestation was referred for consultation regarding a murmur and a gallop. An echocardiogram revealed a distal RPA originating from a

Accepted for publication Feb 6, 2013. Address correspondence to Dr Turek, University of Iowa Hospitals and Clinics, University of Iowa Children’s Hospital, 200 Hawkins Dr, SE 538 GH, Iowa City, IA 52242-1062; e-mail: [email protected].

Ó 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc

Ann Thorac Surg 2013;96:2230–1

closed right-sided ductus arteriosus arising from the innominate artery (Fig 1A, 1B). He had significant right ventricular hypertension that resolved with oxygen therapy. The ductus was opened with prostaglandins, and stenting was attempted to maintain patency. This resulted in ductal dissection, necessitating ductal coiling. He remained under close surveillance until an operation was performed at 3 months of age. Repeated echocardiograms, roentgenograms, and oxygen treatment composed followup efforts to ensure patency of intrapulmonary vessels. Operatively, the innominate artery was dissected out, and the origin of the right ductus was visualized. The distal RPA was visualized posterior and medial to the superior vena cava. The RPA was mobilized circumferentially and into the lung tissue distal to the second order of branching (Fig 2A). For cardiopulmonary bypass, arterial and single venous cannulation was performed, and a vent was inserted into the left ventricle through the right superior pulmonary vein. The operation was performed with a beating heart at only mild hypothermia (34 C). An extension flap was created using the anterior wall of the MPA, leaving it based on the right lateral aspect of the distal MPA (Fig 2A). The proximal incision for the flap terminated just superior to the sinotubular junction. The occluded right ductus was doubly clipped and then divided. The distal RPA was then opened and spatulated. The proximal posterior aspect of the neo-RPA was formed by suturing the flap to the distal opened RPA (Fig 2B). A thawed pulmonary homograft patch was cut into a “hockey stick” shape and used to augment the anterior aspect of the RPA and close the defect created in the MPA. The end result was a gentle curve that extended from the pulmonary valve to the RPA (Fig 2C). Postoperative catheterization at 11 months revealed an excellent angiographic result (Fig 1C). On 17-month follow-up, the RPA was echocardiographically patent, without any turbulent flow. The patient remains asymptomatic and is doing well.

Comment Congenital discontinuity of the RPA results from early involution of the sixth proximal aortic arch [2]. Consequently, the RPA is supplied by a ductal connection to the innominate artery but also receives contributions from bronchial arteries and systemic collaterals [2, 4]. Rightsided UAPA is more common, whereas left-sided UAPA is frequently associated with life-threatening cardiovascular malformations [1, 2]. By contrast, right-sided UAPA may remain asymptomatic until adulthood, with many diagnoses made from incidental findings. It is estimated that the prevalence of UAPA is 1 in 200,000, with only 12% being diagnosed in infancy [1]. Clinical features of right-sided UAPA are variable and may include pulmonary hypertension, recurrent pulmonary infections, congestive heart failure, and hemoptysis. Surgical intervention aims to restore physiologic circulation. Although early intervention has been advocated because of a concern for regression and hypoplasia of 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.02.057

Right lower lobectomy with middle lobe preservation after right upper lobectomy in lung cancer of the right lower lobe.

A 73-year-old woman who underwent right upper lobectomy for tuberculosis 40 years earlier was diagnosed with adenocarcinoma, clinical stage IIA (T2bN0...
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