Optimization of anesthetic tactics in the surgical treatment of multiple primary non-small cell lung cancer

The article describes a clinical case of surgical treatment of a patient with multiple primary malignant lesions of the lungs (cancer of the left lung, central peribronchial nodular tumor with involvement of the upper lobe and distal parts of the main bronchus; cancer of the right lung, central tumor with involvement of the upper lobar bronchus). Radical treatment became possible due to using the potential of artifi cial gas exchange of both lungs with two devices with fundamentally different ventilation mechanics. The choice of an optimal tactics for the functional correction of the supposed hypoxemia by volumetric and high-frequency pulmonary ventilation allowed avoiding an imbalance in the ventilation/perfusion ratio and preventing the development of life-threatening complications, as well as ensured an adequate gas exchange for the patient during surgical treatment.

Anatomical variations of bronchial distribution in the upper lobe of the right lung

Bronchial distribution in the upper lobe of the right lung is subject to many anatomical variations. The control of these variations is essential for the interpretation of endoscopic examinations. It also offers a better guarantee for safe surgery during segmentations in the right upper lobe. In this preliminary work, the operation of 30 heart-lung blocks treated by the injection-corrosion method, 100 CT chest and dissections of 3 resected specimen of right upper lobectomy, allowed us to study the bronchial distribution in the upper lobe of the right lung as well as their anatomical variations in melanoderm subjects. Our results were as follows: out of the 133 specimens, the right upper lobar bronchus was born on average 1.8 cm from the tracheal bifurcation, with an average length of 1.75 cm. There were 6 termination modes, dominated by bifurcations, which involved 52% of the specimens, and in 5 modes. Trifurcation accounted for 47.37% of cases. There was a case of quadrifurcation. These results allowed us to discuss anatomical variations of the bronchial shaft of the upper lobe of the right lung. Taking into account these variations will allow to avoid pitfalls and accidents during endoscopic examinations, medical imaging and pulmonary exeresis. KEY WORDS: Bronchi-Right Upper Lobe-Anatomy-Variations- Endoscopy-Imaging-Surgery.

Bronchial tree of the human embryo: Categorization of the branching mode as monopodial and dipodial

Some human organs are composed of bifurcated structures. Two simple branching modes—monopodial and dipodial—have been proposed. With monopodial branching, child branches extend from the sidewall of the parent branch. With dipodial branching, the tip of the bronchus bifurcates. However, the branching modes of the human bronchial tree have not been elucidated precisely. A total of 48 samples between Carnegie stage (CS) 15 and CS23 belonging to the Kyoto Collection were used to acquire imaging data with phase-contrast X-ray computed tomography. Bronchial trees of all samples were three-dimensionally reconstructed from the image data. We analyzed the lobar bronchus, segmental bronchus, and subsegmental bronchus. After calculating each bronchus length, we categorized the branching mode of the analyzed bronchi based on whether the parent bronchus was divided after generation of the analyzed bronchi. All lobar bronchi were formed with monopodial branching. Twenty-five bifurcations were analyzed to categorize the branching mode of the segmental and subsegmental bronchi; 22 bifurcations were categorized as monopodial branching, two bifurcations were not categorized as any branching pattern, and the only lingular bronchus that bifurcated from the left superior lobar bronchus was categorized as dipodial branching. The left superior lobar bronchus did not shorten during the period from CS17 or CS18, when the child branch was generated, to CS23. All analyzed bronchi that could be categorized, except for one, were categorized as monopodial branching. The branching modes of the lobar bronchus and segmental bronchus were similar in the mouse lung and human lung; however, the modes of the subsegmental bronchi were different. Furthermore, remodeling, such as shrinkage of the bronchus, was not observed during the analysis period. Our three-dimensional reconstructions allowed precise calculation of the bronchus length, thereby improving the knowledge of branching morphogenesis in the human embryonic lung.

Airway Foreign Body Mimicking an Endobronchial Tumor Presenting with Pneumothorax in an Adult: A Case Report

Foreign body (FB) aspiration occurs less frequently in adults than in children. Among the complications related to FB aspiration, pneumothorax is rarely reported in adults. Although the majority of FB aspiration cases can be diagnosed easily and accurately by using radiographs and bronchoscopy, some patients are misdiagnosed with endobronchial tumors. We describe a case of airway FB that mimicked an endobronchial tumor presenting with pneumothorax in an adult. A 77-year-old man was referred to our hospital due to pneumothorax and atelectasis of the right upper lobe caused by an endobronchial nodule. A chest tube was immediately inserted to decompress the pneumothorax. Chest computed tomography with contrast revealed an endobronchial nodule that was seen as contrast-enhanced. Flexible bronchoscopy was performed to biopsy the nodule. The bronchoscopy showed a yellow spherical nodule in the right upper lobar bronchus. Rat tooth forceps were used, because the lesion was too slippery to grasp with ellipsoid cup biopsy forceps. The whole nodule was extracted and was confirmed to be a FB, which was determined to be a green pea vegetable. After the procedure, the chest tube was removed, and the patient was discharged without any complications. This case highlights the importance of suspecting a FB as a cause of pneumothorax and presents the possibility of misdiagnosing an aspirated FB as an endobronchial tumor and selecting the appropriate instrument for removing an endobronchial FB.

A clinical case of bronchoscopic detection and removal of a foreign body from the upper lobar bronchus on the right mimicking lung cancer

Foreign bodies in the respiratory tract are rare in adults. Clinical manifestations include hemoptysis among other signs which requires the examination to detect tuberculosis and lung cancer. The article describes a clinical case that demonstrates the possibilities of endoscopic diagnostics and treatment in the patient with an X-ray negative foreign body (a cigarette filter) that has been in the lumen of the upper lobar bronchus of the right lung for a long time which caused inflammation in the blocked lobe and mimicking endoscopically central lung cancer.

Tracheal swab from front of neck airway for SARS-CoV-2; a bronchial foreign body

We report the case of a bronchial foreign body, following a tracheostomy site swab for SARS-CoV-2, aiming to raise awareness and vigilance. A qualified nurse was performing a routine SARS-CoV-2 swab on a 51-year-old woman, fitted with a tracheostomy in the recent past following a craniotomy. This was part of the discharging protocol to a nursing home. During the sampling, part of the swab stylet snapped and was inadvertently dropped through the tracheostomy site. Initial CT imaging was reported as showing no signs of a foreign body but some inflammatory changes. Bedside flexible endoscopy through the tracheostomy site revealed the swab in a right lobar bronchus. This was subsequently removed by flexible bronchoscopy. This case highlights the need for clear guidance on how samples for SARS-CoV-2 are taken from patients with front of neck airways (laryngectomy/tracheοstomy) and the potential pitfalls involved.

Management of Esophageal Lung in a Patient With VACTERL Anomalies

Esophageal lung is a rare type of bronchopulmonary foregut malformation where an anomalous main bronchus arises from the esophagus rather than the trachea. This differentiates from an esophageal bronchus where a lobar bronchus arises from the esophagus. Fewer than 30 of these anomalies have been reported in the literature. A female infant was born at 35 weeks gestational age and found to have multiple congenital abnormalities including cleft palate, long-gap esophageal atresia, tracheoesophageal fistula (TEF), imperforate anus, and renal anomalies. She initially underwent thoracoscopic ligation of TEF with colostomy and mucus fistula creation. Bronchoscopy found no right mainstem bronchus, and subsequent computed tomography scan was consistent with possible esophageal bronchus. Esophagoscopy through the gastrostomy discovered a fistulous connection between the distal esophagus and anomalous main right bronchus. Right thoracotomy with pneumonectomy of the hypoplastic lung was performed. She subsequently underwent vaginostomy for hydrometrocolpos. Her proximal esophagus was diverted with a cervical esophagostomy for control of secretions. She also required tracheotomy and is currently at home on minimal ventilator settings awaiting staged reconstruction. Esophageal lung is a rare congenital abnormality with few reported cases. Surgical treatment with pneumonectomy is often required, and pediatric surgeons should be familiar with these congenital bronchopulmonary malformations.