Video-Assisted Thoracoscopic Surgery for Intralobar Pulmonary Sequestration: Wedge Resection Is Feasible in Limited Peripheral Lesions Zong-wu Lin1
1 Department of Thoracic Surgery, Zhongshan Hospital, Fudan
University, Shanghai, China
Address for correspondence Qun Wang, MD, Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China (e-mail: [email protected]
► lobectomy ► wedge resection ► intralobar pulmonary sequestration ► thoracoscopy/videoassisted thoracic surgery
Objectives Pulmonary sequestration is a rare developmental abnormality of the lower respiratory system. This study aimed to evaluate the effectiveness of wedge resection compared with lobectomy for the treatment of intralobar pulmonary sequestration. Methods Video-assisted thoracic surgery (VATS) for intralobar pulmonary sequestration was performed in 26 patients in our institute between December 2006 and January 2015. Data regarding patient demographics, major complaints, diagnostic procedures, operative treatment, and treatment outcome were retrospectively analyzed. Results VATS was performed successfully in all patients. Wedge resection was performed in 7 patients and lobectomy in 19 patients. Conversion to thoracotomy was not required in any case. Statistical analysis revealed that operation duration and blood loss with wedge resection were signiﬁcantly less than with lobectomy (p ¼ 0.032 and 0.014, respectively). No signiﬁcant differences were found in the mean drainage time, postoperative length of hospital stay, or complications. During our long-term follow-up, no patients had chronic cough, bloody sputum, or pneumonia. Conclusion VATS for intralobar pulmonary sequestration is feasible and safe. Lobectomy is the generally accepted operative method. However, wedge resection is a feasible alternative to lobectomy in select cases.
Introduction Pulmonary sequestration is a rare developmental abnormality of the lower respiratory system representing approximately 0.15 to 6.4% of all congenital pulmonary anomalies.1,2 It is characterized by a mass of nonfunctioning pulmonary tissue separated from the normal bronchopulmonary tree and receiving an aberrant systemic arterial supply from the descending aorta or its major branches. There are two types of pulmonary sequestration, depending on whether the malformation possesses its own pleural covering: intralobar pulmo-
received March 30, 2015 accepted after revision May 19, 2015
nary sequestration (IPS) is located within the normal pulmonary parenchyma without its own pleural covering, whereas extralobar pulmonary sequestration (EPS) is separated from the normal lung with its own pleural covering.3,4 Despite being a benign lesion, the associated complications, which include recurrent sepsis, hemoptysis, and congestive heart failure, can be serious.5–7 Increasing evidence indicates that thoracoscopic treatment of pulmonary sequestration is feasible, safe, and effective.8–12 Lobectomy by video-assisted thoracic surgery (VATS) is the generally accepted operative approach. However, given
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DOI http://dx.doi.org/ 10.1055/s-0035-1556820. ISSN 0171-6425.
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Thorac Cardiovasc Surg
Treatment for Pulmonary Sequestration
Lin et al.
that pulmonary sequestration is a benign disease, lobectomy may result in a loss of healthy lung tissue. Recently, a single case report and a small case series have shown thoracoscopic wedge resection might be a feasible alternative to lobectomy.8,13,14 However, because of limited cases of previous reports, wedge resection is not widely accepted. More reports that include long-term outcomes are needed. In the present study, we report a larger case series and evaluate two different approaches by VATS regarding feasibility, safety, complications, and long-term outcomes.
Materials and Methods Between December 2006 and January 2015, 26 patients (12 men, 14 women) underwent VATS for IPS in our institute. The median age was 38.5 years (range: 14–68 years). All patients provided written informed consent before the operation. Data were retrospectively collected from hospital charts regarding patient demographics, major complaints, diagnostic procedures, operative treatment, and treatment outcome. The median follow-up period was 46.6 months (range: 1–98 months). All patients underwent thoracic computed tomographic (CT) scan 1 year postoperatively. Patients’ demographics and discomfort were collected in the outpatient clinic.
Operative Technique Patients were placed in the lateral decubitus position under general anesthesia with single-lung ventilation provided by either a double- or a single-lumen endotracheal tube with a bronchial blocker. Thoracic epidural anesthesia was routinely used except in cases that were contraindicated. The surgeon stood at the patient’s back. Three ports were used, which is similar to our routine VATS lobectomy.15 The ﬁrst port for the thoracoscope was located at the eighth intercostal space (ICS) on the midaxillary line. The second port was positioned on the triangle of auscultation regardless of the ICS. The third port was 3 to 4 cm long and positioned on the ﬁfth or sixth ICS between the anterior axillary and midclavicular lines. With preoperatively diagnosed IPS, the inferior pulmonary ligament was dissected ﬁrst to allow identiﬁcation of the aberrant artery based on the location on the contrast-enhanced CT scan ( ►Fig. 1) or magnetic resonance imaging (MRI). Otherwise, a routine VATS lobectomy was performed. When congestion without anthracotic deposition on the lesion was observed during the operation, IPS was considered. The aberrant artery was dissected, closed, and cut with a stapling device. Afterward, a standard lobectomy or wedge resection was performed depending on the condition. Wedge resection was performed only when the CT scan showed that the lesion was restricted to the peripheral lung tissue, which was veriﬁed during the procedure.
Statistical Analysis Statistical analyses were performed with SPSS v11.0 software (SPSS, Inc., Chicago, Illinois, United States). Unless otherwise Thoracic and Cardiovascular Surgeon
Fig. 1 Reconstructed contrast-enhanced computed tomography (CT) showing the aberrant artery (arrow) originating from the descending aorta in intralobar pulmonary sequestration (IPS).
speciﬁed, continuous variables were expressed as mean standard deviation. Differences between the two groups were assessed using unpaired Student’s t-tests. All reported probability values are two-tailed, and p