Importance of preoperative imaging with 64-row three-dimensional multidetector computed tomography for safer video-assisted thoracic surgery in lung cancer

Development of the Split-Bolus Pulmonary Arteriovenous Separating Computed Tomography Angiography Protocol Based on Time Enhancement Curve for Lung Cancer Surgery

OBJECTIVE

We devised a split-bolus injection and imaging protocol for pulmonary artery and vein separation computed tomography (CT) angiography based on time enhancement curve characterization. Furthermore, we aimed to evaluate the contrast enhancement effect and success rate of blood vessel separation between the pulmonary artery and vein of this proposed protocol.

METHODS

In this study, 102 patients (45 patients with the standard protocol and 57 patients with the proposed protocol) who underwent pulmonary arteriovenous computed tomography angiography were included. The CT values of various vessels, CT value difference between the pulmonary trunk and left atrium, and coefficient of variation in pulmonary arteries and veins were obtained from images of the standard and proposed protocols.

RESULTS

The CT values in the proposed protocol for the pulmonary trunk were significantly higher than those in the standard protocol (487.3 [415.5-546.9] HU vs. 293.0 [259.0-350.0] HU, P < 0.01). The CT value difference between the pulmonary trunk and left atrium in the proposed protocol was significantly higher than that in the conventional protocol (211.3 [158.0-265.7] HU vs. 32 [-30.0-55.0] HU, P < 0.01). The coefficient of variation in the proposed protocol was 0.08 (0.06-0.10) and 0.09 (0.08-0.11) in pulmonary arteries and 0.08 (0.06-0.09) and 0.09 (0.07-0.12) in pulmonary veins, respectively.

CONCLUSIONS

The proposed protocol achieved separation between the pulmonary artery and vein in many patients, making it useful for the preoperative assessment of individual thoracic anatomy.

Prospective randomized study on the efficacy of three-dimensional reconstructions of bronchovascular structures on preoperative chest CT scan in patients who are candidates for pulmonary segmentectomy surgery: the PATCHES (Prospective rAndomized sTudy efficaCy of tHree-dimensional rEconstructions Segmentecomy) study protocol

INTRODUCTION

Pulmonary segmentectomy, when combined with hilar and mediastinal lymphadenectomy, is currently considered the gold standard treatment for early-stage lung tumors (NSCLC) smaller than 2 cm in diameter. The preoperative planning for segmentectomies usually includes a contrast-enhanced CT with 2D reconstructions (axial, coronary, and sagittal). Recent technological advances allow 3D (volume rendering) reconstructions of preoperative CT scans, intended to improve the surgeon's understanding of the segmental anatomy. The study aims to investigate the added value of 3D reconstruction in enhancing the surgeon's understanding of anatomical structures, thus facilitating surgical planning and improving oncological outcomes.

METHODS AND ANALYSIS

This is a prospective, randomized, controlled study. Patients will be randomized into two groups: 1. Group 2D: the preoperative workup for these patients will consist of a contrast-enhanced chest CT with two-dimensional (2D) reconstructions (axial, coronary, and sagittal); 2. Group 3D: the preoperative workup for these patients will consist of a contrast-enhanced chest CT with two-dimensional (2D) reconstructions (axial, coronary, and sagittal) and a 3D reconstruction (volume rendering) of the same chest CT employing dedicated software. The primary endpoints will be negative margin (R0) resection rate, resection margin (staple line-to-tumor distance), and thoracotomy conversions. We will use Fisher's exact test for binary outcomes and Mann-Whitney U test for continuous outcomes. For subgroup analyses, we will use regression. Multivariable analyses will be based on logistic regression for binary outcomes and linear regression for continuous outcomes.

ETHICS AND DISSEMINATION

The protocol and the model informed consent forms have been reviewed and approved by the ethics committee (N.: 1-2023) concerning scientific content and compliance with applicable research and human subject regulations. A Subcommittee on Publications was established to review all publications and report its recommendations to the steering committee. The anonymized participant-level dataset and statistical code for generating the results will not be publicly available.

TRIAL REGISTRATION

The protocol was registered at ClinicalTrials.gov (ID: NCT05716815; Prospective rAndomized sTudy efficaCy tHree-dimensional rEconstructions Segmentectomy - Full-Text View - ClinicalTrials.gov). Jan 19, 2023.

An analysis of the left top pulmonary vein and comparison with the right top pulmonary vein for lung resection by three-dimensional CT angiography and thin-section images

PURPOSE

The right top pulmonary vein (RTPV) is defined as an anomalous branch of the right superior PV (SPV) draining into the PV or left atrium (LA). Several previous reports have described the RTPV, but only a few have mentioned the left top PV (LTPV). The present study aimed to evaluate the branching patterns of the RTPV and LTPV using thin-section CT images and three-dimensional CT angiography (3D-CTA).

MATERIALS AND METHODS

This study included 1437 consecutive patients for evaluation of the right side and 1454 consecutive patients for the left side who were suspected of lung cancer and underwent CTA. We assessed the presence of each RTPV and LTPV and their branching patterns on the CTA images. When the RTPV or LTPV was identified, the maximum short-axis diameter was measured.

RESULTS

RTPV was found in 9.1% (131/1437), whereas LTPV was found in 2.9% (42/1454) of the patients. RTPV was also observed in 17.1% (7/41) of LTPV cases, except for one case in which the right side could not be evaluated. The most common RTPV inflow site was the right inferior PV (IPV) in 64.9% (85/131) of the patients, whereas that of the LTPV was the left IPV in 100.0% (42/42) of the patients. The mean diameter of the RTPV and LTPV was 3.3 mm (range, 1.3-7.5 mm) and 2.4 mm (range, 0.9-6.3 mm), respectively (P < 0.01).

CONCLUSION

The top PV branching pattern variations can be evaluated using thin-section CT and 3D-CTA images. RTPV is not a rare finding, and LTPV should also be identified in lung cancer cases scheduled for resection.

Prevalence and anatomical characteristics of subsuperior segment in lung lower lobe

OBJECTIVE

The subsuperior segment is an atypical pulmonary segment of the lung lower lobe. With the increased application of segmentectomy, it has received increased attention from thoracic surgeons. Studies of the subsuperior segment are scarce and mostly on the basis of small-sample autopsy studies, whose described characteristics are inconsistent with intraoperative observations. Our objective was to accurately define the subsuperior segment and elucidate its prevalence and anatomical characteristics in detail.

METHODS

A total of 2194 chest computed tomography images were obtained using separate random sampling on the basis of the amount of data available to each of the 6 thoracic surgery institutions in different provinces covering various regions of China. All of the images were reconstructed in 3 dimensions. Subsuperior segments were screened according to their new definition and statistically analyzed for their prevalence and anatomical characteristics.

RESULTS

The prevalence of subsuperior segments was 32.04%, with 413 on the right (18.79%); the value was higher than that on the left (347; 15.81%). The average volume of the subsuperior segment was 52.81 ± 21.96 cm3. Only 1 bronchus was detected in the unilateral subsuperior segment, with an average diameter of 2.53 ± 0.61 mm. Only 1 pulmonary artery was observed in most of the subsuperior segments (89.34%), but 81 cases (10.66%) had 2 in our study. One intersegmental vein of the subsuperior segment was the most common situation on both sides.

CONCLUSIONS

Using a multicenter large-sample study, we calculated a 32.04% prevalence and systematically detailed the anatomical characteristics of the subsuperior segment in the lung lower lobe, corrected previous reports, and supplemented pulmonary anatomical studies.

Multiscale reconstruction of bronchus and cancer cells in human lung adenocarcinoma

BACKGROUND

While previous studies primarily focused on the structure of the normal whole mouse lung, the whole bronchus and cytoarchitectural details of the mouse intact lung lobe have been discovered at single-cell resolution. Revealing the sophisticated lung adenocarcinoma structure at three-dimensional (3D) and single-cell level remains a fundamental and critical challenge for the pathological mechanism research of lung adenocarcinoma (LA).

METHODS

Fluorescence micro-optical Sectioning Tomography (fMOST) combined with PI staining were used to obtain the 3D imaging of the human LA tissue at single-cell resolution.

RESULTS

With a spatial resolution of 0.32 × 0.32 × 1.0 μm³, the dataset of human LA with single-cell precision consists of two channels, each of which contains information about the bronchi and the cytoarchitecture. The bronchial wall is thicker and the lumen is smaller in the cancer tissue, in which its original normal structure is vanished. More solid components, more clustered cancer cells with larger nucleoli, and more significant atypia are found in cancer tissue. In paracancerous tissue, the bronchial wall cells have a monolayer or bilayer structure, cluster along the wall, and are relatively dispersed. Few fibrous structures and occasional dissemination of spread through air spaces (STAS) are observed.

CONCLUSIONS

Based on the human LA tissue dataset obtained by fMOST and PI staining, the bronchi and cells were reconstructed and visualized. This work provides a technical roadmap for studying the bronchus and cytoarchitectural structure and their spatial relationship in LA tissue, which may help with the understanding of the main histological structure of LA among pathologists.

Application of three-dimensional computed tomography imaging and reconstructive techniques in lung surgery: A mini-review

Background

Pulmonary surgery is an innovative discipline with increasing demands for minimally invasive techniques in complicated anatomical resections, warranting adequate preoperative imaging of relevant surgical anatomy to ensure safe and radical resection of target lesions. Over the recent years, the emergence of imaging techniques enabling three-dimensional reconstruction has exerted promising influence on pulmonary surgery, facilitating optimal surgical planning and easier identification of the spatial relationship between bronchovascular structures in the individual patient and aiding the safe resection of target pulmonary lesions. The goal of this mini-review is to provide an overview of three-dimensional computed tomography imaging within pulmonary surgery.

Methods

The authors performed a targeted qualitative review of the literature to identify current trends and to provide better understanding of three-dimensional reconstruction within the boundaries of pulmonary surgery.

Results

Three-dimensional reconstructive techniques can be used for resectability assessment, identification of surgically relevant interindividual anatomic variance and may improve perioperative outcomes.

Discussion

Three-dimensional reconstruction using computed tomography imaging improves surgical planning and there is evidence that it results in shorter operative times, less intraoperative blood loss and lower rates of surgical conversion, as it can be applied both pre- and intraoperatively.

Accuracy and efficiency of an artificial intelligence-based pulmonary broncho-vascular three-dimensional reconstruction system supporting thoracic surgery: retrospective and prospective validation study

BACKGROUND

Anthropomorphic phantoms are used in surgical planning and intervention. Ideal accuracy and high efficiency are prerequisites for its clinical application. We aimed to develop a fully automated artificial intelligence-based three-dimensional (3D) reconstruction system (AI system) to assist thoracic surgery and to determine its accuracy, efficiency, and safety for clinical use.

METHODS

This AI system was developed based on a 3D convolutional neural network (CNN) and optimized by gradient descent after training with 500 cases, achieving a Dice coefficient of 89.2%. Accuracy was verified by comparing virtual structures predicted by the AI system with anatomical structures of patients in retrospective (n = 113) and prospective cohorts (n = 139) who underwent lobectomy or segmentectomy at the Peking University Cancer Hospital. Operation time and blood loss were compared between the retrospective cohort (without AI assistance) and prospective cohort (with AI assistance) for safety evaluation. The time consumption for reconstruction and the quality score were compared between the AI system and manual reconstruction software (Mimics®) for efficiency validation. This study was registered at https://www.chictr.org.cn as ChiCTR2100050985.

FINDINGS

The AI system reconstructed 13,608 pulmonary segmental branches from retrospective and prospective cohorts, and 1573 branches of interest corresponding to phantoms were detectable during the operation for verification, achieving 100% and 97% accuracy for segmental bronchi, 97.2% and 99.1% for segmental arteries, and 93.2% and 98.8% for segmental veins, respectively. With the assistance of the AI system, the operation time was shortened by 24.5 min for lobectomy (p < 0.001) and 20 min for segmentectomy (p = 0.007). Compared to Mimics®, the AI system reduced the model reconstruction time by 14.2 min (p < 0.001), and it also outperformed Mimics® in model quality scores (p < 0.001).

INTERPRETATION

The AI system can accurately predict thoracic anatomical structures with higher efficiency than manual reconstruction software. Constant optimization and larger population validation are required.

FUNDING

This study was funded by the Beijing Natural Science Foundation (No. L222020) and other sources.

Clinical application of bronchial high-frequency ventilation in 2-port thoracoscopic segmentectomy

To evaluate the safety and clinical application of a computer-aided surgery system (CAS) combined with high-frequency bronchial ventilation in 2-port thoracoscopic anatomical segmentectomy. A total of 301 patients who underwent 2-port thoracoscopic segmentectomy between January 1, 2019 and March 1, 2022 in the 960th Hospital of the People's Liberation Army and the Department of Thoracic Surgery of Zibo Municipal Hospital were retrospectively analyzed. The experimental and control groups were created according to the different methods of appearing the intersegmental plane of the lung. The experimental group comprised 152 patients who underwent CAS reconstruction combined with high-frequency ventilation, and the control group comprised 149 patients who underwent CAS reconstruction combined with expansion collapse. The characteristics of the patients, including age, sex, smoking history, forced expiratory volume in 1 second/forced vital capacity, Maximal ventilation, diameter of pulmonary nodules, intraoperative blood loss, postoperative drainage volume, drainage tube removal time, length of hospital stay after extubation, postoperative complication rate, operation time and appearance time of the intersegmental plane, were compared between the 2 groups. All patients completed the operation between high-frequency bronchial ventilation and expansion collapse group. There was no significant difference in Forced expiratory volume in 1 second/Forced vital capacity [(101.05 ± 11.86) vs (101.86 ± 11.61)], maximum expiratory volume [(86.36 ± 17.59 L) vs (85.28 ± 17.68 L)], the diameter of lung nodules [(13.61 ± 3.51 cm) vs (13.21 ± 3.41 cm)], intraoperative blood loss [(47.50 ± 45.90 mL) vs (48.49 ± 34.65 mL)], postoperative drainage volume [(425.16 ± 221.61 mL) vs (444.70 ± 243.72 mL)], drainage tube removal time [(3.88 ± 1.85 days) vs (3.43 ± 1.81 days)], or postoperative hospital stay [(6.07 ± 2.14 days) vs (5.82 ± 1.88 days) between the experimental group and the control group (P > .05)]. There were significant differences in operation time [(95.05 ± 26.85 min) vs (117.85 ± 31.70 min), P = .017] and intersegmental plane appearance time [(2.37 ± 1.03 min) vs (14.20 ± 3.23 min), P < .001]. High-frequency bronchial ventilation is safe and feasible when used in quickly and accurately identifying the intersegmental plane and is worthy of clinical application in 2-port thoracoscopic segmentectomy.

Progress in three-dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy

The number of minimally invasive surgeries, such as video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery, has increased enormously in recent years. More and more relevant studies report that anatomic pulmonary segmentectomy has the same effect as traditional lobectomy in the surgical treatment of early stage non-small cell lung cancer (diameter less than 2.0 cm). Segmentectomy requires sufficient knowledge of the location of the pulmonary nodules, as well as the anatomy of the target segments, blood vessels, and bronchi. With the rapid development of imaging technology and three-dimensional technology, three-dimensional reconstruction has been widely used in the medical field. It can effectively assess the vascular branching patterns, discover the anatomic variations of the blood vessels and bronchi, determine the location of the lesion, and clarify the division of the segments. Therefore, it is helpful for preoperative positioning, surgical planning, preoperative simulation and intraoperative navigation, and provides a reference for formulating an individualized surgical plan. It therefore plays a positive role in anatomic pulmonary segmentectomy. This study reviews the progress made in three-dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy.

Left Lower Lobectomy in a Patient with Absence of Pulmonary Artery Branching into the Lobe

Here, we report a case in which we resected non-small cell lung cancer of left lower lobe and detected an anomaly in the resected lobe. Three-dimensional computed tomography showed more detailed information on this anomaly than the conventional one. Since we recognized the information regarding anomaly before the operation, we accomplished left lower lobectomy and an uneventful post-operative course. If carcinoma had existed in the other lobe, intra- and post-operative course would have become more serious. Thus, it is essential to pay attention to the information of anatomical abnormality when resecting malignant tumors.

[Single-phase Pulmonary Arteriovenous Separation CT Protocol with Estimated Time of Arrival Method Using 3rd Generation Dual Source CT: Its Success Rate of Pulmonary Arteriovenous Separation in Our Experience of 223 Cases]

We retrospectively investigated the success rate of pulmonary arteriovenous separation in a single-phase computed tomography (CT) protocol using the estimated time of arrival (ETA) method. A total of 223 patients who underwent a single-phase CT protocol using the ETA method for pulmonary arteriovenous separation were included in the analysis. Dual source CT (SOMATOM Force, SIEMENS) was used for imaging. The tube voltage was 80 kVp, and the scan mode was turbo flash spiral mode. CT values of main pulmonary artery (MPA), peripheral pulmonary artery (pPA), peripheral pulmonary vein (pPV), left atrium (LA), ascending aorta (AAo) and descending aorta (DAo) were measured. When the difference in CT values on the central side was 100 Hounsfield unit (HU) or more, it was judged that the separation was successful. The mean CT values were 671.9±154 HU for MPA, 424.4±81.2 HU for LA, 551.1±142.6 HU for pPA, 351.6±94.0 HU for pPV, 362.2±75.8 HU for AAo, and 282.7±83.7 HU for DAo. The mean difference in CT values of the pulmonary artery and vein was 247.5±138.9 HU on the central side and 199.5±133.0 HU on the peripheral side. There were 90.1% of cases where the difference in CT values on the central side was 100 HU or more. In addition, a strong positive correlation (r=0.849, p<0.001) was found between the CT value of MPA and the CT value difference on the central side. The success rate of pulmonary arteriovenous separation by the ETA method, which is a method that enables stable pulmonary arteriovenous separation, was 90.1%.

Three-dimensional virtual planning for nodule resection in solid organs: A systematic review and meta-analysis

OBJECTIVES

To systematically review the effects of 3D-imaging virtual planning for nodule resection in the following solid organs: lung, liver, and kidney.

METHODS

MEDLINE, EMBASE, and Cochrane Library were searched through September 31, 2020 to include randomized and non-randomized controlled studies that compared outcomes of surgical resection of lung, liver, or kidney nodule resection with and without 3D virtual planning with computed tomography. From each article, the mean operation time (OT), mean estimated blood loss (EBL), mean postoperative hospital stay (POHS), and the number of postoperative events (POE) were extracted. The effect size (ES) of 3D virtual planning vs. non-3D planning was extracted from each study to calculate the pooled measurements for continuous variables (OT, EBL, POHS). Data were pooled using a random-effects model.

RESULTS

The literature search yielded 2397 studies and 10 met the inclusion criteria with a total of 897 patients. There was a significant difference in OT between groups with a moderate ES favoring the 3D group (ES,-0.56; 95%CI: 0.91,-0.29; I² = 83.1%; p < .001). Regarding EBL, there was a significant difference between 3D and non-3D with a small ES favoring IGS (ES,-0.18; 95%CI: 0.33,-0.02; I² = 22.5%; p = .0236). There was no difference between the 3D and non-3D groups for both POHS (POHS ES,-0.15; 95%CI: 0.39,0.10; I² = 37.0%; p = .174) and POE (POE odds ratio (OR),0.80; 95%CI:0.54,1.19; I² = 0.0%; p = .0.973).

CONCLUSIONS

3D-imaging planning for surgical resection of lung, kidney, and liver nodules could reduce OT and EBL with no effects on immediate POHS and POE. Improvements in these perioperative variables could improve medium and long-term postoperative clinical outcomes.

Outcome of thoracoscopic anatomical sublobar resection under 3-dimensional computed tomography simulation

BACKGROUND

Previous studies have reported the feasibility and efficacy of thoracoscopic anatomical sublobar resection under three-dimensional computed tomography (3DCT) simulation; however, its long-term outcomes have not been clearly established in primary lung cancer. This study aimed to evaluate the long-term outcomes of this technique.

METHODS

We retrospectively reviewed data from 112 consecutive patients with selected clinical stage IA non-small cell lung cancer (NSCLC) who underwent thoracoscopic anatomical sublobar resection from 2004 to 2014. This procedure was planned using preoperative 3DCT simulation to ensure sufficient surgical margins and enabled tailor-made surgery for each patient. Patients who had predominantly ground glass opacity lung cancers underwent anatomical sublobar resection as a curative-intent resection. Other patients who were high-risk candidates for lobectomy underwent anatomical sublobar resection as a compromised limited resection.

RESULTS

Of the 112 cases, 82 had a curative-intent resection, while 30 had a compromised limited resection. Recurrence occurred in only 2 cases (1.8%), both of which were in the compromised limited group. A second primary lung cancer was observed in 5 cases (4.5%). Of the 5 patients, 4 underwent surgery for a second cancer and had no recurrence. The 5-year overall survival, lung cancer-specific overall survival, and recurrence-free survival rates were 92.5%, 100%, and 98.2%, respectively, for all cases; 97.6%, 100%, and 100%, respectively, in the curative-intent group; and 75.8%, 100% and 92.6%, respectively, in the compromised limited group.

CONCLUSIONS

Thoracoscopic anatomical sublobar resection under 3DCT simulation may be an acceptable alternative treatment in selected patients with NSCLC.

TRIAL AND CLINICAL REGISTRY

Clinical registration number: IRB No. 2020-98 (Dated: 2020.6.30).

Augmented Reality and 3-Dimensional Printing Technologies for Guiding Complex Thoracoscopic Surgery

BACKGROUND

Virtual 3-dimentional models of the lungs have been used for guiding thoracoscopic procedures including segmentectomy and subsegmentectomy. However, the virtual models displayed on the screen were not tangible. A printed model with assistance of augmented reality (AR) might add value to guide surgical performance. We wanted to investigate whether the combined technology with patient-specific printed models and the AR display could offer better surgical outcomes than the on-screen models in complex thoracoscopic surgery.

METHODS

A total of 142 patients with early lung cancers undertaking thoracoscopic segmentectomy or subsegmentectomy. The 3-dimentional lung models were either displayed on screen (n = 87) or printed out and displayed using AR (n = 55) in the operating room. A propensity score-matching analysis was used to compare the surgical outcomes between the 2 groups.

RESULTS

The surgical outcomes data before and after propensity score matching showed 3-dimensional printing with AR had a shorter operating time (P = .001 and .001, respectively), less intraoperative blood loss (P = .024 and .006, respectively), and shorter length of hospital stay (P = .001 and .001, respectively) than the on-screen group. The complications and operating success rate (P = .846 and >.999, respectively) and (P = .567 and >.999, respectively) were not significantly different. Surgeons gave a higher score in the tangible group than in the on-screen group (P = .001 vs .001, respectively).

CONCLUSIONS

The printed 3-dimentional models enabled surgeons to see and touch interior structures of the lung. The AR provided instant guidance to the surgery in the operating room. The combination of these technologies produced positive values in guiding laparoscopic lung surgery.

Preoperative evaluation of the segmental artery by three-dimensional image reconstruction vs. thin-section multi-detector computed tomography

Background

“Exoview” is a three-dimensional (3D) image reconstruction software developed by our medical team independently. The aim of this retrospective study was to compare the use of 3D image reconstruction, and thin-section multi-detector computed tomography (MDCT) in the preoperative evaluation of the segmental artery (SA).

Methods

From May 2018 to May 2019, 52 patients received anatomical segmentectomy in our department. All patients received computed tomography pulmonary angiography (CTPA) by use of a 64-slice MDCT before operation. Then the 2D CT data were converted into 3D format by use of Exoview. We compared the intraoperative findings of the SA branches with 3D images and thin-section MDCT.

Results

The study cohort of 52 patients included 31 women and 21 men and the operative factors include operation time (148.75±53.56 min), blood loss (57.31±79.68 mL), postoperative hospitalization days (6.42±3.48 days), lymph node sampling (3.00±1.50 stations) and postoperative complications (5 patients, 10%). The adenocarcinoma in situ with microinvasion was the predominant type (25 cases, 48%). There were 7 patients accepted for video-assisted thoracoscopic surgery (VATS) lobectomy with radical lymph nodes dissection because invasive adenocarcinoma was confirmed by intraoperative frozen-section analysis. One other patient was confirmed for conversion from VATS segmentectomy to an open operation because of bleeding of the bronchial artery. According to intraoperative findings, 95.7% (132 of 138) and 100% (138 of 138) of these SA branches were precisely identified on preoperative 3D image reconstruction and thin-section MDCT images. The 6 missed branches were less than 1.4 mm in actual diameter.

Conclusions

Both 3D image reconstruction and thin-section MDCT provided precise preoperative information about SA. The 3D image reconstruction software “Exoview” could visualize SA for surgeons. However, the thin-section MDCT provided a better evaluation of small SA branches.

An analysis of anatomical variations of the left pulmonary artery of the interlobar portion for lung resection by three-dimensional CT pulmonary angiography and thin-section images

PURPOSE

The purpose of the present study was to analyze the left pulmonary artery (LPA) branching pattern of the interlobar portion using three-dimensional CT pulmonary angiography (3D-CTPA) and thin-section CT images, and to attempt to diagrammatize these patterns.

MATERIALS AND METHODS

The study included 320 patients suspected of having lung cancer of the left upper/lower lobe who underwent CTPA. The number and origin of the LPA branches of the interlobar portion, A1 + 2c, A6, and lingular artery from pars interlobaris (PI), were identified meticulously using 3D-CTPA and thin-section images. We then diagrammatized the identified LPA branching patterns of the interlobar portion.

RESULTS

The diagrammatized LPA branching patterns of the interlobar portion were broadly classified into seven types in the order of bifurcation from proximal to distal. Type 1 was the most frequent (120/320, 37.5%). PI originated from the lower portion, that is, from A8 or the common trunk of A8 and A9 in 95 cases (29.7%). We could also precisely diagrammatize the LPA branching patterns of the interlobar portion into 85 types in all 320 patients.

CONCLUSION

3D-CTPA and thin-section images provided precise preoperative information regarding the LPA branching patterns of the interlobar portion.

Pulmonary veins variations with potential impact in thoracic surgery: a computed-tomography-based atlas

Background

Pulmonary veins (PVs) are important during segmentectomy. Many case reports prove that they may be the source of bleeding during surgery, especially when anatomical variants are present. We decided to describe venous variations and prepare a computed tomography based atlas of our observations.

Methods

The study was conducted using 135 chest computed tomography studies with intra venous iodine contrast injection. The study population contained 86 females and 49 males, mean age was 60. Thirteen people had atrial fibrillation. Images were analysed using radiological workstation.

Results

The variations were divided into three categories: atypical topography of the PV, atypical venous outflow to the left atrium (LA), atypical venous vascularization of the lung bronchopulmonary segment. Retrobronchial course of the vein of the posterior segment of the right upper lobe was observed in 8.15%. The most common variant of atrial venous outflow was the direct outflow of the middle lobe vein, observed in 25.19% of cases and the long common trunk of left PVs in 11.11%. The split drainage from the middle lobe into the right superior pulmonary vein (RSPV) and the right inferior pulmonary vein (RIPV) was observed in 9.63% as the full drainage into the RIPV in 2.96%.

Conclusions

Long common trunk of left PVs and numerous variants of venous vascularisation of the middle lobe are the variations that may pose potential problems during thoracic surgeries. The frequency is high enough to justify the routine assessment of pulmonary vessels with computed tomography before surgery.

[Utility of Split-bolus Single-phase Protocol for Pulmonary Artery and Vein Separation Preoperative 3D-CTA in Lung Cancer Video-assisted Thoracic Surgery]

There are many variations in branching and running of pulmonary artery (PA) and pulmonary vein (PV). It is desirable to separate as a surgical simulation of lung cancer and important to grasp before video-assisted thoracic surgery (VATS) to perform quick and safe. Therefore, the purpose of this study was to evaluate objective and subjective image quality (contrast attenuation, separation ability, and vascular visualization) of PA and PV of splitbolus single-phase protocol (SBSPP) in preoperative three-dimensional computed tomography angiography (3DCTA). CT value of PA was 410.2±71.0 Hounsfield unit (HU), PV was 245.1±24.8 HU, difference between CT value of PA and CT value of PV was 164.5±60.9 HU. Subjective image quality of PA and PV could be visualized until more than the segmental branch level. SBSPP can obtain sufficient CT value for separate visualization of PA and PV, and before VATS useful PA and PV 3D-CTA imaging.

Morphology and morphometry of pulmonary veins and the left atrium in multi-slice computed tomography

Purpose

Pulmonary veins are involved in pathogenesis and treatment of atrial fibrillation and structures at risk during thoracic surgeries. There is lack of data regarding pulmonary vein morphology and morphometry in normal population.

Methods

The study was conducted using 135 chest computed tomography studies with intra-venous iodine contrast injection. The study population contained 86 females and 49 males, mean age was 60. 13 had atrial fibrillation.
The studies were analyzed using radiological workstation.

Results

Mean dimensions of the left atrium: transverse 52 mm, coronal 49 mm, and sagittal 35 mm. The mean volume of the left atrium was 93 cm³. The mean volume of the left atrium in patients with atrial fibrillation was 176 cm³. The sagittal dimension and the volume of the left atrium were correlated with age, r = 0.43 and r = 0.42, respectively. Surface area of the left inferior pulmonary vein ostium was 136 mm², significantly less than the surface area of other ostia of pulmonary veins. The mean distance between two pulmonary veins was 5.42 mm on the right and 4.02 mm on the left side. 13 types of pulmonary veins outflow patterns were described on the right side and 5 types on the left side. 66.7% of right pulmonary veins and 82% of the left pulmonary veins emptied into the left atrium with two venous trunks on each side (the typical pattern).

Conclusions

Morphological features of pulmonary veins and morphometry of the left atrium and pulmonary veins are important for clinical purposes and are in accordance with previous papers.

Interactive 3D Reconstruction of Pulmonary Anatomy for Preoperative Planning, Virtual Simulation, and Intraoperative Guiding in Video-Assisted Thoracoscopic Lung Surgery

OBJECTIVES

Routine imaging modalities combined with state-of-the-art reconstruction software can substantially improve preoperative planning and simplify complex procedure by enhancing the surgeon's knowledge of the patient's specific anatomy. The aim of the current study was to demonstrate the feasibility of interactive three-dimensional (3D) computed tomography (CT) reconstructions for preoperative planning and intraoperative guiding in video-assisted thoracoscopic lung surgery (VATS) with 3D vision.

METHODS

Twenty-five consecutive patients referred for an anatomic pulmonary resection by a single surgeon were included. Data were collected prospectively. All patients underwent a CT angiography in the diagnostic pathway prior to referral. 3D reconstruction of the pulmonary anatomy was obtained from CT scans with dedicated software. An interactive PDF file of the 3D reconstruction with virtual resection was created, in which all the pulmonary structures could be individually selected. Furthermore, the reconstructions were used for intraoperative guiding on double monitor during VATS with 3D vision.

RESULTS

In total, 26 procedures were performed for 5 benign and 21 malignant conditions. Lobectomy and segmentectomy were performed in 20 (76.9 %) and 6 (23.1%) cases, respectively. In all patients, preoperative 3D reconstruction of pulmonary vessels corresponded with the intraoperative findings. Reconstructions revealed anatomic variations in 4 (15.4%) patients. No conversion to thoracotomy or in-hospital mortality occurred.

CONCLUSIONS

Preoperative planning with interactive 3D CT reconstruction is a useful method to enhance the surgeon's knowledge of the patient's specific anatomy and to reveal anatomic variations. Intraoperative 3D guiding in VATS with 3D vision is feasible and could contribute to the safety and accuracy of anatomic resection.

[Effect of CT Value and CT Value Difference on the Pulmonary Arteriovenous Automatic Extraction Function of the Medical Workstation]

This study aimed to evaluate the effect of pulmonary arteriovenous computed tomography (CT) value and CT value difference on the pulmonary arteriovenous automatic extraction ability of a medical workstation. We classified patients who previously underwent contrast-enhanced CT as those with a pulmonary arteriovenous CT value difference of <50 Hounsfield unit (HU) and ≥100 HU. The groups were further divided into four subgroups each, with a total of eight groups, based on low pulmonary arteriovenous CT values of 200 or more and <250 HU, 250 or more and <300 HU, 300 or more and <350 HU, and 350 HU or more. A radiographer conducted a visual evaluation, and we judged whether it could extract pulmonary arteries A1-A10 and pulmonary veins V1-V10 without errors. When the CT value difference was <50 HU, the low pulmonary arteriovenous CT value of 200 or more and <250 HU significantly decreased the extraction ability compared with the ≥350 HU group (p<0.05), but when the CT value difference was ≥100 HU, no difference in the CT value was found. The pulmonary arteriovenous CT value and CT value difference affect the pulmonary arteriovenous automatic extraction ability of the medical workstation, but revision by the creator is necessary because misrecognition is included even if a CT value and CT value difference is high.

Operative Planning in Thoracic Surgery: A Pilot Study Comparing Imaging Techniques and Three-Dimensional Printing

BACKGROUND

Careful preoperative planning in thoracic surgery is essential for positive outcomes, especially in video-assisted thoracic surgery (VATS), where palpation and 3-dimensional (3D) imaging is restricted. This study evaluated the ability of different imaging techniques, such as computed tomography (CT) scanning, maximal intensity projection imaging, 3D reconstruction, and 3D printing, to define the anatomy of the hilar structures before anatomical lung resection.

METHODS

All patients undergoing elective lung resections by VATS for cancer under a single surgeon were identified over a 3-month period. The surgeon was asked to record the number of pulmonary artery branches supplying the lobe to be resected by using the preoperative CT scans, maximal intensity projection images, and 3D-reconstructed CT images. The lung hilum in 3 patients was printed. These were then compared with the intraoperative findings.

RESULTS

The preoperative imaging of 16 patients was analyzed. The lung hilum was printed in a further 3 patients. Although not statistically significant, the 3D prints of the hilum were the most accurate measurement, with a correlation of 0.92. CT, 3D-reconstructed CT, and maximal intensity projection images tended to underrecognize the number of arterial branches and therefore scored between 0.26 and 0.39 in absolute agreement with the number of arteries found at operation.

CONCLUSIONS

3D printing in the planning of thoracic surgery may suggest a benefit over contemporary available imaging modalities, and the use of 3D printing in practicing operations is being established.

Variations of pulmonary vein drainage critical for lung resection assessed by three-dimensional computed tomography angiography

Background

It is important to understand pulmonary vein drainage pattern variations and their frequency in order to perform safe anatomical pulmonary resection.

Methods

Variations and frequencies were assessed using three‐dimensional computed tomography angiography (3D‐CT) in 194 patients. In cases where the tumor or lymph node caused atelectasis or compression of hilar structures, the involved lobes were excluded from the analyses.

Results

We confirmed variant drainage patterns in 15/189 (8.0%) patients in the right upper lobe (RUL), 29/189 (15.3%) in the right middle lobe (RML), 18/192 (9.5%) in the right lower lobe (RLL), and 5/187 (2.6%) in the left upper lobe (LUL). There was no variant type in the left lower lobe (LLL). There were 14 (7.4%) cases of anomalous superior posterior pulmonary vein of RUL (V²) drainage: V2 draining to the superior pulmonary vein (SPV) (n = 2, 1.1%), V2 to the inferior pulmonary vein (IPV) (n = 7, 3.7%), V2 to the left atrium (LA) (n = 2, 1.1%), and V⁶ to the apical pulmonary vein of the RLL (n = 3, 1.6%). There was a posterior pulmonary vein, V³ to RML pulmonary vein in one case (0.5%). The RML pulmonary vein drained into the IPV in 14 (7.4%) and into the LA in 15 (7.9%) cases. The right V6 directly drained into the LA in 15 (7.9%) and V⁶ into the SPV in 3 (1.6%) cases. The lingular pulmonary vein drained into the IPV in one case (0.5%) and into the LA in two cases (1.1%). The inferior lingular pulmonary vein V⁵ drained into the IPV and into the LA in one case (0.5%), respectively.

Conclusion

We describe anomalous pulmonary venous drainage patterns and their frequencies particular to anatomic surgical resection. 3D‐CT is useful to find such variations.

3D-CT anatomy for VATS segmentectomy

Segmentectomy has become a widely adopted surgical procedure, with recent reports describing the use of video-assisted thoracoscopic surgery (VATS) and robotic surgery. A major feature of segmentectomy is that it requires a three-dimensional (3D) understanding of the patient's pulmonary structure and a thorough preoperative analysis of the patient's individual anatomy. Here, we present our method for VATS segmentectomy based on 3D-computed tomography (3D-CT), with a review of the literature. We focus on techniques for 3D-CT reconstruction, analyses of the individual anatomy and anomalies, preoperative simulations of the procedure and surgical margin, and intraoperative navigation with 3D-CT images. We also reference the roles of members of our multi-disciplinary surgical team.

Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion

Video assisted thoracic surgery (VATS) has become a routinely utilized approach to complex procedures of the chest, such as pulmonary resection. It has been associated with decreased postoperative pain, shorter length of stay and lower incidence of complications such as pneumonia. Limitations to this modality may include limited exposure, lack of tactile feedback, and a two-dimensional view of the surgical field. Furthermore, the lack of an open incision may incur technical challenges in preventing and controlling operative misadventures leading to major hemorrhage or other intraoperative emergencies. While these events may occur in the best of circumstances, prevention strategies are the primary means of avoiding these injuries. Unplanned conversions for major intraoperative bleeding or airway injury during general thoracic surgical procedures are relatively rare and often can be avoided with careful preoperative planning, review of relevant imaging, and meticulous surgical technique. When these events occur, a pre-planned, methodical response with initial control of bleeding, assessment of injury, and appropriate repair and/or salvage procedures are necessary to maximize outcomes. The surgeon should be well versed in injury-specific incisions and approaches to maximize adequate exposure and when feasible, allow completion of the index operation. Decisions to continue with a minimally invasive approach should consider the comfort and experience level of the surgeon with these techniques, and the relative benefit gained against the risk incurred to the patient. These algorithms may be expected to shift in the future with increasing sophistication and capabilities of minimally invasive technologies and approaches.

Planning video-assisted thoracic surgery segmentectomy using three dimensional computed tomography angiography and bronchography with a virtual safety margin

In segmentectomy using video-assisted thoracic surgery (VATS), surgeons view the operative field on a 2-dimensional video monitor. The lack of ability to palpate organs directly frequently leads to difficulties in evaluating anatomic relations. Three-dimensional computed tomography angiography and bronchography (3D-CTAB) using a virtual 3D safety margin enables thoracic surgeons to recognize the distance and positional relation between the primary tumor and intersegmental veins. It also helps with surgical planning, allowing the surgeon to secure an adequate safety margin around the primary tumor. We report two patients with double primary lung cancer who underwent segmentectomy based on preoperative simulation 3D-CTAB with a virtual 3D safety margin.

3D CT simulation in minimally invasive thoracic surgery

Nearly half a century ago Hounsfield had developed computed tomography. In the history of CT, notable progress was accomplished around the year of 2000 by multi-detector scanning CT which could provide volume data of the objects and establish three-dimensional visualization together with advancement of image processing technology. For the thoracic surgeon, the understanding of anatomical structures of the bronchi, the pulmonary arteries and the veins, which originated from the heart and intersect complicatedly, is indispensable for treatment. Now advancement of CT images provides vital information for surgeons and has realized pre- and intra-operative simulation and navigation in minimally invasive thoracoscopic lobectomy.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

Three dimensional model for surgical planning in resection of thoracic tumors

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3D printed model can be made of thoracic malignancy by taking CT image of the patient and creating a 3D surface rendered imaging and printing it on 3D printer.

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3D printed model can help counsel the patient about the planned operation.

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3D printed model can help in surgical planning of the resection of complex thoracic tumors.

Introduction

The computed tomography scan provides vital information about the relationship of thoracic malignancies to the surrounding structures and aids in surgical planning. However, it can be difficult to visualize the images in a two-dimensional screen to interpret the full extent of the relationship between important structures in the surgical field.

Presentation of case

We report two cases where we used a three-dimensional printed model to aid in the surgical resection of thoracic malignancies.

Discussion

Careful planning is necessary to resect thoracic malignancies. Although two-dimensional images of the thoracic malignancies provide vital information about the tumor and its surrounding structures, the three-dimensional printed model can provide more accurate information about the tumor and assist in surgical planning.

Conclusion

Three-dimensional printed model provide better visualization of complex thoracic tumors, aid in counseling the patient about the surgical procedure and assisted in surgical resection of thoracic malignancy.

An analysis of variations in the bronchovascular pattern of the right upper lobe using three-dimensional CT angiography and bronchography

Objectives

General thoracic surgeons must be familiar with anatomical variations in the pulmonary bronchi and vessels. We analyzed variations in the bronchovascular pattern of the right upper lung lobe using three-dimensional CT angiography and bronchography and then compared our results with those of previous reports.

Methods

We reviewed anatomical variations in the right upper pulmonary bronchus and vessels of 263 patients using 3DCT angiography and bronchography images obtained using a 64-channel multidetector CT and workstation running volume-rendering reconstruction software.

Results

Variations in the pulmonary vein were classified into four types: the “anterior-plus-central vein type” was the most common, noted in 219 cases (83.2 %). The “anterior vein type” was evident in 23 cases (8.8 %), a significantly lower incidence than in previous reports (p < 0.001). Also, the branching patterns of the segmental arteries of the pulmonary artery differed partially from those noted in previous reports. Furthermore, we identified some new variations. The “B¹- or B²-defective branch type” bronchus was noted in 19 cases (7.2 %), which was a higher prevalence than that in previous reports.

Conclusion

We explored the bronchovascular pattern and the frequency of variations in the right upper lobe using a large number of 3DCT images. The incidences of variations differed, sometimes significantly, from those noted by previous reports. Moreover, we report some new branching variations. Our data can be used by thoracic surgeons to perform safe and precise lung resections.

Electronic supplementary material

The online version of this article (doi:10.1007/s11748-015-0531-1) contains supplementary material, which is available to authorized users.

Management of the pulmonary artery during video-assisted thoracoscopic left upper lobectomy

BACKGROUND

Complete video-assisted thoracoscopic surgery (c-VATS) for left upper lobectomy is difficult due to the branching pattern of the left pulmonary artery.

OBJECTIVE

Our purpose was to report outcomes of a modified technique of c-VATS left upper lobectomy.

METHODS

We retrospectively compared the outcomes of 83 patients with stage I/II non-small-cell lung cancer (NSCLC) who received left upper lobectomy between 2008 and 2011; 32 underwent conventional c-VATS and 50 received modified c-VATS. In the modified procedure, the order in which hilum of lung was treated was from the lingular segmental artery to the superior pulmonary vein to the bronchus, and then finally the pulmonary artery.

RESULTS

The mean patient age was 63.6 ± 8.4 years, and no differences were observed in age, gender, and largest tumor diameter between the two groups. No conversion occurred in either group. The surgical time for modified c-VATS was significantly shorter than that for conventional c-VATS (210 vs. 270 min, p < 0.001). Drainage time after surgery and length of hospitalization for the modified c-VATS group were significantly less than those for the conventional group (drainage 3 vs. 4 days, respectively, p = 0.041; length of hospitalization 7 versus 12 days, respectively; p < 0.001). Surgical margins were clear in all cases. Four (8.0 %) complications occurred in the modified procedure group compared with ten (31.3 %) in the conventional group (p = 0.015).

CONCLUSION

This new technique offers shorter surgical and postoperative drainage time, shorter hospital stays, and fewer complications than conventional c-VATS upper left lobectomy.

New CT criteria for nodal staging in non-small cell lung cancer

OBJECTIVE

The purpose of our study was to develop a simple noninvasive technique for nodal staging using routine preoperative computed tomography (CT).

MATERIALS AND METHODS

The institutional review board approved this retrospective study, and written informed consent to perform the initial and follow-up CT studies was obtained from all patients. Preoperative CT findings (n=218 patients with resectable non-small cell lung cancer) and pathological diagnoses after surgical resection were evaluated. Using CT images, lymph node section area, circumference, and lesion attenuation values (LAVs) were drawn freehand, and the short axis (SA) and long axis (LA) were measured using caliper software. Receiver operating characteristic (ROC) curves were then used to analyze the section area, circumference, and LAVs.

RESULTS

Based on ROC curves, two cut-off values, lymph node section area >30 mm(2) and circumference >25 mm, showed greater sensitivity for nodal staging than the conventional criterion of lymph node SA ≥10 mm or the LA, SA/LA ratio or LAVs. Using lymph node section area >30 mm(2) for diagnosis, the sensitivity, specificity, and accuracy of nodal staging were 90.5%, 56.3%, and 58.3%, respectively. Using lymph node circumference >25 mm, the values were 76.2%, 70.4%, and 70.8%, respectively.

CONCLUSION

Lymph node section area >30 mm(2) and circumference >25 mm can serve as supportive criteria used by radiologists and surgeons to determine nodal staging. If these CT criteria are met, use of a more sensitive procedure such as positron emission tomography or mediastinoscopy is recommended.

CONCISE ABSTRACT

CT is used routinely during preoperative management of lung cancer. Based on ROC analyses, the cut-off values for surface area, circumference, the SA/LA ratio, and LAVs for diagnosis of lymph node metastasis were 30 mm(2), 25 mm, 0.65, and 50 Hounsfield units, respectively. Our findings indicate that lymph node surface area >30 mm(2) and circumference >25 mm are supportive criteria that can be used by radiologists and thoracic surgeons to determine nodal staging and surgical indications.

Diagnostic imaging in the preoperative management of lung cancer

Surgical resection is the accepted standard of care for patients with non-small cell lung cancer (NSCLC). Several imaging modalities play central roles in the detection and staging of the disease. The aim of this review is to evaluate the utility of computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and PET/CT for NSCLC staging. Radiographic staging refers to the use of CT as a non-invasive diagnostic technique. However, while the vast majority of patients undergo only CT, CT is a notoriously inaccurate means of tumor and nodal staging in many situations. PET/CT clearly improves the staging, particularly nodal staging, compared to CT or PET alone. In addition, as a result of the increased soft-tissue contrast, MRI is superior to CT for distinguishing between tissue characteristics. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), which is a minimally invasive technique, also has pathological diagnostic potential. Extensive research and the resultant improvements in the understanding of genetics, histology, molecular biology and oncology are transforming our understanding of lung cancer, and it is clear that imaging modalities such as CT, MRI, PET and PET/CT will have an important role in its preoperative management. However, thoracic surgeons should also be aware of the limitations of these techniques.

Port-access thoracoscopic anatomical lung subsegmentectomy

OBJECTIVES

The diagnosis of small lung nodules has increased in recent years; limited resection and minimally invasive surgery are highly desirable in patients with these lesions. While wedge resection may be curative for small lung nodules, the technique is sometimes difficult to perform when the tumour nodule is near the pulmonary hilum. In such situations, either anatomical segmentectomy or subsegmentectomy can obtain an adequate surgical margin; port-access thoracoscopic surgery is the preferred type of minimally invasive surgery. Three-dimensional (3D) computed tomography (CT) simulations are reportedly useful in planning and performing thoracoscopic surgery. We use 3D CT simulation to aid thoracoscopic segmentectomy for small lung nodules and subsegmentectomy for even smaller nodules and conduct here a retrospective evaluation of the clinical results of subsegmentectomy. We present our technique for 3D CT simulation-assisted port-access thoracoscopic subsegmentectomy in the superior segment of the left lower lobe.

METHODS

Between July 2008 and June 2012, 15 patients underwent port-access thoracoscopic subsegmentectomy. We evaluated the pathological diagnoses, the tumour sizes, the indications, the operative times and the volumes of blood loss.

RESULTS

Seven patients were diagnosed with lung cancer (LC) and eight had metastatic lung tumours (MLT). The median tumour size was 12 mm. The indication for using this surgical technique was to secure surgical margins in 13 patients (LC, 6; MLT, 7) and because of poor surgical risk in two patients (LC, 1; MLT, 1). The mean surgical time was 166 min and the median blood loss was 19 ml. There were no recurrences.

CONCLUSIONS

Port-access thoracoscopic lung subsegmentectomy using 3D CT simulation can be safely performed and is able to secure adequate surgical margins.

Computed tomography guided thoracoscopic segmentectomy for lung cancer with variant bronchus

Lung segmentectomy with bronchial variation has rarely been reported. We report the case of a lung cancer patient with variant anatomy of the right upper lobe bronchus.Thoracoscopic posterior segmentectomy of the right upper lobe was performed. Variant bronchus and related blood vessels were confirmed preoperatively by three-dimensional multidetector computed tomography (3D-MDCT), which facilitated visualization of the patient's anatomy during surgery.

Cricopharyngeal myotomy for primary cricopharyngeal dysfunction caused by a structural abnormality localized in the cricopharyngeus muscle: report of a case

Primary cricopharyngeal dysfunction (PCD) is a rare idiopathic disorder of the upper esophageal sphincter (UES), characterized by oropharyngeal dysphagia, frequent aspiration, and narrowing at the level of the UES. Cricopharyngeal myotomy (CPM) has been used to treat oropharyngeal dysphagia of different causes including anatomic, neuromuscular, iatrogenic, inflammatory, neoplastic, and idiopathic; however, the indications for CPM and predictors of its outcome are not clearly defined. We report a case of PCD with hypertonic UES caused by a structural abnormality localized in the cricopharyngeus muscle, visualized as a cricopharyngeal bar, which we treated successfully by CPM, achieving long-term relief.

Pharyngolaryngoesophagectomy in a patient with an aberrant right subclavian artery: report of a case

We report a case of carcinoma of the hypopharynx and cervical esophagus in a patient with an aberrant right subclavian artery. Barium esophagography, endoscopy, and computed tomography showed a resectable tumor in the hypopharynx and cervical esophagus, coexistent with an aberrant right subclavian artery. We performed pharyngolaryngoesophagectomy with bilateral neck dissection and gastric pull-up through cervical, right thoracic, and abdominal incisions. We also partially resected the aberrant right subclavian artery with reimplantation in the right common carotid artery. To our knowledge, this is the first report of pharyngolaryngoesophagectomy with transposition of an aberrant right subclavian artery.

Dangerous mediastinal basal pulmonary artery during left upper lobectomy

Anatomical variations in the pulmonary vessels present a potential risk for intraoperative bleeding and damage to the pulmonary circulation during pulmonary resection. Here, we present a patient who underwent left upper lobectomy for lung cancer. The patient had a dangerous mediastinal basal pulmonary artery variation that could be mistaken for the mediastinal lingular pulmonary artery and be divided during left upper lobectomy.