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Triple reconstruction of pulmonary artery, superior vena cava and bronchus for lung cancer
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     Department of Thoracic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan

    Abstract

    We report on a case of a complete resection for bronchogenic carcinoma necessitating right upper sleeve lobectomy with prosthetic replacement of right pulmonary artery (PA) and superior vena cava (SVC). A 74-year-old male with squamous cell carcinoma had a tumor which extended to the right main bronchus, right PA and SVC. After reconstruction of the SVC with a ringed polytetrafluoroethylene (PTFE) graft between the left brachiocephalic vein (BCV) and right atrial auricle, the tumor was completely resected en bloc. Bronchial anastomosis followed by the prosthetic reconstructions of PA and SVC between the right BCV and the origin of SVC were performed. Pathological staging was t4n2m0 (stage IIIB). The postoperative course was uneventful and the patient discharged from the hospital on the 29th postoperative day. He has been doing well without recurrence and keeping a good graft patency for more than 3 years.

    Key Words: Prosthetic replacement; T4 lung cancer; Great vessels

    1. Introduction

    Central type of squamous cell carcinoma frequently invades the main bronchus or great vessels. Although locally advanced T4 tumor is still regarded as an unresectable disease due to requirement of extended resection and poor prognosis [1], extended resection with SVC reconstruction is feasible in selected patients [2]. We described a strategy for a right sleeve upper lobectomy combined with resection and reconstruction of PA and SVC utilizing ringed polytetrafluoroethylene (PTFE) grafts.

    A 74-year-old man with a bloody sputum and continuous cough of 5 months duration was referred to our hospital because of a mass shadow in the right upper lobe on chest X-ray. Chest computed tomography (CT) revealed that the mass of 80 mm in the maximum diameter was located in the S1 segment with invasion to the arch of the right PA (Fig. 1A) and a wide range of SVC between the conjunction of bilateral brachiocephalic veins (BCV) and the azygos vein (Fig. 1B). There was also a direct involvement of a pretracheal lymph node (LN#3) from the tumor. Bronchofiberscopy showed the complete obstruction of B1 subsegmental bronchus and direct tumor invasion to the second carina and the right main bronchus. Complete resection of the tumor was expected since there was only a single N2 lymph node involvement directly from the main tumor (c-T4N2M0, stage IIIB). Although neoadjuvant chemotherapy or chemo-radiotherapy has been reported as a survival benefit [3], postoperative morbidity is high. We thought that this operation was complicated and it might be at a critically high risk of morbidity after neoadjuvant therapy.

    The operation was performed on August 13, 2002. In the left lateral position, the postero-lateral thoracotomy was carried out for confirming the resectability of the tumor. As expected, the tumor invaded the lateral wall of SVC and the long distance of right PA to the origin of the segmental division for the middle lobe. Radical mediastinal lymph nodal dissection was performed and PA, superior pulmonary vein (PV), trachea and bronchi were dissected free from the surrounding tissue. Involvement of the SVC, right PA and second carina made it difficult to obtain a sufficient surgical access to the main stem of the right PA. Furthermore, a long SVC clamp time would be necessary for SVC reconstruction from the right hemi-thorax approach.

    After rough closure of the right chest wall, median sternotomy was performed in the supine position. The left BCV was separated and the right atrial auricule was clamped following intravenous injection of 5000 IU of sodium heparin. The ringed PTFE graft of 8 mm in diameter was interpositioned between the left BCV and the right atrial auricule by a running suture with 5/0 polypropylene. After the perfusion of venous flow in the graft, the right BCV and the origin of SVC were stapled, and the SVC was removed.

    Anterior chest wall was closed and the right hemi-thorax was reopened in the left lateral position. The right main bronchus and the truncus intermedius were amputated with enough margins, respectively. After clamping the PA, the PA was circumferentially resected along the tumor. The tumor resection was completed by upper sleeve lobectomy with SVC and PA resections.

    The airway anastomosis was performed by interrupted suture with 3/0 polypropylene. PA reconstruction was completed by the interposition of the ringed PTFE graft (10 mm in diameter) of 3 cm in length by running suture with 5/0 polypropylene. The ringed PTFE graft (10 mm in diameter) of 7 cm in length was used for SVC conduit between the right BCV and the origin of SVC (Fig. 2A).

    All excised margins were tested microscopically negative for malignancy. The defected pericardium was covered with a PTFE sheet of 0.1 mm thickness. The operative time was 10 h and 20 min and blood loss was 3240 g. As anticoagulation, continuous intravenous heparin was administered 10,000 U per day for 5 days, and switched and continued warfarin for 3 months. The postoperative course was uneventful. However, the patient took a long time to recover because of low cardiopulmonary function, and discharged from the hospital on the 29th postoperative day. Final pathological diagnosis was poorly differentiated squamous cell carcinoma and only lymph node #3 was positive for malignancy, p-t4n2m0 (stage IIIB). He has been fine with a good graft patency (Fig. 2B) and without recurrence for more than 3 years.

    2. Comment

    In this case, there were several issues on discussion, such as the operative indications, surgical strategies and the risk of morbidity as follows; (a) both T4 and N2 diseases are the main causes of incurable operation; (b) the approach into the thoracic cavity from two different directions may be an excessive surgical stress; (c) triple prosthetic reconstruction may lead to high risk of morbidity such as thrombosis and bleeding; and (d) simultaneous manipulation of bronchoplasty and the prosthetic grafting may induce a high risk of intra-thoracic contamination.

    The 5-year survival rate after curative operation for T4 lung cancer ranges from 12 to 29% [4,5]. Since there are few reports which show that neoadjuvant chemotherapy prolongs survival for T4 lung cancer, complete resection has a prognostic benefit for some selected T4 patients [6]. In N2 disease, only neoadjuvant chemotherapy has a beneficial effect on prognosis. However, single level mediastinal lymph node involvement has a favorable prognosis after surgery [7]. Therefore, we selected complete resection without neoadjuvant chemotherapy.

    Prosthetic vascular graft infection is one of the most critical complications. In lung cancer surgery, opening of the bronchial stump may have a risk of contamination by intra-bronchial bacteria. In particular, PA and SVC grafts exist adjacent to the bronchial anastomosis. Therefore, we attempted to isolate the left SVC graft from the right thoracic cavity, to shorten the exposure of the bronchial lumen, and to avoid the PA and right SVC graft implantations before bronchoplasty.

    The approach to the thoracic cavity from two different directions is a complicated procedure. If we had decided to perform a right pneumonectomy, we would have chosen a median sternotomy. However, since it was difficult to determine the cutting line of the bronchial stump, right upper sleeve lobectomy via median sternotomy alone was not appropriate. Right thoracotomy approach alone was not feasible, either. It was difficult to obtain a sufficient access for securing the central side of the right PA, and a long complete interception of central venous flow would have been necessary. Therefore, right thoracotomy was initially selected for confirming tumor extension, and median sternotomy was performed for securing the central venous flow by left SVC reconstruction. We believe these surgical techniques lead to safe and uneventful postoperative course.

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