P.224 A Case Report of Spinal Screws Penetrating the Pulmonary Artery

Background: Spinal instrumentation is commonly utilized to mechanically stabilize the spine in trauma, oncology and degenerative disease. Although several complications have been reported, this is the first case of screw penetration of the pulmonary artery. Methods: We present a case of a 74-year old gentleman who suffered from a thoracic spine chordoma. He underwent a T8 resection with T8-T12 instrumented fusion with subsequent radiation. Recurrence of his disease led to resection of his 3rd and 4th ribs and repeat radiation. He presented 6 years later with 2 episodes of massive hemoptysis. Review of the literature was conducted to search for similar complications. Results: A Chest Computed Tomography scan demonstrated the presence of a pedicle screw tip in the right pulmonary artery. Angiogram revealed no evidence of active arterial extravasation. In the operating room, the patient had a right lower lobectomy, with segmental pulmonary artery sacrifice, as well as replacement of the spinal fixation hardware. Literature review revealed multiple aortic injuries following spinal instrumentation. However, this was the first case of pulmonary artery erosion. Conclusions: Spinal instrumentation has been associated with screw migration and penetration of nearby tissues and vessels. A high incidence of suspicion is required when patients present with delayed and unusual complications.

An aberrant mediastinal mediobasal segmental pulmonary artery in a patient with lung cancer undergoing right lower lobectomy: a case report

Background A mediastinal mediobasal segmental pulmonary artery (A7) from the right main pulmonary artery is extremely rare. Case presentation: We have reported a case of a 71-year-old woman with aberrant A7 who underwent right lower lobectomy for lung cancer (cT1bN0M0, stage IA2). Preoperative three-dimensional computed tomography (CT) angiography revealed an aberrant mediastinal A7 from the right main pulmonary artery. Right lower lobectomy and mediastinal lymph node dissection were performed. Intraoperatively, A7 was observed between the superior and inferior pulmonary veins, and at the front of the lower bronchus near the anterior hilum. The artery was carefully dissected from the caudal side after dissection of the inferior pulmonary vein. Then, the lung parenchyma, which was within the fissure due to poor lobulation between the middle and lower lobes, was safely divided. Conclusions Thoracic surgeons need to evaluate CT angiography or enhanced multidetector CT carefully at preoperative conferences and always keep this anomaly in mind.

Stapling of an endobronchial suction tube with the bronchus during robot-assisted right lower lobectomy: a case report

Background Troubleshooting intraoperative complications requires careful management, and the safest technique should be chosen. We recently experienced a unique intraoperative bronchial complication during pulmonary lobectomy in robot-assisted thoracic surgery (RATS). There is no consensus on whether to continue RATS or convert to a more familiar technique, such as video-assisted thoracic surgery (VATS) or thoracotomy, for intraoperative complications that occur during RATS, and the decision should be determined individually. Case presentation A 74-year-old woman with primary lung adenocarcinoma (clinical stage IA2) underwent robot-assisted right lower lobectomy under one-lung ventilation and CO2 insufflation. Intraoperatively, the anesthesiologist placed the endobronchial suction tube in the right bronchus with intention of maintaining the right lung collapse, which was simultaneously stapled with the right lower bronchus during the right lower lobe bronchial closure using a robotic stapler. During robot-assisted manipulation, we removed the staples involved with the suction tube, one by one, using robotic-arm forceps and sutured the partially opened stump. Subsequently, the bronchial stump was covered with a pedicled pericardial fat pad. The postoperative course was uneventful, and the patient developed no complications when followed up 8 months after discharge. Hence, we could rectify this intraoperative bronchial complication using a robot-assisted technique and avoid conversion to VATS or thoracotomy. Conclusion The precise manipulation techniques in RATS contributed to facilitate the successful execution of surgical procedures, such as staple removal and re-suturing of the bronchial stump and may be a useful as a method for such troubleshooting such intraoperative complications.

Anlotinib Combined With Chemotherapy for Recurrence of Pulmonary Sarcomatoid Cancer Previously Surgically Treated: A Case Report and Literature Review

BackgroundPulmonary sarcomatoid cancer (PSC) is a very rare subtype of poorly differentiated non-small-lung-cancer (NSCLC) with very poor prognosis. To date, the optimal treatment for PSC has not been elucidated, and the efficacy of anlotinib in PSC has not been previously reported.Case PresentationA 77-year-old male patient was admitted with cough, expectoration, and blood-stained sputum for one month. CT showed a soft mass in the inferior lobe of the right lung, which was diagnosed as spindle cell carcinoma (PSC) by histopathology. A videothoracoscopic right lower lobectomy and mediastinal lymph node dissection procedure was performed on the patient, but the disease recurred one month after surgery. The patient was then given first-line chemotherapy with gemcitabine and albumin paclitaxel for one cycle, but the disease continued to progress. The patient then received anlotinib combined with second-line chemotherapy (dacarbazine and cis-platinum) for six cycles, and the response reached complete remission (CR). Then the patient was given maintenance therapy with anlotinib alone, and the disease was still stable at the most recent reexamination. Progression-free survival (PFS) has lasted for more than two years, without any intolerable toxicity.ConclusionThis postoperative recurrent PSC patient achieved significant clinical benefits with anlotinib treatment. Our findings provide direct evidence of the efficacy of anlotinib in PSC. More studies are needed to confirm our observation.

Lung cancer with partial anomalous pulmonary venous connection in a different lobe: a case report

Background Anomalous pulmonary venous connection (APVC) is a congenital malformation in which the pulmonary veins connect to the systemic venous system but not to the left atrium. APVC can be classified as total or partial (PAPVC). PAPVC is rare among surgical patients with lung cancer, and most cases are detected incidentally during surgery. We herein report a patient with lung cancer in whom PAPVC was diagnosed before surgery, which made it difficult to determine the surgical procedure. Case presentation A 71-year-old man was followed-up as an outpatient after surgery for renal cell carcinoma. Chest computed tomography showed a 22-mm nodule in the right lower lobe and PAPVC in the right upper lobe. He was diagnosed with lung adenocarcinoma (cT1cN0M0 stage IA3) and scheduled for surgery. Preoperative catheterization showed a pulmonary to systemic flow ratio (Qp/Qs) of 1.64 and mean pulmonary artery pressure (MPAP) of 16 mmHg. Surgical repair of PAPVC is indicated when a patient is symptomatic and has a Qp/Qs ≥1.5–2.0. The patient was scheduled for right lower lobectomy, but postoperative worsening of right heart strain was considered. Concomitant PAPVC repair was therefore considered, but he had no atrial septal defect and was asymptomatic; therefore, PAPVC treatment was considered unnecessary. However, we planned to perform concomitant PAPVC repair if his circulatory dynamics worsened during surgery or if his MPAP exceeded 25 mmHg. His MPAP was 20 mmHg and his circulatory dynamics remained stable, and right lower lobectomy was therefore completed. His postoperative course was favorable. Follow-up catheterization at 6 months showed a Qp/Qs of 1.19 and MPAP of 18 mmHg, with no evidence of increased right heart strain. There was no evidence of right heart failure or recurrence of lung cancer at last follow-up at 18 months after surgery. Conclusions We present a case of right lower lung cancer complicated by PAPVC in the right upper lobe. This case suggests that concomitant repair of PAPVC in the right upper lobe may not be necessary when performing right lower lobectomy, although the patient’s Qp/Qs and MPAP should be considered.

Management of a primary cardiac leiomyosarcoma in a young woman

Cardiac leiomyosarcoma is an extremely rare tumor with a poor prognosis. An 18-year-old female patient was admitted to our clinic with a left atrial leiomyosarcoma extending to the right lower pulmonary veins. We performed complete tumor excision by the right anterolateral mini-thoracotomy approach using minimally invasive techniques. After pathological confirmation of the tumor, right lower lobectomy was performed with the same incision one week later to prevent recurrence. Although no tumor remnant was found in the lobectomy specimen, adjuvant chemotherapy was started. No recurrence was detected during the 12-month follow-up. In conclusion, the right submammarian minithoracotomy approach has the advantages of its less invasive nature and suitability for complete tumor resection with lobectomy.

A case report of a gastrobronchial fistula and lung abscess caused by leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer

Background Gastrobronchial fistulas are rare, but life-threatening, complications of esophagectomy. They are caused by anastomotic leakage and mainly occur around anastomotic sites. In the present paper, we report a rare case of leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer, which was successfully treated using an intercostal muscle flap and lung resection. Case presentation A 61-year-old male underwent subtotal esophagectomy with regional lymphadenectomy for esophageal cancer. The sutures along the staple line of the gastric tube failed 11 days after surgery, and a pulmonary abscess was also found on imaging. The abscess did not heal after conservative treatment; therefore, right lower lobectomy, gastrobronchial fistula resection, primary closure, and patching of the leaking portion of the gastric tube with an intercostal muscle flap were performed 9 months after the first operation. The patient’s postoperative course was uneventful, and he was discharged on the 354th day. Conclusions We experienced a case involving a gastrobronchial fistula caused by leakage from the staple line of a gastric tube and successfully treated it by performing right lower lobectomy and patching the leak with an intercostal muscle flap.

How to avoid en masse lobectomy using VATS technique in presence of hilar fibrosis

Perivascular fibrosis is technically one of the most challenging issue to manage during thoracoscopic lobectomy and it is associated with increased risk of hemorrhagic injury. Here we report a case of thoracoscopic right lower lobectomy performed with individual dissection of segmental arteries due to dense adventitial fibrosis around the right lower lobe pulmonary artery. This approach may be considered as an alternative to the so-called “en masse” lobectomy and a way to avoid conversion to thoracotomy.

Rare and interesting case of solitary peripheral pulmonary artery aneurysm

We report a rare case of solitary peripheral pulmonary artery aneurysm in a patient who was evaluated for haemoptysis. Incidentally, his total antibodies were positive for Coronavirus 2019 infection. Patient underwent right lower lobectomy uneventfully. Peripheral pulmonary artery aneurysms arising from segmental or intrapulmonary branches are extremely rare. Untreated, the majority end fatally due to sudden rupture and exsanguination. The purpose of this article is to report our rare case and review the pertinent literature.