Preoperative 3D-CT bronchography and angiography facilitates single-direction uniportal thoracoscopic anatomic lobectomy

Pulmonary Arterial Anatomical Patterns: a Classification Scheme Based on Lobectomy and 3D-CTBA

PURPOSE

 Preoperative evaluation of pulmonary vascular and tracheal routes and variations is of great importance to the surgeon. Three-dimensional computed tomography bronchography and angiography (3D-CTBA) has evolved in recent years with the optimization of 3D reconstruction techniques and artificial intelligence. We aim to apply CT angiography and Exoview 3D reconstruction technology to assess patients' pulmonary arterial tree and its anatomical variants and to try to summarize a set of anatomical typing of the pulmonary arterial tree that is relatively easy and conducive to promoting teaching based on surgical habits of lobectomy.

METHODS

 A total of 358 patients hospitalized in the Department of Thoracic Surgery of the First Affiliated Hospital of Soochow University between July 2020 and August 2021 were included in this study. We carefully analyzed the site of emanation, alignment, and number of branches of the pulmonary artery according to a uniform classification method in conjunction with the two-dimensional CT images and transformed them into 3D reconstruction models.

RESULTS

 Different types of pulmonary artery were observed in 358 cases. We evaluated the complete pulmonary artery tree and counted the number and frequency of major arteries of the pulmonary based on the surgical habits of anatomical lobectomy.

CONCLUSION

 The 3D-CTBA technique enables us to adequately assess the anatomy of the pulmonary arteries. Moreover, we provide a practical classification scheme of pulmonary arterial anatomical patterns based on lobectomy and 3D-CTBA. Our data can be used by clinicians in the teaching of pulmonary artery anatomy and the preoperative preparation for anatomical lobectomy.

Pulmonary function protection by single-port thoracoscopic segmental lung resection in elderly patients with IA non-small cell lung cancer: A differential matched analysis

In patients with stage IA non-small cell lung cancer (NSCLC), uniportal video-assisted thoracic surgery (U-VATS) anatomical segmentectomy removes the lung tumor while preserving lung function as much as possible, and it is therefore an alternative to lobectomy. Patients with stage IA NSCLC receiving U-VATS segmental resection at our institution from September 2017 to June 2019 were compared with patients receiving U-VATS lobectomy. A total of 47 patients received segmentectomy and 209 patients received U-VATS lobectomy in the same period. Propensity score matching was conducted to diminish bias. The final study cohort included 42 patients who received segmentectomy and 42 propensity score matching-matched patients who received lobectomy. Perioperative parameters and postoperative complications, length of hospital stay, postoperative forced expiratory volume in 1 s (FEV1), and forced vital capacity (FVC) were compared between the 2 groups. Surgery was successfully completed in all patients. The mean follow-up was for 8.2 months. The postoperative complication rate was comparable between the 2 groups: 31.0% in segmentectomy patients versus 35.7% in lobectomy patients (P = .643). At 1 month after surgery, FEV1% and FVC% were not significantly different between the 2 groups (P > .05). At 3 months after surgery, FEV1 and FVC were higher in segmentectomy patients than in lobectomy patients (FEV1, 82.79% ± 6.36% vs 78.55% ± 5.42%; FVC, 81.66% ± 6.09% vs 78.90% ± 5.58%, P < .05). Patients receiving segmentectomy suffer less pain and have better postoperative lung function and higher quality of life.

Conservative treatment for residual lung congestion after left upper trisegmentectomy: a case report

Background

Currently, segmentectomy is the procedure of choice in approximately 10% of lung cancer surgeries in Japan. However, complications are often observed in that procedure. In particular, residual pulmonary congestion after segmentectomy often leads to surgical intervention.

Case Description

We report a case of improved congestion in the residual lung after left upper trisegmentectomy (LUTS) with conservative treatment under careful observation. A 65-year-old man was diagnosed with bilateral lung cancer and initially underwent LUTS. On the next day after surgery, blood sputum was observed. Computed tomography (CT) showed consolidation in the lingual region of the left lung and stenosis of V4+5 in the left lung. The cause of the congestion was thought to be an isolated segment with part of the remaining S3 and a thin V4+5 with poor flow. Because pulmonary torsion or necrosis of the residual lung was not observed, conservative treatment with antibiotics under careful follow-up by CT was chosen. The pulmonary congestion and inflammatory reaction gradually improved, and the patient was discharged home on the 26th day after surgery.

Conclusions

We experienced a case of residual pulmonary congestion after LUTS that resolved with conservative treatment. Careful follow-up of the patient's general condition and imaging studies are considered to be important.

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.

Anatomical type analysis of right interlobar artery based on chest thin-slice CT scan and three-dimensional reconstruction

PURPOSE

To analyse and summarize branching pattern types of the interlobar portion of right pulmonary arteries (RPA) through chest thin-slice CT scans and three-dimensional reconstruction.

METHODS

A total of 179 patients (58 males and 121 females, with an average age of 53.9 years) at the Thoracic Surgery Department of Ningbo First Hospital were retrospectively included from December 2020 to December 2021. All patients completed preoperative thin-slice CT scans and three-dimensional reconstructions of the chest. The clinical data and branching patterns were collected. Data were analysed using SPSS 21.0.

RESULTS

The branching pattern types of the interlobar portion of RPA were divided into 4 types according to the order and number of branches: Type I (145/179, 81.0%), Asc. A2, MA, A6; Type II (28/179, 15.6%), Asc. A2 deletion, MA, A6; Type III (5/179, 2.8%), Asc. A2, A6, MA; and Type IV (1/179, 0.6%), MA, Asc. A2, A6. Type I was the most common pattern. Furthermore, according to the number of branches of MA and A6, this pattern can be subdivided into 15 subcategories.

CONCLUSION

Chest thin-slice CT scans and 3D reconstructions can provide surgeons with accurate lung anatomy, which helps surgeons perform preoperative planning and complete surgery successfully.

Three-dimensional CT angiography facilitates uniportal thoracoscopic anatomic lung resection for pulmonary sequestration: a retrospective cohort study

Background

Pulmonary sequestration (PS) is a rare lesion with independent blood supply from an anomalous systemic artery. A timely resection is considered as the best treatment for PS. Three-dimensional computed tomography angiography (3D-CTA) has been widely utilized for precise thoracic surgery. This study aimed to investigate the role of preoperative 3D-CTA and resection simulation in uniportal video-assisted thoracoscopic surgery (VATS) anatomical lung surgery for PS.

Methods

The data of 20 consecutive PS patents undergoing anatomic lung resection between April 2011 and May 2021 in a single centre were retrospectively reviewed. These patients were divided into the 3D-CTA group (10 patients) and the control group (10 patients) according to the initial surgical planning with or without 3D-CTA. The perioperative parameters regarding safety and fluency such as the incidence of conversion to open thoracotomy, operation time, blood loss, complications and chest tube duration were analyzed.

Results

This cohort included 12 female and 8 male patients, with a mean age of 45 years old (range 24–60 years). Nine cases demonstrated recurrent febrile, cough, or hemoptysis; whereas the other 11 patients were asymptomatic on admission. Eighteen (90.0%) intralobar and 2 extralobar PS were confirmed, whereas 18 (90.0%) lesions were located in the left thorax. The feeding vessels originated from the thoracic aorta in 16 patients (80.0%), the abdominal aorta in 3 (15.0%), and the inferior phrenic artery in 1 patient (5.0%). There was no major bleeding or 30 days mortality. The initial surgical planning included 9 uniportal and 1 two-port VATS in the 3D-CTA group, as compared with 10 two-port VATS in the control group. Thirteen lobectomies, 5 segmentectomies and 2 mass excisions were performed. However, no conversion was needed in the 3D-CTA group; whereas 6 (60.0%) conversions (4 to multiple-port and 2 to thoracotomy) occurred in the control group, indicating a significant difference (P = 0.003). In addition, the operation time in the 3D-CTA group was significantly shorter than those in the control group [(108.5 ± 24.9) min vs. (154.5 ± 39.4) min, P = 0.006]. The other surgery-related outcomes were similar between the two groups.

Conclusion

Preoperative 3D-CTA facilitates the safe and fluent performance of uniportal VATS anatomical lung resection for PS with shortened operation time and lessened surgical conversions.

Surgeon Knowledge of the Pulmonary Arterial System and Surgical Plan Confidence Is Improved by Interactive Virtual 3D-CT Models of Lung Cancer Patient Anatomies

Objective: Interactive three-dimensional virtual models of pulmonary structures (3D-CT) may improve the safety and accuracy of robotic-assisted thoracic surgery (RATS). The aim of this study was to evaluate the impact of 3D-CT models as an imaging adjunct on surgical confidence and anatomical assessment for lobectomy planning. Methods: We retrospectively analyzed the response of 10 specialist thoracic surgeons who each reviewed 10 pre-operative images of patients undergoing robotic-assisted lobectomy lung cancer cases from June to November 2018 in our institute, resulting in 100 data points. The number of arteries, veins, and bronchi entering the resected lobes were determined from the operation video recording by the operating surgeon. 3D-CT models were generated for each case and made available for online visualization and manipulation. Thoracic surgeons were invited to participate in the survey which consisted of evaluation of CT (control) and 3D-CT (intervention) models. A questionnaire regarding anatomical structures, surgical approach, and confidence was administered. Results: Ten participants were recruited. 3D-CT models led to a significant (p < 0.003) increase in the surgeons' ability to correctly identifying pulmonary arteries entering the resection lobes in 35% (CT) and 57% (3D-CT) of cases. A significant (p < 1e-13) improvement in anatomy assessment and surgical plan confidence was observed for the 3D-CT arm, with median Likert scale scores of "2-Slightly easy" (CT) and "4-Very easy" (3D-CT). Conclusion: The use of 3D-CT models for thoracic surgery planning increases the surgeon confidence in recognizing anatomical structures, largely by enhanced appreciation of anatomical variations in the segmental pulmonary arterial system. Further studies are needed to investigate if 3D-CT models can be used in providing precise information about segmental artery distribution and therefore surgical planning of sub-lobar resections.

Utility of preoperative three-dimensional CT bronchography and angiography in uniportal video-assisted thoracoscopic anatomical lobectomy: a retrospective propensity score-matched analysis

Background

Personalized three-dimensional (3D) reconstruction can help surgeons to overcome technical challenges and variations of pulmonary anatomic structures in the performance of uniportal video-assisted thoracoscopic surgery (UVATS), thus improving the safety and efficacy of the procedure. This study aims to evaluate the utility of preoperative 3D-CT bronchography and angiography (3D-CTBA) with Exoview software in the assessment of anatomical variations of pulmonary vessels, and to analyze short-term surgical outcomes in patients undergoing UVATS lobectomy.

Methods

We retrospectively analyzed the data of 198 consecutive patients who underwent curative UVATS lobectomy between November 2019 and September 2020. The patients were divided into an “Exoview” group (n=53) and a “non-Exoview” group (n=145). We performed 1:1 propensity score matching and compared intraoperative and postoperative outcomes between the two groups. A subgroup analysis of 74 patients who underwent single-direction uniportal lobectomy was also conducted. Aberrant pulmonary vessel patterns related to the surgery were also examined.

Results

The operative time in the Exoview group was significantly shorter than that in the non-Exoview group, both before (145.7±33.9 vs. 159.5±41.6 minutes, P=0.032) and after (145.7±33.9 vs. 164.2±41.8 minutes, P=0.014) propensity score matching. The number of mediastinal lymph nodes dissected was higher in the Exoview group than in the non-Exoview group (8.19±6.89 vs. 5.78±3.3, P=0.024) after propensity score matching. Intraoperative blood loss showed a statistical difference between the Exoview and non-Exoview groups (60.4±45.4 vs. 100.8±83.9, P=0.009). Four types of arterial variations and 2 types of venous variations related to the surgery were observed among 8 patients (15%), which have rarely been reported before.

Conclusions

Personalized preoperative 3D-CT bronchography and angiography helped to clearly visualize the pulmonary anatomical structures and could contribute to the safe and efficient performance of UVATS anatomical lobectomy.

Three-dimensional computed tomography angiography and bronchography combined with three-dimensional printing for thoracoscopic pulmonary segmentectomy in stage IA non-small cell lung cancer

Background

Compared with lobectomy, the anatomical structure of the lung segment is relatively complex and easy to occur variation, thus it increases the difficulty and risk of precise segmentectomy. The application of three-dimensional computed tomography bronchography and angiography (3D-CTBA) combined with a three-dimensional printing (3D printing) model can ensure the safety of operation and simplify the surgical procedure to a certain extent. We aimed to estimate the value of 3D-CTBA and 3D printing in thoracoscopic precise pulmonary segmentectomy.

Methods

We retrospectively reviewed the clinical data of 65 patients who underwent anatomical segmentectomy at the Affiliated Hospital of Shaoxing University from January 2019 to August 2020. The patients were divided into two groups: a 3D-CTBA combined with 3D printing group (30 patients) and a general group (35 patients). The perioperative data of the two groups were compared.

Results

Compared with the general segmentectomy group at the same period in our center, the surgery time of the group guided by 3D-CTBA and 3D printing was significantly shorter. Intraoperative blood loss in the 3D-CTBA and 3D printing group was also apparently lower than in the general group. Hospital stay and postoperative chest tube duration showed no significant differences between the two groups, and neither did postoperative complications such as pneumonia, hemoptysis, arrhythmia, and pulmonary air leakage.

Conclusions

3D-CTBA combined with 3D printing clearly identifies the precise pulmonary segmental structures, avoids intraoperative accidental injury, reduces intraoperative blood loss, shortens the operation time and improves the safety of thoracoscopic pulmonary segmentectomy in stage IA non-small cell lung cancer (NSCLC).

Extralobar pulmonary sequestration with elevated serum neuron-specific enolase: A case report and review of the literature

RATIONALE

Pulmonary sequestration (PS) presenting with elevated serum tumor markers is rare, and it might be misdiagnosed as malignancy.

PATIENT CONCERNS

A 26-year-old asymptomatic male patient was admitted because the x-ray showed an intrathoracic lesion. Meanwhile, the serum neuron-specific enolase (NSE) was elevated. Three-dimensional computed tomography angiography revealed an isolated feeding vessel arising from the aorta.

DIAGNOSES

Extralobular PS was confirmed by computed tomography angiography and postoperative pathological staining.

INTERVENTIONS

Two-port thoracoscopic resection of the sequestrated lobe was performed.

OUTCOMES

The serum NSE decreased to within the normal range and persisted during the follow up of 10 months.

LESSONS

A thorough work-up should be considered for the PS patients presenting with abnormal serum NSE. Detailed knowledge regarding the relationship between NSE and PS necessitates further studies.

Contralateral spontaneous rupture of the esophagus following severe emesis after non-intubated pulmonary wedge resection

Background

Non-intubated thoracoscopic lung surgery has been reported to be technically feasible and safe. Spontaneous rupture of the esophagus, also known as Boerhaave’s syndrome (BS), is rare after chest surgery.

Case presentation

A 60-year-old female non-smoker underwent non-intubated uniportal thoracoscopic wedge resection for a pulmonary nodule. Ultrasound-guided serratus anterior plane block was utilized for postoperative analgesia. However, the patient suffered from severe emesis, chest pain and dyspnea 6 h after the surgery. Emergency chest x-ray revealed right-sided hydropneumothorax. BS was diagnosed by chest tube drainage and computed tomography. Besides antibiotics and tube feeding, a naso-leakage drainage tube was inserted into the right thorax for pleural evacuation. Finally, the esophagus was healed 40d after the conservative treatment.

Conclusions

Perioperative antiemetic therapy is an indispensable item of fast-track surgery. Moreover, BS should be kept in mind when the patients complain of chest distress following emesis after thoracic surgery.

Ganglioneurofibroma arising within the extralobar pulmonary sequestration

Background

Neurogenic tumor arising within the pulmonary sequestration (PS) is rare.

Case presentation

A 42-year-old asymptomatic female was referred to our hospital for work-up of extralobar PS. The independent feeding artery from the thoracic aorta was confirmed by three-dimensional computed tomography angiography (3D-CTA). Uniportal thoracoscopic resection of the sequestrated lung with mediastinal lymph node sampling was performed successfully. Ganglioneurofibroma within the PS was diagnosed as the specimen revealed positive expression of SRY-related HMG-box 10 protein, neuron-specific enolase, S-100, chromogranin A and synuclein. Tumor recurrence was not recorded 1 year after the surgery.

Conclusion

Preoperative 3D-CTA is useful to identify the aberrant vessels of PS. An elaborate diagnostic work-up after a timely resection is necessary for subsequent management and follow-up plan.