Transitory blocking of pulmonary artery and veins as a novel strategy in pulmonary surgery: an experimental study in a rabbit model

Ex situ reimplantation technique, in central lung tumors

BACKGROUND

The parenchyma-sparing resection is most often performed in patients with impaired preoperative lung or cardiovascular function who would not be able to tolerate a pneumonectomy.

METHODS

Our experience on the ex situ reimplantation procedure and the outcome of patients with lung malignancies, who underwent upper or upper-middle lobectomy, with reimplantation of the lower lobe was reported.

RESULTS

We present 9 patients mean age 62.6+16.2 years (7 males/2 females) underwent ex situ reimplantation due to extensive lung tumor of upper lobes. The surgical technique precludes IV heparinization and then radical pneumonectomy. The entire lung was immersed in Ringer's solution (temperature 4 degrees centigrade) and bench surgery was performed. The involved upper (or upper-middle) lobes with involved lymph nodes were resected, thus leaving the healthy lower lobe of the lung. Pneumoplegia solution, named "Papworth pneumoplegia", was administered (1,473 mL) through catheterization of the pulmonary artery and vein stumps (ante grade and retrograde) along with 250 mL of prostaglandin E1. Re-implantation of the lower lobe was performed (I) on the right side, implantation involved the anastomosis of lower pulmonary vein in the site of the cuff of left atrium, followed by suturing the stump of the intermedius pulmonary artery to the right main pulmonary artery and finally the bronchial stumps-intermedius bronchus to the right main bronchus; (II) on the left side the pulmonary vein was anastomosed first, followed by the bronchial stumps and finally by the pulmonary artery. The graft ischemia time was 70.2+8.4 minutes ranged between 55 and 80 minutes.

CONCLUSIONS

Re-implantation or auto-transplantation should be considered as a safe option for the appropriate patient with lung cancer. The ex situ separation of the cancerous lobes is technically feasible and allows extensive pulmonary resection while minimizing the loss of pulmonary reserve. Based on our work, the major factors that play a role for the survival of initially resected and then re-implanted lung graft, are: (I) the ischemia time of the re-implanted lobe; (II) the proper use of pneumoplegia solutions, along with prostaglandin E1 and heparin; (III) the occurrence of pulmonary vein thrombosis; and (IV) the bronchial anastomosis.

Partial removal of the pulmonary artery in video-assisted thoracic surgery for non-small cell lung cancer

Lobectomy with partial removal of the pulmonary artery in video-assisted thoracic surgery (VATS) currently remains a challenge for thoracic surgeons. We were interested in introducing pulmonary vessel blocking techniques in open thoracic surgery into video-assisted thoracic surgery (VATS) procedures. In this study, we reported a surgical technique simultaneously blocking the pulmonary artery and the pulmonary vein for partial removal of the pulmonary artery under VATS. Seven patients with non-small-cell lung cancer (NSCLC) received lobectomy with partial removal of the pulmonary artery using the technique between December 2007 and March 2012. Briefly, rather than using a small clamp on the distal pulmonary artery to the area of invading cancer, we replaced a vascular clamp with a ribbon and Hem-o-lock clip to block the preserved pulmonary veins so as to prevent back bleeding and yield a better view for surgeons. The mean occlusion time of the pulmonary artery and pulmonary veins were 44.0±10.0 and 41.3±9.7 minutes, respectively. The mean repair time of the pulmonary artery was 25.3±13.7 minutes. No complications occurred. No patients showed abnormal blood flow through the reconstructed vessel. There were no local recurrences on the pulmonary artery. In conclusion, the technique for blocking the pulmonary artery and veins is feasible and safe in VATS and reduces the risk of abrupt intraoperative bleeding and the chance of converting to open thoracotomy, and extends the indications of VATS lobectomy.