Ex situ reimplantation technique, in central lung tumors

Abstract

Background: The parenchyma-sparing resection is most often performed in patients with impaired preoperative lung or cardiovascular function who would not be able to tolerate a pneumonectomy.

Methods: Our experience on the ex situ reimplantation procedure and the outcome of patients with lung malignancies, who underwent upper or upper-middle lobectomy, with reimplantation of the lower lobe was reported.

Results: We present 9 patients mean age 62.6+16.2 years (7 males/2 females) underwent ex situ reimplantation due to extensive lung tumor of upper lobes. The surgical technique precludes IV heparinization and then radical pneumonectomy. The entire lung was immersed in Ringer's solution (temperature 4 degrees centigrade) and bench surgery was performed. The involved upper (or upper-middle) lobes with involved lymph nodes were resected, thus leaving the healthy lower lobe of the lung. Pneumoplegia solution, named "Papworth pneumoplegia", was administered (1,473 mL) through catheterization of the pulmonary artery and vein stumps (ante grade and retrograde) along with 250 mL of prostaglandin E1. Re-implantation of the lower lobe was performed (I) on the right side, implantation involved the anastomosis of lower pulmonary vein in the site of the cuff of left atrium, followed by suturing the stump of the intermedius pulmonary artery to the right main pulmonary artery and finally the bronchial stumps-intermedius bronchus to the right main bronchus; (II) on the left side the pulmonary vein was anastomosed first, followed by the bronchial stumps and finally by the pulmonary artery. The graft ischemia time was 70.2+8.4 minutes ranged between 55 and 80 minutes.

Conclusions: Re-implantation or auto-transplantation should be considered as a safe option for the appropriate patient with lung cancer. The ex situ separation of the cancerous lobes is technically feasible and allows extensive pulmonary resection while minimizing the loss of pulmonary reserve. Based on our work, the major factors that play a role for the survival of initially resected and then re-implanted lung graft, are: (I) the ischemia time of the re-implanted lobe; (II) the proper use of pneumoplegia solutions, along with prostaglandin E1 and heparin; (III) the occurrence of pulmonary vein thrombosis; and (IV) the bronchial anastomosis.

Keywords: Non-small lung cancer; auto-transplantation; bench surgery; ex situ; re-implantation.

Figure 1

CT of the thorax findings and bronchoscopy findings.

Figure 2

Intraoperative findings of the patient No.1, showed extensive infiltration of pulmonary artery by a lung tumor. In such cases, the decision by the surgeon was the ex situ re-implantation technique.

Figure 3

The left lower lobe is showed out of the thorax into the “surgical bowl”—the meaning of bench surgery—just before the re-implantation procedure begins. Also, the antegrade administration of pneumoplegia solution, named “Papworth pneumoplegia”, is showed through catheterization of the pulmonary artery, along with prostaglandin E1.

Figure 4

The left lower lobe is showed out of the thorax during the retrograde administration of pneumoplegia solution, along with prostaglandin E1 through catheterization of the pulmonary veins. The administration of this solution is necessary to be infused through pulmonary artery and veins in order to “close the loop” of lung lobe vessels and to maximize the protection of these structures from thrombosis.

Figure 5

Schematic depiction of the re-implantation technique of the right lower lobe. This technique involved the anastomosis of lower pulmonary vein in the site of the cuff of left atrium, followed by suturing the stump of the intermedius pulmonary artery to the right main pulmonary artery. The bronchial stumps—intermedius bronchus to the right main bronchus—were stitched together at the end of the procedure.

Figure 6

Schematic depiction of the re-implantation technique of the left lower lobe. In this technique the sequence of anastomosis differed to that from the right lung; the pulmonary vein was anastomosed first, followed by the bronchial stumps and finally by the pulmonary artery.

Figure 7

Intraoperative anastomoses of the left lower bronchus to the left main bronchus. The double lumen endotracheal tube was showed through the main left bronchus.

Figure 8

Intraoperative anastomoses of the left lower artery to the left main pulmonary artery. This is the last anatomical anastomosis of the left side re-implantation technique. In this figure also the surgical resolution of the mismatching between the diameters of the lumen of the left lower pulmonary artery to the one of the left main pulmonary artery is showed.

Figure 9

Post surgery evaluation (1^st day) with bronchoscopy and chest X-ray.