Three-port thoracoscopic middle lobectomy in a patient after left pneumonectomy.

Lung lobectomy after contralateral pneumonectomy is a challenging procedure associated with high morbidity and mortality. To date, only limited evidence has been available, and adequate indication or surgical approach remain unclear. We herein report a successful case of thoracoscopic lobectomy in a single-lung patient. A 63-year-old man, who had a history of left pneumonectomy for lung cancer, was found to have an abnormal opacity in the right middle zone at a health checkup 13 years after the previous operation. This nodule was later diagnosed as squamous cell cancer (cT2N0M0, stage IB) and surgical resection was considered. Thoracoscopic middle lobectomy with D1 lymph node dissection was performed for this patient under selective ventilation of the right upper and lower lobes. Postoperative course was uneventful and he was discharged on postoperative day 7, requiring no oxygen. The patient is doing well with no evidence of recurrence for 5 years. Given the lower invasiveness, thoracoscopic lobectomy under the selective ventilation of residual lobes could be an option after contralateral pneumonectomy in selected patients.

[Change of the bronchial morphology, supine to lateral position on the 3DCT].

BACKGROUND: It is more difficult to intubate the double-lumen bronchial tube into the left bronchus than the right bronchus, and it is more difficult in a left decubitus position than normal position. And it is most difficult in the flexional decubitus position. METHODS: We examined the cause of the difficulty in intubation of the left main bronchus which is solved by 3DCT. RESULTS: The cause of the difficulty was the increase in size of the divergence angle of the left bronchus. Once the double-lumen left bronchial tube in the left bronchus has been pulled out, it is difficult to return the tube back to the left bronchus in the flexional position. For returning the tube to the bronchus, we place the head higher and change the flexional position to the extended position. CONCLUSIONS: We examined the cause of difficulty in intubation of the left bronchus in the decubitus position with 3DCT. We concluded that the cause is the increase in the size of the angle, and for the tube to be intubated in the left bronchus, the patient position must be changed from the flexional position.

Magnetic resonance-thoracic ductography: imaging aid for thoracic surgery and thoracic duct depiction based on embryological considerations.

PURPOSE: We describe the optimal protocol of magnetic resonance-thoracic ductography (MRTD) and provide examples of thoracic ducts (TD) and various anomalies. The anatomical pathway of the TD was analyzed based on embryological considerations. METHODS: A total of 78 subjects, consisting of noncancer adults and patients with esophageal cancer and lung cancer, were enrolled. The MRTD protocol included a long echo time and was based on emphasizing signals from the liquid fraction and suppressing other signals, based on the principle that lymph flow through the TD appears hyperintense on T2-weighted images. The TD configuration was classified into nine types based on location [right and/or left side(s) of the descending aorta] and outflow [right and/or left venous angle(s)]. RESULTS: MRTD was conducted in 78 patients, and the three-dimensional reconstruction was considered to provide excellent view of the TD in 69 patients, segmentalization of TD in 4, and a poor view of the TD in 5. MRTD achieved a visualization rate of 94%. Most of the patients had a right-side TD that flowed into the left venous angle. Major configuration variations were noted in 14% of cases. Minor anomalies, such as divergence and meandering, were frequently seen. CONCLUSION: MRTD allows noninvasive evaluation of TD and can be used to identify TD configuration. Thus, this technique is considered to contribute positively to safer performance of thoracic surgery.

Imaging aid for thoracic surgery: multidetector-row computed tomography evaluation of the tracheobronchial structure and bronchial tube selection for one-lung anesthesia.

OBJECTIVE: The tracheobronchial structures were evaluated by multidetector-row computed tomography (MDCT), which provided imaging information for one-lung anesthesia during thoracic surgery. METHODS: The subjects consisted of 100 patients. Three-dimensional (3D) images of the tracheobronchial structures and the bronchial tubes were created. RESULTS: Individual differences were found in the tracheobronchial structures in 100 patients. The length and the diameter of the right main bronchus were measured with 3D images and were not related to the patient's physical appearance, such as body height. Problematic intubation cases included a short right main bronchus <10 mm, an anomaly of the right bronchus, and tracheal stenosis. CONCLUSION: The 3D images demonstrated problematic areas of the tracheobronchial structure and helped the anesthesiologists select the most appropriate bronchial tube suitable for the tracheobronchial structure variations. Therefore, this technique is considered to contribute to safer performance of one-lung anesthesia.

[Difficult airway in a child with multiple juvenile xanthogranulomas].

Juvenile xanthogranuloma (JXG) is a benign and self-healing histiocytosis on the skin. A 4-year-old boy with multiple JXG was scheduled for plastic surgery to correct the scar contraction of the neck. The patient was expected to have difficult airway caused by small mouth, limitation of neck movement and numerous nodular lesions located at the face. Initially he underwent resection of the neck scar under local anesthesia with added inhalation anesthesia via mask, and the restricted neck recurvation was improved. One week later, he underwent skin grafting under general anesthesia. We used a spiral tube of 3 mm diameter inserted to the nostril for manual ventilation, and bronchofiberscope-aided tracheal intubation was successfully performed through the laryngeal mask airway under general anesthesia without any problems.