Ann Thorac Surg 2009;87:954-955. doi:10.1016/j.athoracsur.2008.07.054
© 2009 The Society of Thoracic Surgeons
Case Reports
The Common Trunk of the Left Pulmonary Vein Injured Incidentally During Lung Cancer Surgery
Toru Nakamura, MDa,*,
Masaaki Koide, MDb,
Hidenori Nakamura, MDc,
Futoru Toyoda, MDa
a Department of General Thoracic Surgery, Seirei Hamamatsu General Hospital, Hamamatsu City, Shizuoka, Japan
b Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital, Hamamatsu City, Shizuoka, Japan
c Department of Respiratory Medicine, Seirei Hamamatsu General Hospital, Hamamatsu City, Shizuoka, Japan
Accepted for publication July 16, 2008.
* Address correspondence to Dr Nakamura, Seirei Hamamatsu General Hospital, Sumiyoshi 2-12-12, Hamamatsu City, Shizuoka, 430-8558, Japan (Email: tonakamu{at}nifty.ne.jp).
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Abstract
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We report a case in which the common trunk of the left pulmonary vein was injured incidentally due to a misunderstanding of the anatomy. After cutting the trunk, we recognized that the vessel included not only the superior but also the inferior component of the pulmonary vein. The cut end of the trunk and the left atrium were successfully anastomosed without any surgical morbidity. Although we retrospectively determined that the common trunk was visualized on preoperative computed tomography, we missed this finding during the preoperative evaluation. Furthermore, because we used the endostapler to cut the vessel, exposure of the pulmonary hilum was too short to identify the anomaly correctly. In the era of the endoscopic devices, exposure of the anatomical structures at surgery has become more limited, resulting in a tendency to misunderstand the anatomy during surgery. Because the common trunk of the left pulmonary vein occurs in 14% of patients demonstrating anatomical variations, thoracic surgeons should be aware of this type of anomaly not only before but also during surgery, and meticulous intraoperative confirmation of the vascular anatomy is required when using endoscopic devices.
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Introduction
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There is a wide range of anatomical variation in the pulmonary vessels, and some of these variations may cause surgical morbidity during general thoracic surgery. Most such complications are related to pulmonary venous anomaly, and preoperative diagnosis is important to achieve a safe surgery. We encountered the case of common trunk of the left pulmonary vein injured incidentally during lung cancer surgery and report it here.
A 60-year-old man demonstrated an abnormal shadow in the left lung on annual health examination and was referred to our institute. Transbronchial biopsy diagnosed the lesion as nonsmall cell lung cancer (T2N0M0, stage 1B) and he was scheduled for a left upper lobectomy.
We exposed the left superior pulmonary vein, which was later proven to be the common trunk, under thoracotomy and cut the vessel with an endostapler. Because we then realized that the vessel was the common trunk that also included the inferior vein, we cut the vessel at the side of the upper lobe again and completed the left upper lobectomy. Thereafter, the cut margin of the trunk, which equals the inferior vein, was anastomosed to the left atrium. Part of the pericardium was harvested and used as a patch to dilate the caliber of the trunk. The postoperative course was uneventful; the patient was discharged on postoperative day 6. Postoperative histologic diagnosis was large cell carcinoma; the pathologic stage was 1B (T2N0M0). Magnetic resonance imaging 30 days after surgery demonstrated a good flow of the anastomosis (Fig 1). Presently, the patient remains alive with no evidence of pulmonary congestion or recurrence of cancer 17 months after surgery.
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Fig 1. Postoperative magnetic resonance imaging. Magnetic resonance imaging 30 days after surgery demonstrated a good flow of the anastomosis between the left atrium and the inferior pulmonary vein (arrow).
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Comment
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There are many reports of venous anomaly in lung cancer surgery and partial anomalous pulmonary venous connection is one of the most frequent variations. Because the risk of postoperative heart failure will increase with this anomaly in the preserved lung parenchyma, venous return should be corrected before or during lung cancer surgery [1–3]. Therefore, identifying partial anomalous pulmonary venous connection is very important and essential for safe surgery, as well as the avoidance of postoperative morbidity [4]. However, there are few reports of surgical morbidity due to the other type of pulmonary venous anomaly. Asai and colleagues [5] reported right upper lobe venous drainage posterior to the bronchus intermedius and emphasized the importance of preoperative identification of the anomaly to avoid surgical injury [5]. In addition, because upper lobe venous drainage posterior to the bronchus intermedius could be visualized as the subcarinal lymph node on computed tomography, thoracic surgeons should pay attention to the anomaly [6]. The common trunk of the left pulmonary veins as seen in our case was reported on computed tomographic findings in 14% of 201 cases [7]. Furthermore, a common trunk of the right and left inferior pulmonary veins has also been reported; thus, we should recognize that there is a wide variation in pulmonary venous anatomy [8].
Retrospectively, the common trunk was visualized in the preoperative computed tomographic scan, but we did not correctly recognize this finding before surgery (Fig 2).
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Fig 2. Preoperative computed tomographic findings of the left hilum. (A) Computed tomographic scan demonstrated the superior pulmonary vein (white arrow), (B) the common trunk (black arrow), and (C) the inferior pulmonary vein (white arrow head).
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In addition, we should have exposed the hilar structure widely enough to identify the whole anatomy intraoperatively. Because the use of video-assisted surgery and endoscopic devices has become more widespread, skin incisions and exposure of the anatomical structure has become more limited. Therefore, an anatomical anomaly that remains unidentified during the preoperative evaluation tends to be missed even during surgery. Although we performed surgery by open thoracotomy, exposure of the hilar structure was insufficient to correctly identify the anatomy. Both sufficient preoperative radiological evaluation and intraoperative confirmation of the anatomy seems to be essential for a safe operation.
We encountered a case demonstrating a common trunk of the left pulmonary vein, which is not a very rare anomaly. Because there is a wide range of variations in pulmonary venous anatomy, and because there are anomalous variations that can not be detected on preoperative imaging, thoracic surgeons should pay close attention to the possibility of venous anomaly not only before but also during surgery.
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References
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- Black MD, Shamji FM, Goldstein W, Sachs HJ. Pulmonary resection and contralateral anomalous venous drainage: a lethal combination Ann Thorac Surg 1992;53:689-691.[Abstract/Free Full Text]
- Takei H, Suzuki K, Asamura H, Kondo H, Tsuchiya R. Successful pulmonary resection of lung cancer in a patient with partial anomalous pulmonary venous connection: report of a case Surg Today 2002;32:899-901.[Medline]
- Sakurai H, Kondo H, Sekiguchi A, et al. Left pneumonectomy for lung cancer after correction of contralateral partial anomalous pulmonary venous return Ann Thorac Surg 2005;79:1778-1780.[Abstract/Free Full Text]
- Greene R, Miller SW. Cross-sectional imaging of silent pulmonary venous anomalies Radiology 1986;159:279-281.[Abstract/Free Full Text]
- Asai K, Urabe N, Yajima K, Suzuki K, Kazui T. Right upper lobe venous drainage posterior to the bronchus intermedius: preoperative identification by computed tomography Ann Thorac Surg 2005;79:1866-1871.[Abstract/Free Full Text]
- Matsubara T. Rare but dangerous anomaly of the right pulmonary vein in subcarinal dissection Ann Thorac Surg 2003;75:1026.[Free Full Text]
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- Shapiro M, Dodd JD, Brady TJ, Abbara S. Common pulmonary venous ostium of the right and left inferior pulmonary veins: an unusual pulmonary vein anomaly depicted with 64-slice cardiac computed tomography J Cardiovasc Electrophysiol 2007;18:110.[Medline]
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Abstract
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