*From the Sections of Thoracic Surgery (Drs. Kim, DeCamp, and Gangadharan) and Interventional Pulmonology (Dr. Ernst), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Correspondence to: Sidhu P. Gangadharan, MD, Section of Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 2A, Boston, MA 02215; e-mail: email@example.com
A 19-year-old man presented with pneumonia, cough, and occasional dyspnea. Chest CT scan and bronchoscopy with biopsy revealed a typical carcinoid tumor obstructing the orifice of the right middle lobe, leading to lobar collapse. Preoperative surgical planning included radial endobronchial ultrasound, which confirmed that the tumor was not invasive into the bronchus intermedius. With that information, a video-assisted right middle lobectomy was performed with a wedge bronchoplasty in order to preserve the right lower lobe. The operation was performed completely thoracoscopically with three 1.2-cm ports and one 3.5-cm utility incision. With the intralobar pulmonary artery retracted, the bronchus was divided with a scalpel in wedge fashion to obtain a margin on the endobronchial tumor, and the defect was closed with absorbable suture. The patient recovered without complication and was doing well at 8-month follow-up, without evidence of recurrent disease.
Typical carcinoid tumors of the lung have an excellent prognosis, with surgical series1–2 reporting 10-year survival rates of approximately 90%. Standard treatment is surgical resection via thoracotomy. Parenchymal-sparing resections appear to have similar efficacy as more radical resections such as pneumonectomy or bilobectomy.1–2 Video-assisted anatomic resection for typical carcinoid tumors has been described previously,3 but the technique of minimally invasive bronchoplasty for resection of these tumors is novel. We report the use of video-assisted right middle lobectomy with wedge bronchoplasty, which combined the benefits of parenchymal preservation and minimally invasive surgery. This primary approach was facilitated by preoperative imaging with endobronchial ultrasound (EBUS).
A 19-year-old man with a history of recurrent respiratory infections presented with persistent productive cough and dyspnea. A chest CT scan revealed a 12-mm endobronchial lesion obstructing the right middle lobe bronchial orifice, causing total lobar collapse. Bronchoscopy confirmed an endobronchial tumor completely obstructing the right middle lobe orifice (Fig 1
). EBUS was performed with a 20-MHz radial system (Olympus Surgical and Industrial; Orangeburg, NY). The ultrasound examination showed a normal wall structure without infiltration of tumor into the bronchus intermedius (Fig 1, inset). Biopsy findings were consistent with a carcinoid tumor.
With the information obtained by EBUS, a decision was made to pursue a primary video-assisted right middle lobectomy with wedge bronchoplasty. The operation was conducted totally thoracoscopically, with a 10-mm videoscope placed in the seventh interspace in the posterior axillary line, and two 12-mm working ports, one positioned in the eighth interspace posteriorly, and the other in the sixth interspace anteriorly. A 3.5-cm utility incision was created in the fourth interspace anteriorly, and no rib spreading was done. Standard thoracic instruments were used.
The fissures were completed using an endostapler (Endo-GIA; United States Surgical Corporation; Norwalk, CT). The pulmonary arterial and venous branches to the middle lobe were also taken with the endostapler. The intralobar pulmonary artery and the trunks to the basilar segments were dissected, and umbilical tape was used to retract the vessel away from the middle lobe bronchus in preparation for division and reconstruction of the airway.
With a scalpel, the middle lobe bronchus was cut free of the bronchus intermedius in wedge fashion, taking a margin of the bronchus intermedius and basilar segmental airways on either side of the middle lobe orifice, with its luminal tumor (Fig 2
, left, A) The contralateral wall was thus maintained intact, although nearly two thirds of the circumference of the airway was opened.
The lobe was placed in a specimen retrieval bag (Lap-Sac; Cook Medical; Bloomington, IN) and removed through the utility incision. After ensuring negative margins on frozen sectioning, six 4-0 absorbable sutures (Vicryl; Ethicon; Somerville, NJ) were used to close the bronchus (Fig 2, right, B). The sutures were tied extracorporeally and secured by hand or with the assistance of a knot pusher or forceps. The pericardial fat pad was harvested and tacked down to buttress the bronchoplastic closure. Finally, a lymph node dissection was performed. Flexible bronchoscopy verified a patent airway to the right lower lobe, without kinking or retained secretions. There were no intraoperative complications.
Chest tubes were removed postoperative day 3, and the patient was discharged in good condition on day 4. The final pathology report showed a 1.1 × 0.8-cm typical carcinoid tumor with negative margins and lymph nodes. At the 8-month follow-up, the patient was doing well, without evidence of recurrence on CT scan or examination.
Central typical carcinoid tumors of the lung often require bronchoplastic techniques combined with anatomic resection in order to preserve pulmonary parenchyma.2 One such technique is sleeve lobectomy, which requires a tubular bronchoplasty, in which the lobe is removed with a circumferential segment of airway, which is then anastomosed. Another is a wedge bronchoplasty, which resects a portion of the airway, in combination with lobectomy. Although this latter technique has been described via open thoracotomy and minithoracotomy,4–5 to our knowledge, this report is the first detailing a fully thoracoscopic, minimally invasive approach.
Several details of the operation should be restressed. First, EBUS was integral for preoperatively planning the margins of resection in the airway. As a more posterior utility incision would have been necessary to complete a tubular bronchoplasty, it was necessary to know the extent of tumor involvement of the airway at the outset of the operation. EBUS appears to be more accurate than CT alone in determining tumor infiltration in the airway.6Although this has not been described previously in surgical planning, the use of EBUS has been reported in the planning of bronchoscopic resection of carcinoid tumors because of its ability to determine tumor involvement of the airway (ie, beyond standard bronchoscopic assessment).7 Second, airway resection was facilitated by the dissection and retraction of the intralobar pulmonary artery to maximize exposure. Lastly, frozen-section analysis of the bronchial margin was essential to confirm the adequacy of resection.
The advantages of video-assisted lobectomy in regards to recuperation have been well established.8Parenchymal-sparing lung surgery has also been shown to have functional benefit, with the preserved lobe adequately contributing toward overall ventilation.9 In this patient, we were able to preserve the right lower lobe, while still ensuring a complete resection, in a completely thoracoscopic operation.
The patient gave his informed consent for the publication of this case report, which was exempt from review under the Beth Israel Deaconess Medical Center Institutional Review Board policy.
Abbreviation: EBUS = endobronchial ultrasound
The authors have no conflicts of interest to report.
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