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Clinical case: Incidental pneumonectomy: want to learn more about it?

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Clinical case: Incidental pneumonectomy

This article is an eye opener about the importance of proper preoperative preparation and meticulous analysis of a patient's anatomy. During a surgical intervention for lung cancer, the surgeons mistakingly resected the common trunk of the pulmonary vein in a patient that showed a degree of anatomical variability. Keep reading and see what happened in the end and what was the reason for this mistake.

Key facts
Hilum of the lung

It contains the following structures: primary bronchus, pulmonary artery and veins, bronchial arteries and veins, tracheobronchial lymph nodes, lymph vessels, and autonomic nerves.

Link between smoking and lung cancer The risk for lung cancer never goes away even after smoking cessation. Carcinogens in cigarette smoking cause permanent DNA mutations in epithelial cells, making them more susceptible to oncogenic transformation. Exposure to other environmental carcinogens even in the absence of smoking can now induce cancer in later years.
Lymphatics of the lungs The lymphatics of the lungs drain into the bronchopulmonary lymph nodes, which in turn drain into the tracheobronchial nodes. Lymph finally passes into the bronchomediastinal trunk.
Lung cancer staging Criteria includes tumour size, lymph node involvement, and the presence/absence of distal metastases (TNM classification).

After reviewing this case you should be able to describe the following:

  • The structures and anatomical relationships normally found at the hilum of the lung.
  • Why this patient likely had continued smoking cigarettes. Also, why even if he had stopped smoking many years ago, his cancer still likely was a result of that smoking. 
  • The lymph drainage and nodes of the lungs.
  • How sequential axial CT scans could have failed to show the common trunk of the superior and inferior pulmonary veins.
  • What is unique about this report in terms of the scientific literature?

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

Case description

History and investigations

Figure 1. Dissection image of the left lung showing the superior and inferior veins.

The patient is a 73-year-old male with suspected left lung cancer, which was characterized as stage Ia. A CT scan of the chest showed a rounded opacity (lesion) in the left upper lobe (Figure 2). Eight years ago, the patient had coronary atherectomy resulting from an old myocardial infarction with hyperlipidemia and hypertension.

Figure 2. Axial CT showing the tumor in the left upper lung lobe.

Management

A left upper lung lobectomy was now scheduled by open thoracotomy to remove the tumor. After the thoracotomy at the fifth intercostal space, the surgeons noted that the pleurae was adherent to the thoracic wall (Figure 3).

Figure 3. Cadaver image showing lungs covered by the parietal pleura. For the patient described in this case, the surgeons had difficulty separating the pleurae from the thoracic wall because of adhesions presumably due to the cancer.

The surgeons did not peel off the whole lesion from the lower lobe because of potential bleeding and air leaks resulting from possible injuries of the lower lobe, and therefore were unable to identify the exact location of the inferior pulmonary vein (IPV). The superior pulmonary vein (SPV) was exposed at its normal location (Figure 4).

Figure 4. Postoperative photograph showing extirpated lung with aberrant common left pulmonary venous trunk.

The interlobular arterial vessels were hidden within a moderate fibrotic adhesion. After division of the lung parenchyma and incomplete fissures, the interlobular pulmonary arterial branches were cut after ligation with sutures. The SPV was also sutured closed and then transected. As the upper bronchial veins were exposed, the surgeons found the that the IPV was not at its expected normal location. They then explored the intralobular peripheral venous tree of the resected SPV and found a small IPV that aberrantly formed a common trunk with the SPV (Figures 4&5).

Figure 5. Sequential CT images (A is superior to B). A. This axial level revealed the connection of the superior pulmonary vein (highlighted with green) with the common venous trunk; B. This axial level showed the connection of the inferior pulmonary vein (highlighted with green) and the common venous trunk.

The small IPV combined with the SPV in such a manner that the combined trunk could not be recognized as such intraoperatively. The surgeons thus then realized that they had inadvertently resected the common trunk of the SPV and IPV, mistaking the trunk for the SPV only.

Although the surgeons considered reconstructing the resected common trunk and IPV, this course was rejected in order to prevent possible postoperative complications such as pulmonary venous occlusion, congestion due to thrombus, and pulmonary edema due to the anastomotic stenosis. The surgeons decided to now perform a complete pneumonectomy with dissection of the mediastinal lymph nodes.

While the surgery was in progress, the surgeons explained to the patient’s family the unexpected adverse event and the conversion of the scheduled operation to a complete pneumonectomy. The surgeons obtained informed consent from the patient’s family. After the pneumonectomy, the patient’s postoperative recovery was good. 

Evolution

The postoperative pathology revealed the tumor to be an adenocarcinoma. During the 5.5-year follow-up, the patient remained healthy with good quality of life. Metastases did not develop and neither did local recurrences. At this time the postoperative pulmonary function test showed a restrictive pattern.

Anatomical and surgical considerations

Variations in the pulmonary venous drainage pattern are well known. The variation is based on how much of the pulmonary veins are incorporated into the left atrium during development. In order to perform a successful surgery for lung cancer, a preoperative evaluation on the staging, general anesthesia tolerance and preoperative risk are very important in surgical planning. Preoperatively, in this case there was a flawed determination of the anatomical location and relationship of vessels and bronchus. Although contrast enhanced CT was performed prior to surgery, the common trunk was poorly visualized (Figure 5). 

Figure 6. Overview of the medial surface of the lung.

The extirpated lung revealed that the SPV and IPV formed a common trunk inside the upper pulmonary lobe (Figure 4). During the operation the surgeons were unsure as to whether they should reconstruct the IPV or perform a complete pneumonectomy. They decided to perform the pneumonectomy in order to minimize postoperative complications such as postoperative venous occlusion and congestion of the lower lobe. Retrospectively, the CT images were reexamined and they did indeed show a small IPV that joined the SPV to form a common trunk. However this connection was not visible in any single axial image (Figure 5).

Although the present case was rare and the common trunk of the pulmonary vein was unexpectedly resected, the surgeons reported that they learned a basic lesson in thoracic surgery. That is, at the preoperative phase, detailed assessment of the pulmonary vascular anatomical locations and their three-dimensional relationships are essential

Clinical case: Incidental pneumonectomy: want to learn more about it?

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