VATS surgical anatomical resection of bronchopulmonary sequestration presenting as chest sepsis

Abstract

Background: Bronchopulmonary sequestration (BPS) is a malformation of the lungs resulting in lung tissue lacking direct communication to the tracheobronchial tree. Most cases demonstrate systemic arterial blood supply from the descending thoracic aorta, the abdominal aorta, celiac axis or splenic artery and venous drainage via the pulmonary veins with occasional drainage into azygos vein. BPS is considered a childhood disease and accounts for 0.15-6.40% of congenital pulmonary malformations. BPS is divided into intralobar sequestrations (ILS) and extralobar sequestrations (ELS) with ILS accounting for 75% of all cases.

Methods: Here we present our 11-year experience of dealing with BPS; all cases presented with recurrent chest sepsis in young-late adulthood regardless of the type of pathological sequestration. The surgical technique employed was a minimally invasive video-assisted thoracoscopic anterior approach (VATS).

Results: Between May 2010 and September 2021, we have operated on nine adult patients with bronchopulmonary sequestration who presented late with symptoms of recurrent chest sepsis. Most patients in the cohort had lower lobe pathology, with a roughly even split between right and left sided pathology. Moreover, the majority were life-long never smokers and an equal preponderance in males and females. The majority were extralobar sequestrations (56%) with pathological features in keeping with extensive bronchopneumonia and bronchiectasis. There were no major intra-operative or indeed post-operative complications. Median length of stay was 3 days.

Conclusions: Dissection and division of the systemic feeding vessel was readily achievable through a successful anterior VATS approach, regardless of the type of sequestration and without the use of pre-operative coiling of embolization techniques. This approach gave excellent access to the hilar structures yet in this pathology, judicious and perhaps a lower threshold for open approach should be considered.

Keywords: Broncho-pulmonary sequestration (BPS); Chest sepsis; Extralobar sequestration (ELS); Intralobar sequestration (ILS); Pneumonia; Video assisted thoracoscopic surgery (VATS).

Fig. 1

CT slices to illustrate feeding vessels from the retro-aortic position with posterolateral take-off (demarcated with arrows)

Fig. 2

Left sided VATS approach: aberrant direct aortic feeding vessel dissected out using hook diathermy and retro-posteriorly passed using right-angled instrument (left-hand panel). L sided VATS approach: aberrant aortic feeding vessel encircled using rubber sloup in preparation for division with vascular stapler (right-hand panel)

Fig. 3

Intra-operative image illustrating the extra-lobar sequestration with direct feeding from an aberrant intercostal artery (black arrow)

Fig. 4

Pre-operative PET-CT slice to correlate findings from Fig. 2. Within this consolidation, there is impression of a rounded abnormality on the PET component showing nodular peripheral activity (SUV Max 8.7) with central inactivity. This measures approximately 3.4 cm × 3.3 cm. The remainder of the consolidation shows no significant activity