Contralateral pulmonary resection using selective bronchial blockade in postpneumonectomy patients

Abstract

Background: Pulmonary resection is occasionally performed in postpneumonectomy patients with contralateral lung lesions, such as metachronous or metastatic lung cancer. Careful intraoperative respiratory management is essential in such patients. This study evaluated the respiratory management of postpneumonectomy patients who underwent contralateral pulmonary resection with selective bronchial blockade of the lobe or segment to be resected.

Methods: We retrospectively analyzed the surgical findings and safety of surgery in six patients who underwent contralateral pulmonary resection with selective bronchial blockade after pneumonectomy for non-small cell lung cancer (NSCLC).

Results: The percutaneous oxygen saturation did not decrease in any of the patients during bronchial blockade under high oxygen concentration. The median blockade time was 57.5 minutes. The operative field was tolerable secured under conditions of partial lung collapse, and partial pulmonary resection was performed as planned. Postoperatively, one patient developed acute respiratory distress syndrome due to acute exacerbation of interstitial pneumonia; however, no patients died within one month postoperatively. Two patients underwent pulmonary resection in order to obtain adequate tissue specimens to evaluate the biomarkers of multiple lung metastases. On histopathology, one patient tested positive for anaplastic lymphoma kinase (ALK) and was subsequently administered an ALK inhibitor, which prolonged survival.

Conclusions: In all patients, intraoperative respiratory condition under partial lung collapse remained stable, and all partial pulmonary resections were safely performed. However, surgical indications should be carefully reviewed preoperatively in patients with interstitial pneumonia.

Key points: SIGNIFICANT FINDINGS OF THE STUDY: Contralateral partial pulmonary resection was performed using selective bronchial blockade in postpneumonectomy patients. Percutaneous oxygen saturation did not decrease during the bronchial blockade under high oxygen concentration, and the operative field was tolerable secured under conditions of partial lung collapse.

What this study adds: Oxygen concentration can be set to the minimum level, sufficient to maintain oxygenation, during contralateral partial pulmonary resection with selective bronchial blockade.

Keywords: Lung cancer; postpneumonectomy; pulmonary resection; selective bronchial blockade; video-assisted thoracoscopic surgery.

Figure 1

Selective bronchial blockade method. The wire‐guided endobronchial blocker is advanced through the blocker port (yellow arrow), and a bronchoscope is passed through the wire loop of the endobronchial blocker (red arrow). The bronchoscope is then inserted into the desired bronchus, and the endobronchial blocker is placed into position. The bronchoscope is removed, and the balloon of the blocker is inflated.

Figure 2

Computed tomography images of Case 1. (a) Interstitial pneumonia is observed in the left lower lobe before surgery. (b) Acute exacerbation of interstitial pneumonia developed on postoperative day 5. (c) After high‐dose corticosteroid pulse therapy and blood purification therapy, the ground‐glass shadow improved on postoperative day 38.

Figure 3

Clinical findings of Case 4. (a) Chest radiography after left pneumonectomy. (b) Computed tomography image shows a 1.4 cm sized lung tumor in the right 10th segment (red arrow). (c) In respiratory management, the endobronchial blocker is positioned in the right basal segmental bronchus. (d) Surgical findings show that partial pulmonary resection is performed under partial lung collapse by video‐assisted thoracoscopic surgery (VATS). The white arrow indicates a VATS marker. The yellow arrows indicate the nonventilated lung of the right lower lobe, which is the right basal segment. S6, right sixth segment.