- Email: [email protected]
Intrapulmonary Gallstone
1420
CASE REPORT JONES ET AL INTRAPULMONARY GALLSTONE
Ann Thorac Surg 2015;99:1420–2
Fig 3. (A) Postoperative chest radiograph showing breast implant in the right chest (white arrow). (B) Postoperative picture showing symmetry of the chest wall and a successfully healed wound.
FEATURE ARTICLES
technique has prevented scoliosis, pulmonary insufficiency, and chest wall asymmetry. Our patient has full range of movement in the shoulder postoperatively and manages to perform daily activities independently. There is limited experience of this technique but this case suggests that it may be considered in patients with chronic suppurative conditions in the future.
References 1. Deslauriers J, Jacques LF, Gr egoire J. Role of Eloesser flap and thoracoplasty in the third millennium. Chest Surg Clin N Am 2002;12:605–23. 2. Botianu AM. Personal procedure of thoracopleuroplasty for the treatment of the thoracic empyema, with or without bronchial fistula. Jurnalul de Chirurgie Toracica/J Thorac Surg 1996;1(3):251–60. 3. Icard P, Le Rochais JP, Rabut B, Cazaban S, Martel B, Evrard C. Andrews thoracoplasty as a treatment of postpneumonectomy empyema: experience in 23 cases. Ann Thorac Surg 1999;68:1159–64. 4. Peppas G, Molnar TF, Jeyasingham K, Kirk AB. Thoracoplasty in the context of current surgical practice. Ann Thorac Surg 1993;56:903–9. 5. Garcia-Yuste M, Ramos G, Duque JL, et al. Open-window thoracostomy and thoracomyoplasty to manage chronic pleural empyema. Ann Thorac Surg 1998;65: 818–22. 6. Gaensler EA. The surgery for pulmonary tuberculosis. Am Rev Respir Dis 1982;125(3 Pt 2):73–84. 7. Schede M. Die Behandlung der Empyeme. Verh Cong Innere Med Wiesbaden 1890;9:41–141. 8. Andrews NC. The surgical treatment of chronic empyema. Dis Chest 1965;47:533–8. 9. Alexander J. The collapse therapy of pulmonary tuberculosis. Springfield, IL: Charles C. Thomas; 1937. 10. Lindskog GE. Treatment of pulmonary tuberculosisthoracoplasty and pneumonolysis. In: Glenn WWL, Liebow AA, Lindskog GE (eds)). Thoracic and cardiovascular surgery with related pathology, 3rd ed. New York: Appleton-Century-Crofts; 1975:244–50. 11. Loynes RD. Scoliosis after thoracoplasty. J Bone Joint Surg (Br) 1972;54:484–98. 12. Miller JI, Mansour KA, Nahai F, Jurkiewicz MJ, Hatcher CR Jr. Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984;38:227–31. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Intrapulmonary Gallstone Richard O. Jones, MD, MRCSEd, Grant D. Turnbull, and Jonathan Forty, FRCS The Freeman Hospital, High Heaton, and Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
An octogenarian presented to her primary care physician with hemoptysis and a disabling chronic cough that developed several months after a complicated partial cholecystectomy. During investigation, a biopsy sample showed a right lower lobe inflammatory mass containing bile pigment and abundant neutrophils. Thoracotomy performed approximately 18 months after symptom onset confirmed a right lower lobe lung abscess together with a large gallstone embedded at its center and a healed defect in the right hemidiaphragm. A wedge excision of this mass was performed. The patient made an excellent uncomplicated recovery from this rare complication of a gallbladder operation. (Ann Thorac Surg 2015;99:1420–2) Ó 2015 by The Society of Thoracic Surgeons
S
erious thoracic complications after gallbladder operations are rare. Nevertheless, there are a few reports in the literature of intrapulmonary gallstones presenting several months or years after cholecystectomy. Gallstone spillage is usually noted at the time of operation, with subsequent transdiaphragmatic migration of these “dropped gallstones.” Patients typically present with cough, hemoptysis, cholelithoptysis, or empyema. We report the case of an intrapulmonary gallstone in an 84-year-old woman who presented in August 2012 Accepted for publication May 27, 2014. Address correspondence to Dr Jones, The Freeman Hospital, High Heaton, Newcastle upon Tyne, NE7 7DN, United Kingdom; e-mail: r.o.jones@ doctors.org.uk.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.099
Ann Thorac Surg 2015;99:1420–2
1421
Fig 1. Right lower lobe inflammatory mass with a focus of attenuation within (taken from computed tomography [CT] of the thorax performed on November 19, 2013).
for an exploratory posterolateral thoracotomy and wedge excision of the lung for symptomatic relief, which was performed on January 20, 2014. At thoracotomy, dense adhesions of the right lower lobe to the right hemidiaphragm were freed. This revealed a lung abscess cavity in contact with the diaphragm, and a gallstone was found within it. Wedge excision was performed with a linear stapler (Fig 2). A small defect in the right hemidiaphragm was noted and likely represented a healed fistula. Microbiology swabs taken at the time of operation produced negative culture results, and her last chest drain was removed on postoperative day 3 after minimal drainage. Although she made an excellent
Fig 2. Photograph of the wedge of the right lower lobe with a large gallstone embedded within an abscess cavity.
FEATURE ARTICLES
with a chronic cough associated with hemoptysis. This severely impacted her quality of life with disruption to her speech and sleep. There was no hoarseness, chest pain, dyspnea, weight loss, fever, or rigors. She was an ex-smoker with a 40 pack-year history. She had a complex history of biliary intervention dating back to February 2008 with an episode of acute cholangitis requiring endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) stone extraction. She remained well for a number of years until March 2012 when she was admitted with a further episode of acute cholangitis. Repeated ERCP revealed pus in the CBD, and after balloon dilation a plastic stent was inserted to decompress the biliary tree. Computed tomography (CT) of the abdomen revealed a large calculus in the gallbladder neck, although no stones were seen in the CBD, raising the possible diagnosis of Mirizzi’s syndrome. She proceeded to laparoscopy on March 19, 2012 at which time an abscess of the gallbladder fundus was found together with a large calculus eroding into the CBD. A laparoscopic subtotal cholecystectomy was performed to preserve the bile duct and posterior wall of the gallbladder. She made a slow but steady recovery and was discharged home on April 4, 2012. The CBD stent was left in situ. Her medical history was also notable for a pulmonary embolism in 1988 (for which she was on lifelong warfarin), hypertension, stage III chronic kidney disease, osteoarthritis, Helicobacter pylori gastritis in 2003, diverticulosis in 2007, a thyroidectomy in 1985, and labyrinthitis in 2006. Despite her age and comorbidities, she lived alone and was independent with her daily activities, maintaining mobility with a walking stick. She was referred to a respiratory physician for further investigation of her cough and hemoptysis in November 2012. Contrast-enhanced CT of the thorax was performed and showed an area of opacification in the right lower lobe measuring 38 27 mm. It abutted the right hemidiaphragm and liver and was reported as suspicious for malignancy. Biliary dilatation was also noted. A computed tomographic guided biopsy of the lung mass was performed, which revealed large numbers of polymorphs and bile pigment. This prompted referral to the tertiary hepatobiliary team at our institution. Cholescintigraphy (HIDA scan) did not reveal an ongoing bile leak, although dilatated bile ducts were noted. ERCP was undertaken in July 2013, at which time the CBD stent was removed and biliary sludge drained. Because of the persistent symptoms of cough and hemoptysis, repeated CT of the thorax was performed on November 19, 2013. This showed a mild increase in the opacification, now measuring 43 37 mm, together with a focus of attenuation within it (Fig 1). This was reported to be consistent with a “dropped” gallstone and surrounding inflammatory change. There was no subdiaphragmatic collection. She was referred to the thoracic surgery department in December 2013. The patient was counseled
CASE REPORT JONES ET AL INTRAPULMONARY GALLSTONE
1422
CASE REPORT FUKUI ET AL MIDDLE LOBECTOMY AFTER PNEUMONECTOMY
uncomplicated recovery, she remained in hospital until postoperative day 6 to arrange a social care package for discharge. Final histopathologic examination revealed a wedge excision of lung measuring 133 74 39 mm containing a pulmonary abscess and a 23 14 mm gallstone.
FEATURE ARTICLES
Comment Serious thoracic complications after cholecystectomy are fortunately rare [1]. Pleurobiliary and bronchobiliary fistulas after cholecystectomy were first reported in 1955 [2]. Several cases of intrapulmonary and intrapleural gallstones have since been reported [1]. These cases typically presented with cholelithoptysis/hemoptysis several months or years after operation. One case presented as a massive hemoptysis [3]. The culprit stone was usually found in the right lower lobe, although one case reported a stone in the middle lobe [4]. Although the operation note at the time of the partial cholecystectomy in this case did not report a “dropped” gallstone, this is most likely to be the source. We postulate that this created an inflammatory reaction leading to migration and fistulization through the diaphragm into the right lower lobe. Indeed, we noted a healed defect in the right hemidiaphragm at the time of operation, with no congenital diaphragmatic defect found. Gallstone spillage is relatively common at laparoscopic cholecystectomy, although transdiaphragmatic migration is rare [5]. The gallbladder abscess in this case was most likely a significant contributing factor, releasing an infected gallstone. The use of a retrieval bag in which to place the resected gallbladder at the time of the laparoscopic operation may help reduce the incidence of dropped stones. Further, clear documentation if gallstones are lost may help alert physicians early to possible thoracic complications during follow-up. In summary, prolonged chest symptoms and inflammatory reactions in the right hemithorax, notably the right lower lobe, after biliary operations should raise the clinical suspicion of gallstone migration.
References 1. Fontaine JP, Issa RA, Yantiss RK, Podbielski FJ. Intrathoracic gallstones: a case report and literature review. JSLS 2006;10: 375–8. 2. Adams HD. Pleurobiliary and bronchobiliary fistulas. J Thorac Surg 1955;30:255–60. 3. Werber Y, Wright C. Massive hemoptysis from a lung abscess due to retained gallstones. Ann Thorac Surg 2001;72: 278–9. 4. Barnard SP, Pallister I, Hendrick D, Walter N, Morritt GN. Cholelithoptysis and empyema formation after laparoscopic cholecystectomy. Ann Thorac Surg 1995;60: 1100–2. 5. Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and analysis of 77,604 cases. Am J Surg 1993;165:9–14. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;99:1422–5
Three-Port Thoracoscopic Middle Lobectomy in a Patient After Left Pneumonectomy Yudai Fukui, MD, Tadasu Kohno, MD, PhD, Sakashi Fujimori, MD, PhD, Takashi Harano, MD, Souichiro Suzuki, MD, Masayuki Fujii, MD, and Hiromi Yamase, MD Department of Thoracic Surgery and Department of Anesthesia, Toranomon Hospital, Tokyo, Japan
Lung lobectomy after contralateral pneumonectomy is a challenging procedure associated with high morbidity and mortality. To date, only limited evidence has been available, and adequate indication or surgical approach remain unclear. We herein report a successful case of thoracoscopic lobectomy in a single-lung patient. A 63-year-old man, who had a history of left pneumonectomy for lung cancer, was found to have an abnormal opacity in the right middle zone at a health checkup 13 years after the previous operation. This nodule was later diagnosed as squamous cell cancer (cT2N0M0, stage IB) and surgical resection was considered. Thoracoscopic middle lobectomy with D1 lymph node dissection was performed for this patient under selective ventilation of the right upper and lower lobes. Postoperative course was uneventful and he was discharged on postoperative day 7, requiring no oxygen. The patient is doing well with no evidence of recurrence for 5 years. Given the lower invasiveness, thoracoscopic lobectomy under the selective ventilation of residual lobes could be an option after contralateral pneumonectomy in selected patients. (Ann Thorac Surg 2015;99:1422–5) Ó 2015 by The Society of Thoracic Surgeons
P
atients who have undergone pneumonectomy for any reason may develop new or metastatic cancer in the contralateral lung [1, 2]. Lung resection for such patients is a challenging procedure and rarely indicated because of their inadequate respiratory reserve or cancer metastases to the other organs [3–7]. Recently, thoracoscopic approach has become a standard procedure in the field of lung resection. However, its advantage in high-risk surgery has not yet been well studied. In this report, we describe a case of successful thoracoscopic middle lobectomy under selective ventilation of residual lobes for a patient presenting with lung cancer after contralateral pneumonectomy. A 63-year-old man was found to have a lung nodule with abnormal opacity in the right middle zone and referred to our department. At the time of presentation, he was in good condition with no complaint of dyspnea or signs of hypoxia. All laboratory studies were within normal limits, Accepted for publication May 14, 2014. Address correspondence to Dr Fukui, Toranomon2-2-2, Minato-ku, Tokyo, Japan 105-0001; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.095
CASE REPORT JONES ET AL INTRAPULMONARY GALLSTONE
Ann Thorac Surg 2015;99:1420–2
Fig 3. (A) Postoperative chest radiograph showing breast implant in the right chest (white arrow). (B) Postoperative picture showing symmetry of the chest wall and a successfully healed wound.
FEATURE ARTICLES
technique has prevented scoliosis, pulmonary insufficiency, and chest wall asymmetry. Our patient has full range of movement in the shoulder postoperatively and manages to perform daily activities independently. There is limited experience of this technique but this case suggests that it may be considered in patients with chronic suppurative conditions in the future.
References 1. Deslauriers J, Jacques LF, Gr egoire J. Role of Eloesser flap and thoracoplasty in the third millennium. Chest Surg Clin N Am 2002;12:605–23. 2. Botianu AM. Personal procedure of thoracopleuroplasty for the treatment of the thoracic empyema, with or without bronchial fistula. Jurnalul de Chirurgie Toracica/J Thorac Surg 1996;1(3):251–60. 3. Icard P, Le Rochais JP, Rabut B, Cazaban S, Martel B, Evrard C. Andrews thoracoplasty as a treatment of postpneumonectomy empyema: experience in 23 cases. Ann Thorac Surg 1999;68:1159–64. 4. Peppas G, Molnar TF, Jeyasingham K, Kirk AB. Thoracoplasty in the context of current surgical practice. Ann Thorac Surg 1993;56:903–9. 5. Garcia-Yuste M, Ramos G, Duque JL, et al. Open-window thoracostomy and thoracomyoplasty to manage chronic pleural empyema. Ann Thorac Surg 1998;65: 818–22. 6. Gaensler EA. The surgery for pulmonary tuberculosis. Am Rev Respir Dis 1982;125(3 Pt 2):73–84. 7. Schede M. Die Behandlung der Empyeme. Verh Cong Innere Med Wiesbaden 1890;9:41–141. 8. Andrews NC. The surgical treatment of chronic empyema. Dis Chest 1965;47:533–8. 9. Alexander J. The collapse therapy of pulmonary tuberculosis. Springfield, IL: Charles C. Thomas; 1937. 10. Lindskog GE. Treatment of pulmonary tuberculosisthoracoplasty and pneumonolysis. In: Glenn WWL, Liebow AA, Lindskog GE (eds)). Thoracic and cardiovascular surgery with related pathology, 3rd ed. New York: Appleton-Century-Crofts; 1975:244–50. 11. Loynes RD. Scoliosis after thoracoplasty. J Bone Joint Surg (Br) 1972;54:484–98. 12. Miller JI, Mansour KA, Nahai F, Jurkiewicz MJ, Hatcher CR Jr. Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984;38:227–31. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Intrapulmonary Gallstone Richard O. Jones, MD, MRCSEd, Grant D. Turnbull, and Jonathan Forty, FRCS The Freeman Hospital, High Heaton, and Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
An octogenarian presented to her primary care physician with hemoptysis and a disabling chronic cough that developed several months after a complicated partial cholecystectomy. During investigation, a biopsy sample showed a right lower lobe inflammatory mass containing bile pigment and abundant neutrophils. Thoracotomy performed approximately 18 months after symptom onset confirmed a right lower lobe lung abscess together with a large gallstone embedded at its center and a healed defect in the right hemidiaphragm. A wedge excision of this mass was performed. The patient made an excellent uncomplicated recovery from this rare complication of a gallbladder operation. (Ann Thorac Surg 2015;99:1420–2) Ó 2015 by The Society of Thoracic Surgeons
S
erious thoracic complications after gallbladder operations are rare. Nevertheless, there are a few reports in the literature of intrapulmonary gallstones presenting several months or years after cholecystectomy. Gallstone spillage is usually noted at the time of operation, with subsequent transdiaphragmatic migration of these “dropped gallstones.” Patients typically present with cough, hemoptysis, cholelithoptysis, or empyema. We report the case of an intrapulmonary gallstone in an 84-year-old woman who presented in August 2012 Accepted for publication May 27, 2014. Address correspondence to Dr Jones, The Freeman Hospital, High Heaton, Newcastle upon Tyne, NE7 7DN, United Kingdom; e-mail: r.o.jones@ doctors.org.uk.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.099
Ann Thorac Surg 2015;99:1420–2
1421
Fig 1. Right lower lobe inflammatory mass with a focus of attenuation within (taken from computed tomography [CT] of the thorax performed on November 19, 2013).
for an exploratory posterolateral thoracotomy and wedge excision of the lung for symptomatic relief, which was performed on January 20, 2014. At thoracotomy, dense adhesions of the right lower lobe to the right hemidiaphragm were freed. This revealed a lung abscess cavity in contact with the diaphragm, and a gallstone was found within it. Wedge excision was performed with a linear stapler (Fig 2). A small defect in the right hemidiaphragm was noted and likely represented a healed fistula. Microbiology swabs taken at the time of operation produced negative culture results, and her last chest drain was removed on postoperative day 3 after minimal drainage. Although she made an excellent
Fig 2. Photograph of the wedge of the right lower lobe with a large gallstone embedded within an abscess cavity.
FEATURE ARTICLES
with a chronic cough associated with hemoptysis. This severely impacted her quality of life with disruption to her speech and sleep. There was no hoarseness, chest pain, dyspnea, weight loss, fever, or rigors. She was an ex-smoker with a 40 pack-year history. She had a complex history of biliary intervention dating back to February 2008 with an episode of acute cholangitis requiring endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) stone extraction. She remained well for a number of years until March 2012 when she was admitted with a further episode of acute cholangitis. Repeated ERCP revealed pus in the CBD, and after balloon dilation a plastic stent was inserted to decompress the biliary tree. Computed tomography (CT) of the abdomen revealed a large calculus in the gallbladder neck, although no stones were seen in the CBD, raising the possible diagnosis of Mirizzi’s syndrome. She proceeded to laparoscopy on March 19, 2012 at which time an abscess of the gallbladder fundus was found together with a large calculus eroding into the CBD. A laparoscopic subtotal cholecystectomy was performed to preserve the bile duct and posterior wall of the gallbladder. She made a slow but steady recovery and was discharged home on April 4, 2012. The CBD stent was left in situ. Her medical history was also notable for a pulmonary embolism in 1988 (for which she was on lifelong warfarin), hypertension, stage III chronic kidney disease, osteoarthritis, Helicobacter pylori gastritis in 2003, diverticulosis in 2007, a thyroidectomy in 1985, and labyrinthitis in 2006. Despite her age and comorbidities, she lived alone and was independent with her daily activities, maintaining mobility with a walking stick. She was referred to a respiratory physician for further investigation of her cough and hemoptysis in November 2012. Contrast-enhanced CT of the thorax was performed and showed an area of opacification in the right lower lobe measuring 38 27 mm. It abutted the right hemidiaphragm and liver and was reported as suspicious for malignancy. Biliary dilatation was also noted. A computed tomographic guided biopsy of the lung mass was performed, which revealed large numbers of polymorphs and bile pigment. This prompted referral to the tertiary hepatobiliary team at our institution. Cholescintigraphy (HIDA scan) did not reveal an ongoing bile leak, although dilatated bile ducts were noted. ERCP was undertaken in July 2013, at which time the CBD stent was removed and biliary sludge drained. Because of the persistent symptoms of cough and hemoptysis, repeated CT of the thorax was performed on November 19, 2013. This showed a mild increase in the opacification, now measuring 43 37 mm, together with a focus of attenuation within it (Fig 1). This was reported to be consistent with a “dropped” gallstone and surrounding inflammatory change. There was no subdiaphragmatic collection. She was referred to the thoracic surgery department in December 2013. The patient was counseled
CASE REPORT JONES ET AL INTRAPULMONARY GALLSTONE
1422
CASE REPORT FUKUI ET AL MIDDLE LOBECTOMY AFTER PNEUMONECTOMY
uncomplicated recovery, she remained in hospital until postoperative day 6 to arrange a social care package for discharge. Final histopathologic examination revealed a wedge excision of lung measuring 133 74 39 mm containing a pulmonary abscess and a 23 14 mm gallstone.
FEATURE ARTICLES
Comment Serious thoracic complications after cholecystectomy are fortunately rare [1]. Pleurobiliary and bronchobiliary fistulas after cholecystectomy were first reported in 1955 [2]. Several cases of intrapulmonary and intrapleural gallstones have since been reported [1]. These cases typically presented with cholelithoptysis/hemoptysis several months or years after operation. One case presented as a massive hemoptysis [3]. The culprit stone was usually found in the right lower lobe, although one case reported a stone in the middle lobe [4]. Although the operation note at the time of the partial cholecystectomy in this case did not report a “dropped” gallstone, this is most likely to be the source. We postulate that this created an inflammatory reaction leading to migration and fistulization through the diaphragm into the right lower lobe. Indeed, we noted a healed defect in the right hemidiaphragm at the time of operation, with no congenital diaphragmatic defect found. Gallstone spillage is relatively common at laparoscopic cholecystectomy, although transdiaphragmatic migration is rare [5]. The gallbladder abscess in this case was most likely a significant contributing factor, releasing an infected gallstone. The use of a retrieval bag in which to place the resected gallbladder at the time of the laparoscopic operation may help reduce the incidence of dropped stones. Further, clear documentation if gallstones are lost may help alert physicians early to possible thoracic complications during follow-up. In summary, prolonged chest symptoms and inflammatory reactions in the right hemithorax, notably the right lower lobe, after biliary operations should raise the clinical suspicion of gallstone migration.
References 1. Fontaine JP, Issa RA, Yantiss RK, Podbielski FJ. Intrathoracic gallstones: a case report and literature review. JSLS 2006;10: 375–8. 2. Adams HD. Pleurobiliary and bronchobiliary fistulas. J Thorac Surg 1955;30:255–60. 3. Werber Y, Wright C. Massive hemoptysis from a lung abscess due to retained gallstones. Ann Thorac Surg 2001;72: 278–9. 4. Barnard SP, Pallister I, Hendrick D, Walter N, Morritt GN. Cholelithoptysis and empyema formation after laparoscopic cholecystectomy. Ann Thorac Surg 1995;60: 1100–2. 5. Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and analysis of 77,604 cases. Am J Surg 1993;165:9–14. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;99:1422–5
Three-Port Thoracoscopic Middle Lobectomy in a Patient After Left Pneumonectomy Yudai Fukui, MD, Tadasu Kohno, MD, PhD, Sakashi Fujimori, MD, PhD, Takashi Harano, MD, Souichiro Suzuki, MD, Masayuki Fujii, MD, and Hiromi Yamase, MD Department of Thoracic Surgery and Department of Anesthesia, Toranomon Hospital, Tokyo, Japan
Lung lobectomy after contralateral pneumonectomy is a challenging procedure associated with high morbidity and mortality. To date, only limited evidence has been available, and adequate indication or surgical approach remain unclear. We herein report a successful case of thoracoscopic lobectomy in a single-lung patient. A 63-year-old man, who had a history of left pneumonectomy for lung cancer, was found to have an abnormal opacity in the right middle zone at a health checkup 13 years after the previous operation. This nodule was later diagnosed as squamous cell cancer (cT2N0M0, stage IB) and surgical resection was considered. Thoracoscopic middle lobectomy with D1 lymph node dissection was performed for this patient under selective ventilation of the right upper and lower lobes. Postoperative course was uneventful and he was discharged on postoperative day 7, requiring no oxygen. The patient is doing well with no evidence of recurrence for 5 years. Given the lower invasiveness, thoracoscopic lobectomy under the selective ventilation of residual lobes could be an option after contralateral pneumonectomy in selected patients. (Ann Thorac Surg 2015;99:1422–5) Ó 2015 by The Society of Thoracic Surgeons
P
atients who have undergone pneumonectomy for any reason may develop new or metastatic cancer in the contralateral lung [1, 2]. Lung resection for such patients is a challenging procedure and rarely indicated because of their inadequate respiratory reserve or cancer metastases to the other organs [3–7]. Recently, thoracoscopic approach has become a standard procedure in the field of lung resection. However, its advantage in high-risk surgery has not yet been well studied. In this report, we describe a case of successful thoracoscopic middle lobectomy under selective ventilation of residual lobes for a patient presenting with lung cancer after contralateral pneumonectomy. A 63-year-old man was found to have a lung nodule with abnormal opacity in the right middle zone and referred to our department. At the time of presentation, he was in good condition with no complaint of dyspnea or signs of hypoxia. All laboratory studies were within normal limits, Accepted for publication May 14, 2014. Address correspondence to Dr Fukui, Toranomon2-2-2, Minato-ku, Tokyo, Japan 105-0001; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.095