JTCS Sign the Guestbook
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
James W. Klena
Joel A. Johnson
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Klena, J. W.
Right arrow Articles by Johnson, J. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Klena, J. W.
Right arrow Articles by Johnson, J. A.
Related Collections
Right arrow Minimally invasive surgery

J Thorac Cardiovasc Surg 2003;126:857-859
© 2003 The American Association for Thoracic Surgery

Brief communications

Video-assisted thoracoscopic resection for intralobar pulmonary sequestration: single modality treatment with video-assisted thoracic surgery

James W. Klena, MDa,*, Steven J. Danek, MD, FACP, FCCPb, Todd K. Bostwick, MDc, Melissa Romero, CNPa, Joel A. Johnson, MD, FACSa

a Cardiothoracic Surgery,a Marquette General Hospital, Marquette, Mich, USA
b Pulmonary Medicine,b Marquette General Hospital, Marquette, Mich, USA
c Radiology,c Marquette General Hospital, Marquette, Mich, USA

Received for publication December 14, 2002; accepted for publication January 28, 2003.

* Address for reprints: James W. Klena, MD, 528 Bishop Woods Road, Marquette, MI 49855, USA
jwklena{at}yahoo.com


Dr Klena


Pulmonary sequestration is an uncommon congenital malformation of the foregut. Intralobar sequestrations are delineated by investment of the visceral pleura, lack of communication with the tracheobronchial tree, arterial supply from the aorta, and venous drainage to the left atrium through the pulmonary veins. The lesions usually present with recurrent pneumonia. Traditional management of these lesions has included arteriography to identify the systemic blood supply followed by thoracotomy and lobectomy to resect the sequestration. We report the successful treatment of intralobar pulmonary sequestration with video-assisted thoracoscopic surgery (VATS). VATS allows single modality treatment of intralobar sequestration with reduced morbidity compared with traditional management.

Clinical summary

A 34-year-old woman, previously in good health, was admitted to our institution with a 4-month history of recurrent right lower lobe pneumonia and hemoptysis. The chest x-ray film revealed a persistent consolidation in the right lower lobe despite multiple courses of antimicrobial therapy. Bronchoscopic examination revealed blood in the right lower lobe bronchus but no other abnormalities. Cytology and culture results from the right lower lobe were negative. Spiral computed tomography (CT) of the thorax revealed a mass in the right lower lobe indicating a calcified aberrant blood vessel (Figure 1). The patient was referred to the cardiothoracic surgery service for definitive treatment. A VATS surgical exploration was planned.



View larger version (106K):
[in this window]
[in a new window]
  		Figure 1. Spiral CT scan of the lower lungs indicating a calcified aberrant feeder artery originating from the descending aorta to the area of right lower lobe consolidation (long arrow).

 
The patient was placed in a left lateral decubitus position. A single-lumen endotracheal tube was used with a bronchial blocker placed in the right main-stem bronchus. A 10-mm, 0-degree thoracoscope was used through a port site placed in the seventh intercostal space on the midaxillary line. Two additional port sites were placed in the fifth intercostal space on the anterior and posterior axillary lines, respectively. Port sites were chosen to facilitate the completion of a right lower lobectomy. VATS exploration revealed an aberrant blood vessel emerging from the diaphragm entering the posterior basal segment of the right lower lobe (Figure 2). The affected segment was noted to be consolidated and could be grossly differentiated from the rest of the right lower lobe parenchyma. There was no evidence of other abnormalities of the right lung or pleural space.



View larger version (127K):
[in this window]
[in a new window]
  		Figure 2. Intraoperative photograph of aberrant feeder artery to right lower lobe sequestration as it emerges from the diaphragm (long arrow).

 
The feeding artery from the descending aorta was meticulously dissected from surrounding tissue and divided using a 45-mm articulating endothoracic linear cutting device (Endopath ETS Flex 45, Ethicon, Inc, Cincinnati, Ohio) with 2.5-mm staples. The same device with 3.5-mm staples was used to perform a tailored wedge resection of the right lower lobe removing the sequestration. A single 36F chest tube was placed, and the lung was reinflated under direct thoracoscopic visualization. The complement of the right lower lobe appeared anatomically normal after resection of the sequestration.

The patient made an uneventful recovery. Her chest tube was removed on postoperative day 2, and she was discharged from the hospital on postoperative day 3. Final pathology reports revealed intra-alveolar hemorrhage with abnormal vasculature consistent with intralobar pulmonary sequestration. She remains in good health 3 months after surgery.

Comment

Pulmonary sequestrations are uncommon congenital malformations of the foregut. There are 2 types: intralobar and extralobar. Intralobar sequestrations are surrounded by visceral pleura, whereas extralobar sequestrations have their own pleura. Both types receive their arterial supply through feeding arteries from the systemic circulation, most commonly the descending aorta. The venous drainage from intralobar sequestrations is through the pulmonary venous system, whereas extralobar sequestrations always drain through systemic routes.1 Both types of sequestrations are usually asymptomatic, and presentation occurs when they become infected. Diagnosis requires a high index of suspicion. The importance of identifying aberrant blood supply has been advocated to reduce the possibility of serious hemorrhage during resection.

Surgical resection is the definitive treatment for pulmonary sequestration. Preoperative arteriography and open resection have been the recommended approaches for treating the malformation.2 Newer radiologic modalities such as spiral CT and magnetic resonance angiography have been used in place of arteriography recently, although open resection through posterolateral thoracotomy is still used.3 The ability of VATS to be used as both a diagnostic and therapeutic intervention for numerous thoracic disorders has been described.4 VATS lobectomy involving hilar dissection and endovascular division of lobar vessels has been used for non-small–cell lung cancers. In addition, VATS lobectomy for reasons other than malignancy has been advocated because of its reduced postoperative pain and decreased recovery period.5

VATS offers the surgeon and patient an alternative method of treatment for intralobar pulmonary sequestration. A presumptive diagnosis can be made from spiral CT. The diagnosis can be confirmed and treated with VATS exploration. Intralobar sequestrations with their venous outflow through the pulmonary veins are ideally suited to VATS resection. If control of the aberrant feeder artery can be obtained with endovascular techniques, a wedge resection of the sequestration or a formal lobectomy can than be performed safely. This method avoids the morbidity of arteriography and thoracotomy for the patient and allows a quicker recovery. Magnetic resonance angiography can also be a useful tool to delineate the vascular anatomy of the sequestration preoperatively.

References

  1. Clements BS, Warner JO. Pulmonary sequestration and related congenital bronchopulmonary malformations: nomenclature and classification based on anatomical and embryologic considerations. Thorax. 1987;42:401–408[Abstract/Free Full Text]
  2. Gustafson RA, Murray GF, Warden HE, Hill RC, Rozar GE. Intralobar sequestration. A missed diagnosis. Ann Thorac Surg. 1989;47:841–847[Abstract]
  3. Halkic N, Cuenoud PF, Corthesy ME, Ksontini R, Boumghar M. Pulmonary sequestration: a review of 26 cases. Eur J Cardiothorac Surg. 1998;14:127–133
  4. Demmy TL. Overview and general considerations for video-assisted thoracic surgery. Demmy TL. Video-assisted thoracic surgery (VATS). 1st ed. Georgetown (TX): Landes Bioscience; 2001. p. 1–24
  5. Wan IYP, Lee TW, Sihoe ADL, Ng CSH, Yim APC. Video-assisted thoracic surgery lobectomy for pulmonary sequestration. Ann Thorac Surg. 2002;73:639–640[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
S. Schena, T. D. Crabtree, J. B. Zoole, and G. A. Patterson
Intralobar pulmonary sequestration associated with an aneurysmal aberrant aortic branch
J. Thorac. Cardiovasc. Surg., August 1, 2007; 134(2): 535 - 536.
[Full Text] [PDF]

Home page
 ICVTSHome page
F. H.F. Tsang, S.-S. Chung, and A. D.L. Sihoe
Video-assisted thoracic surgery for bronchopulmonary sequestration
Interactive CardioVascular and Thoracic Surgery, August 1, 2006; 5(4): 424 - 426.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
P. B. Kestenholz, D. Schneiter, S. Hillinger, D. Lardinois, and W. Weder
Thoracoscopic treatment of pulmonary sequestration.
Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 815 - 818.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
C. R. Morse, M. B. Ishitani, and S. D. Cassivi
Video-assisted resection of bilateral intralobar pulmonary sequestrations
J. Thorac. Cardiovasc. Surg., April 1, 2006; 131(4): 917 - 918.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
P. de Lagausie, A. Bonnard, D. Berrebi, P. Petit, S. Dorgeret, and J. M. Guys
Video-Assisted Thoracoscopic Surgery for Pulmonary Sequestration in Children
Ann. Thorac. Surg., October 1, 2005; 80(4): 1266 - 1269.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
Y. Sato, S. Endo, N. Saito, S. Otani, T. Hasegawa, and Y. Sohara
A rare case of extralobar sequestration with hemoptysis
J. Thorac. Cardiovasc. Surg., November 1, 2004; 128(5): 778 - 779.
[Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
James W. Klena
Joel A. Johnson
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Klena, J. W.
Right arrow Articles by Johnson, J. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Klena, J. W.
Right arrow Articles by Johnson, J. A.
Related Collections
Right arrow Minimally invasive surgery

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS