ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Lewis, R. J.
Right arrow Articles by Spaggiari, L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Lewis, R. J.
Right arrow Articles by Spaggiari, L.

Ann Thorac Surg 1997;64:583-584
© 1997 The Society of Thoracic Surgeons

Correspondence

Pulmonary Resection After Pneumonectomy

Ralph J. Lewis, MD, Robert J. Caccavale, MD

185 Livingston Ave, New Brunswick, Nj 08901

To the Editor:

We agree with Spaggiari and associates [1] that the opportunity to resect a contralateral malignancy after a pneumonectomy for bronchogenic carcinoma is indeed very rare. When this infrequent set of circumstances does present itself, video-assisted thoracic surgery should be considered as a possible technique. A full and complete exploration of the thoracic cavity, including resection of the parenchymal lesion and mediastinal nodes, can be accomplished safely and efficiently using video-assisted thoracic surgery. Because the functioning thoracic wall is minimally traumatized, postoperative unassisted respiration remains optimal. Recovery to the preoperative ambulatory status can be exceedingly rapid and uneventful.

A 75-year-old man in good health had a left pneumonectomy 9 years previously for a T2 N0, squamous cell carcinoma. A chest roentgenogram revealed a right middle lobe nodule that was not present 1 year ago. A computed tomographic scan confirmed a 2-cm, irregular, right middle lobe mass without mediastinal or hilar adenopathy visualized (Fig 1Go). Fine-needle aspiration at the referring hospital confirmed squamous cell carcinoma. Complete evaluation failed to reveal any metastases. Limited resection was recommended.



View larger version (97K):
[in this window]
[in a new window]
  		Fig 1. . Two-centimeter non–small cell carcinoma in the right lung. The left lung is surgically absent.

 
Bronchoscopy affirmed a normal left bronchial stump. The lobar and segmental bronchi of all three lobes on the right were normal. The bronchial blocker of a Phycon Endotracheal Tube (Univent-Fuji Systems Corporation, Tokyo, Japan) was positioned in the proximal bronchus intermedius under direct visualization. The right chest was prepared and draped in the usual fashion. Four incisions, each 2 cm in length, were made through the fifth and seventh intercostal spaces; two along the anterior axillary line and two along the posterior axillary line. The bronchial blocker was inflated, causing the middle and lower lobes to deflate. Ventilation of only the right upper lobe maintained oxygen saturations in the mid-90% range. The lesion was identified in the lateral segment of the right middle lobe. A generous wedge resection was safely and expeditiously accomplished using the E-Z45 Linear Stapler (Ethicon Endosurgery, Cincinnati, OH). The tumor was placed in a specimen bag and removed through the upper anterior intercostal incision. The mediastinum and hilum were unremarkable. Pathologic examination confirmed a 2-cm moderately differentiated squamous cell carcinoma with 2-cm margins. Total operative time was 40 minutes. The endotracheal tube was removed in the operating room.

After 1 hour of observation in the recovery room, the patient was transferred to routine floor care. There was no air leak, and complete expansion of the lung was noted on chest roentgenogram. The single, no. 20 silicone chest tube was removed 6 hours after the operation. A second chest roentgenogram confirmed complete lung expansion. At this time, the patient was ambulating and tolerating oral feedings, and had only minimal pain controlled by ketorolac tromethamine, 30 mg. No other type of analgesia was used (eg, epidural or narcotics).

On the morning of postoperative day 1, the patient was discharged at his request. During a routine postoperative visit 14 days after surgical resection, all wounds were healed, and the patient had returned to his previous preoperative activity status. He continues to do well 6 months after resection. In some patients video-assisted thoracic surgery could be an option for resection of a contralateral lesion detected after a curative pneumonectomy.

Reference

  1. Spaggiari L, Grunenwald D, Girard P, et al. Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma. Ann Thorac Surg 1996;62:1598–602.
 
Dominique Grunenwald, MD, Philippe Girard, MD, Lorenzo Spaggiari, MD, PhD

Thoracic Department, Institut Mutualiste Montsouris, 6 Place de Port au Prince, 75013 Paris, France

Reply To the Editor:

We thank Drs Lewis and Caccavale for their comments about our article [1]. We are very glad to see this controversial concept accepted in some selected cases, and our article deserving discussion. We find their proposition very attractive; however, we would like to express the following reservations:

  1. During the video-assisted wedge resection, Lewis and Caccavale used an endobronchial blocker affording middle and lower lobe deflation. Obviously this technique is a nice means to allow video-assisted thoracic surgery in patients with a single residual lung. But depending on the preoperative respiratory function of the patient, the tolerance of single upper lobe ventilation, even for a short duration, is not preoperatively evident, and a thoracotomy conversion should be planned.
  2. The tumor mass must be very peripheral to be excised with sufficient normal tissue margins using an endoscopic stapler.
  3. It is universally accepted that lobectomy provides a better chance of cure than limited resection in squamous cell lung cancer [2]. In the case of a right middle lobe tumor, one can probably hope that a middle lobectomy could be well tolerated in terms of postoperative pulmonary function, considering the very good result after treatment of the first left lung cancer.
  4. In our experience, the results of video-assisted thoracic surgery or short posterolateral thoracotomy for limited lung resection are very similar in terms of chest pain, drainage duration, and hospital stay.

Nevertheless, we agree with the conclusion of Lewis and Caccavale that in some patients video-assisted thoracic surgery could be an option. We congratulate them for this nice observation and their proposition.

References

  1. Spaggiari L, Grunenwald D, Girard P, et al. Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma. Ann Thorac Surg 1996;62:1598–602.[Abstract/Free Full Text]
  2. Lung Cancer Study Group (Prepared by Ginsberg RJ and Rubinstein LV). Randomized trial of lobectomy versus limited resection for T1 N0 non–small-cell lung cancer. Ann Thorac Surg 1995;60:615–23.[Abstract/Free Full Text]




This Article
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Lewis, R. J.
Right arrow Articles by Spaggiari, L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Lewis, R. J.
Right arrow Articles by Spaggiari, L.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS