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Ann Thorac Surg 2004;78:1844-1845
© 2004 The Society of Thoracic Surgeons

Case report

Video-Assisted Thoracoscopic Wedge Resection for Pulmonary Sequestration

Tsutomu Sakuma, MD, PhD*,a, Makoto Sugita, MD, PhDa, Motoyasu Sagawa, MD, PhDa, Masanobu Ishigaki, MD, PhDb, Hirohisa Toga, MD, PhDb

a Department of Thoracic Surgery, Uchinada, Ishikawa, Japan
b Department of Pulmonary Medicine, Kanazawa Medical University, Uchinada, Ishikawa, Japan

Accepted for publication July 17, 2003.

* Address reprint requests to Dr Sakuma, Department of Thoracic Surgery, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan
sakuma-t{at}kanazawa-med.ac.jp


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
A 60-year-old woman underwent a video-assisted thoracoscopic wedge resection of intralobar pulmonary sequestration instead of a lobotomy because the lesion was localized in the right basal segment. Preoperative 3-dimensional computed tomography was useful for identifying an aberrant artery arising from the thoracic aorta and distributing to the lesion. A successful outcome more than 4 years after the surgery indicates that a wedge resection under video-assisted thoracoscopy may prove to be a therapeutic option for localized pulmonary sequestration.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
A lobectomy has been considered to be an effective treatment for pulmonary sequestration that is characterized by repeated episodes of pneumonia [1]. Recently, a lobectomy under video-assisted thoracoscopic surgery (VATS) was successfully performed to excise sequestrated lung lobes [2–6]. However, a lobectomy may result in a loss of a large fraction of healthy lung tissue if the sequestrated lesion is small and localized. Therefore, a wedge resection of a pulmonary sequestration can be considered as an appropriate treatment to preserve lung volume and pulmonary function. This report illustrates a case in which wedge lung resection under VATS for pulmonary sequestration resulted in a successful outcome for more than 4 years after the surgery.

A 60-year-old woman had suffered from purulent sputum since she was 35 years old. Although treatment with antibiotics was effective for an episode of pneumonia at a local hospital, she was referred to our hospital because of a radiographic abnormality in the right lower lung field. Computed tomography visualized an abnormal cystic mass shadow in the right lower basal segment (Fig 1), and 3-dimensional computed tomographic angiography identified an aberrant artery arising from the descending thoracic aorta at the level of the 11th rib and distributing to the lesion (Fig 2). The patient was diagnosed with intralobar pulmonary sequestration. Under general anesthesia with a double-lumen endotracheal tube, a small lateral thoracotomy (7 cm in length) was made in the sixth intercostal space, and two ports were inserted between the intercostal spaces. There were no intrathoracic adhesions between the lung and the chest wall. The pleural surface of the sequestrated lesion appeared congested, and the margin of the lesion was delineated from the surrounding normal lung tissue. The aberrant artery was identified in the pulmonary ligament and transected with an endoscopic 2.5 mm staple (Endo GIA [Auto Suture Co, US Surgical Corp]). The sequestrated part of the lung was excised with three endoscopic 4.8 mm staples (Endo GIA [Auto Suture Co, US Surgical Corp]). There were no intraoperative problems. The size of the resected specimen was 6.5 x 5.3 x 2.8 cm. The pathologic examination confirmed that the lesion was intralobar cystic pulmonary sequestration, and there were airway connections. A computed tomographic scan was performed 1 year after the VATS that revealed the presence of the normal lung volume of the remaining right lower lobe and absence of any recurrent lesion (Fig 3). The postoperative course was uneventful for more than 4 years after the VATS, although the patient was treated by a pacemaker implant and a resection of a malignant ovarian tumor under general anesthesia, 1 and 2 years after the VATS, respectively. The postoperative change in lung function was minimal; preoperative versus postoperative values were forced vital capacity (2.54 L vs 2.20 L), percent of forced expiratory volume in one second (82% vs 94%), PaO2 (76 mm Hg vs 86 mm Hg), and PaCO2 (46 mm Hg vs 41 mm Hg).



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  		Fig 1. Preoperative conventional computed tomographic chest scan shows an abnormal mass with multiple cysts at the right basal segment.

 


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  		Fig 2. Three-dimensional computed tomography reveals an aberrant artery arising from the descending thoracic aorta at the 11th rib and flowing into the sequestrated lesion.

 


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  		Fig 3. Postoperative computed tomographic chest scan 1 year after surgery shows no recurrent lesion and large lung volume remaining in the right lower lobe.

 

   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Intrapulmonary sequestration is characterized by repeated episodes of pneumonia with purulent sputum [1]. Therefore, it is possible to suspect this disease by taking a detailed past history. However, before the surgery it is necessary to diagnose intrapulmonary sequestration by visualizing an aberrant artery arising from the aorta with blood flow into the lesion [7]. In the present case, conventional computed tomography did not show the artery, but contrast aortography and magnetic resonance imaging angiography depicted the artery, and the 3-dimensional computed tomographic angiography visualized the anatomic pathway of the artery in a 3-dimensional fashion that made it possible to separate the artery during surgery.

Recently lobectomy has been carried out under VATS for pulmonary sequestration [2–6]. However, because the pulmonary sequestration is a benign disease, a partial resection may be more appropriate than a lobectomy because postoperative lung function will be superior in a patient with a partial resection than in a patient with a lobectomy. In the present case, the sequestration was localized only at the basal segment of the right lower lobe and delineated from the surrounding normal tissue. Therefore it was possible to excise the sequestrated lesion and the outcome was successful without an episode of pneumonia after surgery.

Potential problems associated with VATS wedge resection of the lung are bleeding and air leaks that can be caused by the incomplete suture and tears of the tissue at the deep thick base. To control the problems, additional suture ligatures, electrocautery, clips, or an argon beam coagulator can be helpful. If it is difficult to manage these issues; a standard thoracotomy should be considered. In the present case, we used the largest endoscopic 4.8 mm 6-row staplers that provided a complete suture without bleeding or an air leak.

The length of incision (7 cm) was long enough to carry out a lobectomy under VATS, but not long enough to carry out a traditional lobectomy. In the present case, such length of incision was necessary to remove the excised pulmonary sequestration.

In conclusion, this case indicates that a wedge resection under VATS is an appropriate treatment for localized pulmonary sequestration.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Halkic N, Cuenoud PF, Corthesy ME, Ksontini R, Boumghar M. Pulmonary sequestration: a review of 26 cases. Eur J Cardiothorac Surg. 1998;14:127–133
  2. Kaseda S, Aoki T, Shimizu K, Nakamura Y, Kiguchi H. Techniques for treating aberrant arteries during resection of pulmonary sequestration by video-assisted thoracic surgery: report of two cases. Surg Today. 2003;33:52–54[Medline]
  3. Mezzetti M, Dell'Agnola CA, Bedoni M, Cappelli R, Fumagalli F, Panigalli T. Video-assisted thoracoscopic resection of pulmonary sequestration in an infant. Ann Thorac Surg. 1996;61:1836–1837[Abstract/Free Full Text]
  4. Tanaka T, Ueda K, Sakano H, Hayashi M, Li TS, Zempo N. Video-assisted thoracoscopic surgery for intralobar pulmonary sequestration. Surgery. 2003;133:216–218[Medline]
  5. Wan IY, Lee TW, Sihoe AD, Ng CS, Yim AP. Video-assisted thoracic surgery lobectomy for pulmonary sequestration. Ann Thorac Surg. 2002;73:639–640[Abstract/Free Full Text]
  6. Watine O, Mensier E, Delecluse P, Ribet M. Pulmonary sequestration treated by video-assisted thoracoscopic resection. Eur J Cardiothorac Surg. 1994;8:155–156[Abstract]
  7. Yamanaka A, Hirai T, Fujimoto T, Hase M, Noguchi M, Konishi F. Anomalous systemic arterial supply to normal basal segments of the left lower lobe. Ann Thorac Surg. 1999;68:332–338[Abstract/Free Full Text]



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