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Ann Thorac Surg 1997;64:1519
© 1997 The Society of Thoracic Surgeons
Departments of Thoracic Surgery Cardiac Surgery, University of Parma, 14 Gramsci St, 43100 Parma, Italy
To the Editor:
After pneumonectomy for bronchogenic carcinoma, a second primary non–small cell lung cancer may develop in the residual lung [1]. Traditionally, pneumonectomy contraindicated further resection(s); however, in the last years, reports suggested the feasibility of a wedge resection or segmentectomy on a single lung with effective results in terms of long-term survival with limited postoperative mortality [1].
However, several rules must be respected to reach these results [1], and lobectomy or extended segmentectomy for centrally located tumors should be avoided. Even if the patient's cardiorespiratory function and the TNM stage of the new malignancy did not contraindicate radical resection, the lack of pulmonary exclusion during operation might heavily compromise postoperative results because of multiple parenchymal contusions especially for centrally located neoplasm(s). So, theoretically, the use of femorofemoral temporary cardiopulmonary bypass (CPB) for oxygenation without cardiac arrest may be useful during segmentectomy, allowing lung exclusion and easier resection. This technique has been used previously; unfortunately, the patients died in the postoperative course for venous infarction [2].
We report our recent experience concerning a 60-year-old man who underwent, in June 1993, a left pneumonectomy for T2 N0 squamous cell carcinoma. Forty-two months later, in December 1996, a second primary squamous cell carcinoma (Martini and Melamed criteria) [3] was diagnosed. A careful staging was performed [1], and the cardiorespiratory data were as follows: forced expiratory volume in 1 second, 67%; forced vital capacity, 87%; and ratio of forced expiratory volume in 1 second to forced vital capacity, 59, with no echocardiographic signs of pulmonary hypertension, whereas a very limited perfusion defect was observed in the area of the planned lung resection on systematic perfusion lung scan. The color Doppler echography of the femoral vessels had normal results. Therefore, we decided to plan the intervention using femorofemoral temporary CPB without cardiac arrest.
The thoracic approach was a right posterolateral thoracotomy. The right femoral vessels were isolated and, after thoracotomy, the patient was placed on CPB using 28F venous and 21F arterial femoral cannulas, respectively. Without cardiac arrest, the lung collapsed completely. The mediastinal structures as well as lymph nodes groups were explored; subsequently, segmentectomy of the apical segment of the lower lobe was performed. The extracorporeal circulation was stopped 60 minutes after it began and before the closure of the thoracotomy. The femorofemoral CPB was able to maintain blood gas exchanges, requiring only a short lung ventilation every 10 minutes to maintain optimal oxygen saturation.
The postoperative course was uneventful, and the patient was discharged on the 10th postoperative day. He is, 4 months after operation, alive without evidence of disease and he performs daily activities without dyspnea.
The mediastinal shift as well as pulmonary distention can hardly affect lung resection and dissection of mediastinal lymph nodes during the operation on a patient with one lung. Therefore, segmentectomy (differently from wedge resection for peripheral lesion) on the residual lung without CPB requires multiple pulmonary manipulations that determine areas of pulmonary contusions that, associated with the thoracotomy effects and lung resection, might weigh on the results even in patients with good cardiorespiratory function. By contrast, CPB per se may increase the risk of complications due to heparinization and extracorporeal circulation; in spite of that, we believe that accurate hemostasis during resection, gentle lung manipulation, and a short time of extracorporeal circulation may decrease the risks.
Temporary perioperative oxygenation by femorofemoral CPB without cardiac arrest might facilitate segmentectomy in patients with one lung, but a rigid selection must be always performed on a case-by-case basis.
References
This article has been cited by other articles:
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  P.-E. Falcoz, J. Assouad, F. Le Pimpec-Barthes, and M. Riquet Lobectomy for metachronous lung cancer after pneumonectomy Eur J Cardiothorac Surg, February 1, 2009; 35(2): 373 - 374. [Abstract] [Full Text] [PDF]
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 T. J. Birdas, D. H. Beckart, and R. J. Keenan Contralateral spontaneous pneumothorax after pneumonectomy: thoracoscopic management with cardiopulmonary bypass Interact CardioVasc Thorac Surg, February 1, 2005; 4(1): 27 - 29. [Abstract] [Full Text] [PDF]
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I. F. Oey, G. J. Peek, R. K. Firmin, and D. A. Waller Post-pneumonectomy video-assisted thoracoscopic bullectomy using extra-corporeal membrane oxygenation Eur J Cardiothorac Surg, October 1, 2001; 20(4): 874 - 876. [Abstract] [Full Text] [PDF]
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