Tumor distance from the mediastinum predicts N2 upstaging in clinical stage I lower-lobe non-small cell lung cancer.

OBJECTIVE: Pulmonary lymphatic drainage of the lower lobe into the mediastinal lymph nodes includes not only the pathway via the hilar lymph nodes but also the pathway directly into the mediastinum via the pulmonary ligament. This study aimed to determine the association between the distance from the mediastinum to the tumor and the frequency of occult mediastinal nodal metastasis (OMNM) in patients with clinical stage I lower-lobe non-small cell lung cancer (NSCLC). METHODS: Between April 2007 and March 2022, data of patients who underwent anatomical pulmonary resection and mediastinal lymph node dissection for clinical stage I radiological pure-solid lower-lobe NSCLC were retrospectively reviewed. In computed tomography axial sections, the ratio of the distance from the inner edge of the lung to the inner margin of the tumor within the lung width of the affected lung was defined as the inner margin ratio. Patients were divided into 2 groups based on whether the inner margin ratio was ≤0.50 (inner-type) or >0.50 (outer-type), and the association between inner margin ratio status and clinicopathological findings was assessed. RESULTS: In total, 200 patients were enrolled in the study. OMNM frequency was 8.5%. More inner-type than outer-type patients had OMNM (13.2% vs 3.2%; P = .012) and skip N2 metastasis (7.5% vs 1.1%; P = .038). Multivariable analysis revealed that the inner margin ratio was the only independent preoperative predictor of OMNM (odds ratio, 4.72; 95% CI, 1.31-17.07; P = .018). CONCLUSIONS: Tumor distance from the mediastinum was the most important preoperative predictor of OMNM in patients with lower-lobe NSCLC.

Preservation vs. dissection of inferior pulmonary ligament for thoracoscopic upper lobectomy: a prospective randomized controlled trial.

OBJECTIVES: The proper procedure for inferior pulmonary ligament (IPL) during upper lobectomy remains a topic of debate. To address this matter, we carried out a trial comparing the clinical outcomes of IPL preservation versus IPL dissection during thoracoscopic upper lobectomy (TUL). METHODS: Patients undergoing thoracoscopic left/right upper lobectomy (TLUL/TRUL) were assigned to either the dissection group (Group D) or the preservation group (Group P). Our primary objective was to quantify and compare the alterations in postoperative residual bronchial angle and lung volume changes between the two groups. Our secondary objective encompassed the assessment of various other intraoperative and postoperative outcomes. RESULTS: Following adherence to the inclusion and exclusion criteria, we enrolled 100 patients (41 left and 59 right) in Group P and 108 patients (41 left and 67 right) in Group D for the study. Our findings revealed that in TLUL, Group P was able to reduce the degree of postoperative residual bronchial angle change (P < 0.05). Conversely, the situation was distinct for TRUL. We found no notable disparity between the two groups (P > 0.05) with regard to alterations in lung volume or the occurrence of postoperative complications-except for the duration of postoperative hospital stay (P < 0.05). CONCLUSIONS: Our study suggests IPL preservation especially for TLUL when compared to TRUL, which have important implications for the clinical management of patients undergoing upper lobectomy.

Comparison of different approaches in complete thoracoscopic segmentectomy of lung lower lobe.

Background: Safe and oncologically acceptable segmentectomy outcomes were reported for early-stage lung cancer. The high-resolution computed tomography allowed us to find detailed structures inside the lungs, such as the pulmonary ligaments (PLs). Hence, we have presented the relatively anatomically challenging thoracoscopic segmentectomy, for the resection of the lateral basal segment, the posterior basal segment, and both segments through the PL as a PL approach. This study aimed to retrospectively examine the lung lower lobe segmentectomy, excluding the superior and basal segments (from S7 to S10), using the PL approach as an option to treat the lower lobe tumors of the lung. We then compared the efficacy of the PL approach in terms of safety with the interlobar fissure (IF) approach. The characteristics of the patients, intra- and postoperative complications, and surgical outcomes were analyzed. Methods: Of the 510 patients who underwent segmentectomy for malignant lung tumors from February 2009 to December 2020, 85 were included in this study. Among them, 41 underwent a complete lung lower lobe thoracoscopic segmentectomy, excluding S6 and basal segments (from S7 to S10), using the PL approach, and the remaining 44 used the IF approach. Results: The median age in 41 patients in the PL group was 64.0 years (range, 22-82), and that in 44 patients in the IF group was 66.5 years (range, 44-88), with significant differences in gender between these groups. Video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery were performed on 37 and 4 patients in the PL group and 43 and 1 patient in the IF group, respectively. Postoperative complication frequency was not significantly different between these groups. The most common complications were the air leaks that persisted for over 7 days in 1 and 5 patients in the PL and IF groups, respectively. Conclusions: Complete thoracoscopic segmentectomy of the lower lobe, excluding S6 and basal segments, using the PL approach is a reasonable option for lung lower lobe tumors compared with the IF approach.

Complete thoracoscopic S9 and/or S10 segmentectomy through a pulmonary ligament approach: a retrospective study.

BACKGROUND: The high resolution of computed tomography has found the pulmonary ligaments that consists of a double serous layer of visceral pleura, forms the intersegmental septum, and enters the lung parenchyma. This study aimed to investigate the clinical feasibility of thoracoscopic segmentectomy (TS) of the lateral basal segment (S9), posterior basal segment (S10), and both through the pulmonary ligament (PL). METHODS: Between February 2009 and November 2021, 542 patients underwent segmentectomy for malignant lung tumors at Tokyo Women's Medical University Hospital (Tokyo, Japan). This study included 51 patients. Among them, 40 underwent a complete TS of the S9, S10, or both by the PL approach (PL group), and the remaining 11 by the interlobar fissure approach (IF group). RESULTS: Patients' characteristics did not significantly differ between the two groups. In the PL group, 34 underwent video-assisted thoracoscopic surgery (VATS), and 6 underwent robot-assisted thoracoscopic surgery. In the IF group, all 11 underwent VATS. Operation duration, estimated blood loss, and postoperative complication frequency were not significantly different between these groups, but the maximum tumor diameter showed a significant difference. CONCLUSIONS: Complete TS of the S9, S10, and both through the PL is a reasonable option for tumors located in such segments. This approach is a feasible option for performing TS.

Inferior pulmonary ligament division during left upper lobectomy causes pulmonary dysfunction.

OBJECTIVES: The division of inferior pulmonary ligament (IPL) during upper lobectomy (UL) was believed to be mandatory to dilate the remaining lung sufficiently. However, the benefits, especially postoperative pulmonary function, remain controversial. This study aimed to evaluate whether IPL division leads to pulmonary dysfunction. METHODS: This retrospective study included 213 patients who underwent UL between 2005 and 2018. They were categorized into an IPL division group (D group, n = 106) and a preservation group (P group, n = 107). Postoperative dead space at the lung apex, pulmonary function and complications were assessed using chest X-rays and spirometry. Changes in bronchial angle, cross-sectional area and circumference of the narrowed bronchus on the excised side were measured on three-dimensional computed tomography. RESULTS: There was no significant difference in the postoperative complication rate, the dead space area, forced vital capacity (FVC), or forced expiratory volume in 1 s (FEV1) between the 2 groups after right UL (FVC; P = 0.838, FEV1; P = 0.693). By contrast, after left UL pulmonary function was significantly better in the P than in the D group (FVC; P = 0.038, FEV1; P = 0.027). Changes in bronchial angle did not significantly differ between the 2 groups. The narrowed bronchus's cross-sectional area (P = 0.021) and circumference (P = 0.009) were significantly smaller in the D group than in the P group after left UL. CONCLUSIONS: IPL division during left UL caused postoperative pulmonary dysfunction and airflow limitation due to bronchial kinking. IPL preservation may have a beneficial impact on postoperative pulmonary function.

The impact of dissection of station 9 on survival and the necessity of pulmonary ligament division during upper lobectomy for lung cancer.

BACKGROUND: We conducted this study to investigate the need for dissection of station 9 lymph nodes during upper lobectomy for non-small-cell lung cancer (NSCLC) and to find out the operative results of inferior pulmonary ligament division. METHODS: A total of 840 patients who underwent upper lobectomy for NSCLC between January 2007 and June 2020 were evaluated retrospectively. The patients were separated into two groups - those having undergone lymph node dissection of station 9 and inferior pulmonary ligament dissection (Group I) and those who did not (Group II). In these groups, the prognostic value of station 9 lymph nodes and postoperative effects (drainage time, prolonged air leak, dead space and length of hospital stay) of ligament division or preservation were analyzed. RESULTS: The number of patients with station 9 lymph node metastasis was only one (0.1%) and that was multi-station pN2 disease. Station 9 lymph nodes were found in 675 (80.4%) patients, while 22 (2.6%) patients had no lymph nodes in the dissected material. In the other 143 (17%) patients, the inferior pulmonary ligament and station 9 were not dissected. While 5-year survival was 64.9% in 697 patients of Group I, it was 61.3% in 143 patients of Group II (p = 0.56). There was no statistically significant difference between the groups in postoperative effects of ligament division or preservation. CONCLUSIONS: In upper lobectomies, status of station 9 does not have a significant impact on patients' survival and lymph node staging. Additionally, preservation or division of the inferior pulmonary ligament has no significant advantage or disadvantage.

Does the division of the inferior pulmonary ligament in upper lobectomy result in improved short-term clinical outcomes and long-term survival?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Does the division of the inferior pulmonary ligament (IPL) in upper lobectomy result in improved short-term clinical outcomes and long-term survival?'. Altogether 43 papers were found using the reported search, of which 6 studies represented the best evidence to answer the clinical question, including a previous best evidence topic study, a meta-analysis and 4 retrospective cohort studies. The author, journal, date and country of publication, patient group studied, study type and relevant outcomes and results of these papers are tabulated. Most of the enrolled studies reported that there is no significant difference between the division groups and the preservation groups in terms of drainage time, drainage volume, postoperative dead space and complications. While 3 cohort studies revealed unfavoured postoperative pulmonary function in the division groups, including lung volume, forced vital capacity and forced expiratory volume in 1 s. The previous meta-analysis and a recent cohort study also found that the division of IPL might lead to increased bronchus angle change or torsion. Moreover, 2 cohort studies found that the division of IPL could not improve the long-term survival of patients undergoing upper lobectomy. Current evidence showed that dividing the IPL could not result in clinical benefits but might lead to decreased pulmonary function instead. Therefore, we recommended not dissecting the IPL routinely during upper lobectomy.

Evaluation of the necessity of Pulmonary Ligament Lymph Node Dissection for Upper Lobe Stage IB NSCLC: A Propensity Score-matched Study.

Objective: The purpose of this study was to explore whether the resection of pulmonary ligament lymph nodes would affect the prognosis of patients with stage IB non-small cell lung cancer (NSCLC). Methods: We retrospectively analyzed 341 patients with upper lobe stage IB NSCLC who underwent radical surgery for lung cancer at Sun Yat-Sen University Cancer Center from 1999 to 2009. The Cox proportional hazard regression model was used to analyze the prognostic factors. After propensity score matching (PSM), 204 cases were selected. The Kaplan-Meier method and log-rank test were applied to compare overall survival (OS) and recurrence-free survival (RFS). Results: Among the 341 cases included in the study, 217 had no pulmonary ligament lymph nodes resected, and 124 had pulmonary ligament lymph nodes resected. They were divided into two groups according to whether the pulmonary ligament lymph nodes were resected; there were significant differences between the two groups in laterality, resected lymph node stations, and resected lymph node numbers (P<0.05). Univariate and multivariate analyses by the Cox proportional hazards model showed that age and family history of malignant tumors were prognostic factors for OS, and no variables were prognostic factors for RFS (P<0.05). Resection of the pulmonary ligament lymph node was not associated with OS or RFS. After propensity score matching (PSM), survival analysis was performed again using the Kaplan-Meier method and log-rank test; the results suggested that resection of the pulmonary ligament lymph node is not statistically associated with OS and RFS (P>0.05). Conclusions: For stage IB NSCLC, resection of the pulmonary ligament lymph nodes was not statistically associated with OS or RFS. Pulmonary ligament lymph node resection is not necessary for early-stage NSCLC.

Treatment of massive hemoptysis after thoracic aortic aneurysm repair.

BACKGROUND: Massive hemoptysis after thoracic aortic aneurysm (TAA) repair is a rare but potentially lethal condition. Endovascular management is a challenging treatment option due to the complexity of culprit vessel access. CASE PRESENTATION: An 81-year-old woman was referred to our hospital with massive hemoptysis. She had a history of graft replacement and thoracic endovascular aortic repair (TEVAR) for dissecting TAA. Computed tomography (CT) showed massive atelectasis with hematoma in the left lower lung lobe adjacent to the descending aortic aneurysm treated with TEVAR. Contrast-enhanced CT revealed a pseudoaneurysm and proliferation of abnormal vessels at the peripheral side of the left pulmonary ligament artery (PLA) in the atelectasis. The PLA continued to the right subscapular artery via a complex collateral pathway. Diagnostic angiography of the right subcapsular artery revealed a pseudoaneurysm and abnormal vessels at the peripheral side of the left PLA with a systemic-pulmonary artery shunt. Transcatheter arterial embolization (TAE) for the left PLA via the collateral pathway with N-butyl cyanoacrylate achieved complete embolization. The patient's hemoptysis was controlled and she was discharged. CONCLUSIONS: Here we presented a case of massive hemoptysis due to PLA disruption that occurred after TAA repair. TAE via a complex collateral pathway is a feasible and effective treatment for hemoptysis, even in patients who have undergone surgical or endovascular TAA repair.

Inferior pulmonary ligament approach and/or interlobar fissure approach for posterior and/or lateral basal segment resection: a case-series of 31 patients.

Background: Thoracoscopic posterior and/ or lateral basal segment resection is a major difficult segmentectomy for thoracic surgeons, because of its high surgical difficulty and high incidence of postoperative complications. Here we describe the surgical procedure and techniques of the transpulmonary ligament approach and/or interlobar fissure approach for the thoracoscopic posterior and/or lateral basal segment resection. Methods: The clinical data of 31 patients who underwent thoracoscopic posterior and/or lateral basal segment resection from January 2020 to June 2022 were included. All patients underwent posterior and/or lateral basal segment resection via the inferior pulmonary ligament and/or interlobar fissure approach. Follow-up was continued to September 2022. Results: All patients including 7 males and 24 females, with a median age of 51 [31-62] years, completed the operation successfully. One patient was converted to lobectomy due to insufficient margins intraoperatively. Two patients were treated using the interlobar fissure approach, 25 patients were treated via the inferior pulmonary ligament approach, and four patients were treated by employing both methods. Also, 20 patients had a single lesion and 1 patient had two lesions. Eleven patients underwent surgical resections on other lesions when posterior and/or lateral basal segment lesions resected. The median operation time was 120 [50-290] minutes, the median intraoperative blood loss was 50 [10-100] mL, the median postoperative drainage time was 4 [2-10] days, and the median postoperative hospital stay was 4 [2-13] days. There was no perioperative death. Postoperative complications included five cases of persistent air leakage longer than 5 days (7, 7, 8, 9, and 10 days), and one patient developed a pulmonary infection and abnormal liver function after the operation. The median maximum diameter of the lesion was 0.8 [0.2-1.5] cm, lymph nodes were resected in a median of 8 [4-15] case. Conclusions: The approach of the inferior pulmonary ligament to resect posterior and/or the lateral basal segment can optimize the surgical procedure. The surgical trauma and postoperative complications are reduced, which is worthy of popularization and application.

Inferior Pulmonary Ligament Division May Be Unnecessary during Left Upper Lobectomy: Effects on Lung Volume, Bronchial Angle and Bronchial Tortuosity.

The benefits of dissecting inferior pulmonary ligament (IPL) during upper lobectomy using video-assisted thoracoscopic surgery (VATS) for early-stage lung cancer remains controversial. This study evaluates the effect of IPL dissection by comparing the lung volume, bronchial angle, and bronchial tortuosity of the left lower lobe (LLL) during VATS upper lobectomy. Medical records of all patients who underwent VATS left upper lobectomy for early-stage lung cancer were evaluated. Patients were divided into group P (preservation) and group D (dissection). Pre- and post-surgery lung volumes, bronchial angles (angle 1: axial angulation; angle 2: vertical angulation), and bronchial tortuosity (curvature index of the left main bronchus) were measured using computed tomography images for comparison. Forty patients were included in each group. Patient characteristics such as age, gender, body mass index, and smoking status, and preoperative lung volume, bronchial angles, and tortuosity were not significantly different between the two groups, and there was no statistically significant difference in the axial and vertical angulations; however, the change in pre- and postoperative bronchial tortuosity (0.03 ± 0.03 vs. 0.06 ± 0.03) and lung volume (-558.1 ± 410.0 mL vs. -736.3 ± 382.7 mL) showed a significant difference (p < 0.001 and p = 0.04, respectively). Preservation of IPLs during left upper lobectomy may be beneficial for LLL expansion and induces less movement and positional change in the left main bronchus.

A pulmonary ligament approach for portal robotic segmentectomy of the lateral and posterior basal segments: a case report.

BACKGROUND: Thoracoscopic segmentectomy of the lateral and posterior basal segments is extremely technically challenging. Appropriate segmentectomy requires exposure and recognition of the branches of the bronchi and pulmonary vessels deep in the lung parenchyma. Although various approaches for these segmentectomies have been reported, the use of a pulmonary ligament approach is rational because it does not require any interlobar separation. Here, we report a successful case of portal robotic segmentectomy of the lateral and posterior basal segments through the pulmonary ligament approach. CASE PRESENTATION: A 60-year-old Japanese man with a history of low anterior resection for rectal cancer was referred to our department because of a lung nodule. His chest computed tomography revealed a 15-mm tumor in the left posterior basal bronchus. Robotic left S9-10 segmentectomy through the pulmonary ligament was performed with five-port incisions. CONCLUSIONS: An extremely technically challenging thoracoscopic segmentectomy of the lateral and posterior basal segments was performed through the pulmonary ligament using a robotic surgical system.

Retrocardiac Lucency in Neonates: Air Trapped in the Pulmonary Ligament.

Air trapped in neonates' pulmonary ligament is often the consequence of positive pressure ventilation and its typical radiographic appearance must be recognized in order to prevent the use of aggravating factors. TEACHING POINT: Air trapped in neonates' pulmonary ligament is often the consequence of positive pressure ventilation; its typical waterdrop appearance must be recognized on radiographs to prevent unnecessary additional measures.

The choice of dissection or preservation of the inferior pulmonary ligament after an upper lobectomy: a systematic review and meta-analysis.

BACKGROUND: The necessity of the inferior pulmonary ligament (IPL) dissection after an upper lobectomy remains controversial. This meta-analysis aimed to evaluate whether this accessional procedure could reduce the postoperative complications and improve outcomes. METHODS: PubMed, Embase, Ovid, Cochrane Library, CBM, and CNKI databases were searched for the relevant studies which compared the dissection with preservation of IPL during the upper lobectomy. The Review Manager 5.3 software was used for this meta-analysis. RESULTS: Three RCTs and five CCTs were included in this meta-analysis. These studies contained a total of 610 patients, in which 315 patients received a pulmonary ligament dissection (group D) after the upper lobectomy, while the other 295 patients preserved the pulmonary ligament (group P). No significant difference was demonstrated between the group D and group P in terms of drainage time after surgery (MD 0.14, 95%CI - 0.05 to 0.33, P = 0.15), rate of postoperative dead space (OR 1.33, 95%CI 0.72 to 2.46, P = 0.36), rate of postoperative complications (OR 1.20, 95%CI 0.66 to 2.19, P = 0.56). However, the pooled comparison revealed a greater change of the right main bronchial angle (MD 5.00, 95%CI 1.68 to 8.33, P = 0.003) in group D compared with group P, indicated that the dissection of IPL may lead to a greater distortion of bronchus. CONCLUSIONS: This meta-analysis confirmed that the dissection of IPL do not effectively reduce the postoperative complications and improve the prognosis. Therefore, it is not necessary to dissect the IPL after an upper lobectomy.

[Clinical Value of Four-hole Unilateral Dissecting Lobectomy and Mediastinal Lymph Node Dissection in the Treatment of Early Non-small Cell Lung Cancer].

BACKGROUND: Thoracoscopic lobectomy combined with mediastinal lymph node dissection has been considered as one of the standard surgical procedures for early lung cancer. After 20 years of development, thoracoscopic lobectomy has reached a consensus on reliability and minimally invasive. At present, thoracoscopic lobectomy has a variety of incisions, which gradually evolve into four holes based on three holes, and two or one hole as the operative approach. The aim of this study was to evaluate the clinical value of four-hole unilateral dissecting lobectomy and mediastinal lymph node dissection in the treatment of non-small cell lung cancer (NSCLC). The aim of this study was to investigate the clinical value of anatomical lobectomy with mediastinal lymphadenectomy under four-hole completely video-assisted thoracoscopic surgery (C-VATS) in the treatment of non-small cell lung cancer. METHODS: The patients undergoing lobectomy with mediastinal lymphadenectomy for NSCLC were identified in the Department of Thoracic Surgery, Yangzhou First People's Hospital, Yangzhou University from March 2015 to July 2016. Preoperative clinical diagnosis of peripheral-type early NSCLC. The patients were randomly divided into four-hole monophasic group (experimental group) and three-hole group (control group) according to the number of hospitalization before surgery. According to inclusion and exclusion criteria, the 39 cases assign in experimental group and 34 cases in the control group, including 36 males and 37 females; aged 38 to 84 years. The mean operation time, average blood loss, lymph node dissection group, average drainage, average extubation time and postoperative complications were compared between the two groups for statistical analysis. RESULTS: The two groups of patients were successfully completed surgery, no death after surgery. Mean bleeding in the two groups, the number of lymph node dissection group, the average postoperative drainage, the average time of extubation, postoperative complications, with no significant difference. The average operation time of the four-hole unidirectional group was shorter than that of the three-hole group. The difference was statistically significant (P<0.05). CONCLUSIONS: The safety and efficacy of a four-hole one-way operation under VATS are satisfactory. The operation is smooth during operation, which shortens the course of operation and deserves the clinical promotion.
.

Clinical Value of Four-hole Unilateral Dissecting Lobectomy and Mediastinal Lymph Node Dissection in the Treatment of Early Non-small Cell Lung Cancer / 中国肺癌杂志

BACKGROUND@#Thoracoscopic lobectomy combined with mediastinal lymph node dissection has been considered as one of the standard surgical procedures for early lung cancer. After 20 years of development, thoracoscopic lobectomy has reached a consensus on reliability and minimally invasive. At present, thoracoscopic lobectomy has a variety of incisions, which gradually evolve into four holes based on three holes, and two or one hole as the operative approach. The aim of this study was to evaluate the clinical value of four-hole unilateral dissecting lobectomy and mediastinal lymph node dissection in the treatment of non-small cell lung cancer (NSCLC). The aim of this study was to investigate the clinical value of anatomical lobectomy with mediastinal lymphadenectomy under four-hole completely video-assisted thoracoscopic surgery (C-VATS) in the treatment of non-small cell lung cancer.@*METHODS@#The patients undergoing lobectomy with mediastinal lymphadenectomy for NSCLC were identified in the Department of Thoracic Surgery, Yangzhou First People's Hospital, Yangzhou University from March 2015 to July 2016. Preoperative clinical diagnosis of peripheral-type early NSCLC. The patients were randomly divided into four-hole monophasic group (experimental group) and three-hole group (control group) according to the number of hospitalization before surgery. According to inclusion and exclusion criteria, the 39 cases assign in experimental group and 34 cases in the control group, including 36 males and 37 females; aged 38 to 84 years. The mean operation time, average blood loss, lymph node dissection group, average drainage, average extubation time and postoperative complications were compared between the two groups for statistical analysis.@*RESULTS@#The two groups of patients were successfully completed surgery, no death after surgery. Mean bleeding in the two groups, the number of lymph node dissection group, the average postoperative drainage, the average time of extubation, postoperative complications, with no significant difference. The average operation time of the four-hole unidirectional group was shorter than that of the three-hole group. The difference was statistically significant (P<0.05).@*CONCLUSIONS@#The safety and efficacy of a four-hole one-way operation under VATS are satisfactory. The operation is smooth during operation, which shortens the course of operation and deserves the clinical promotion.
.

Effects of releasing inferior pulmonary ligament in resecting right upper lobe of the lung under thoracoscope on postoperative compensatory dilation of the rest lung / 第二军医大学学报

Objective To discuss if the intraoperative releasing inferior pulmonary ligament would affect the postoperative compensatory dilation of the residual lung in the patients going through the resection of the upper lobe under the thoracoscope. MethodFrom January 2010 to June 2014, 100 patients with lung cancer of right upper lobe were undergone resection of the upper lobe under thoracoscope in our department. They were randomly divided into two groups, the experimental group(the non-released group) with 50 people who were not released inferior pulmonary ligament during resection of the right upper lobe under thoracoscope. The control group(the released group) with 50 people who were released inferior pulmonary ligament during resection of the right upper lobe under thoracoscope. Observed the amount of daily thoracic cavity drainage, total drainage, the average extubation time and length of stay after the operation. Results Statistically compare postoperative residual cavity fluid level reserved rate of two groups of patients.There does not exist significant difference (P > 0.05) and the average drainage on the chest also is not significant (P > 0.05). Besides, there does not exist significant difference (P > 0.05) in the average time of decannulation of chest drainage tube, pleural biopsy cases and times, and postoperative hospital stay between two groups either. ConclusionIt’s unnecessary to release the inferior pulmonary ligament during resection of the right upper lobe under thoracoscope, which will not affect postoperative recovery and prolong length of hospital stay. Therefore it’s suitable for clinical promotion.

Clinical significance of dissection of pulmonary ligament for the video assisted thoracic surgery with bullectomy for spontaneous pneumothorax / 中华胸心血管外科杂志

Objective To evaluate the clinical significance of dissection of pulmonary ligament was operated on videoassisted thoracic surgery(VATS) with bullectomy for spontaneous pneumothorax.Methods From Jan 2012 to Dec 2013, 232 patients (188 males, 44 females) underwent VATS with bullectomy for spontaneous pneumothorax or hemopeumothorax, whose age were between 14 and 45 years and mean age was(26.4 ± 10.1) years.202 patients resulted from upper lobe spontaneous pneumothorax, 23 patients for lower lobe spontaneous pneumothorax, 7 patients for hemopeumothorax, and 18 cases because of recurrence after bullectomy (7.7 ％, 18/232).all the patients were accepted bullectomy with or without dissection of pulmonary ligament.Results Between 112 patients who underwent upper lobe bullectomy with dissection of pulmonary ligament, at 1 st postoperative day, it was found 92 patients whose pleural effusion were less than 300 ml (82.1％ ,92/112);20 patients whose pleural effusion were greater than or equal to 300 ml(17.9％, 20/112), and the mean drainage from thoracic cavity was(147.0 ± 61.0)ml.At 3 rd day, the mean drainage was(33.4 ± 20.0) ml.Within 23 cases who underwent lower lobe bullectomy with dissection of pulmonary ligament, the mean drainage from thoracic cavity, at 1 st postoperative day, was (155.2 ±41.1)ml,and the mean drainage, at the 3rd day, was(52.1 ± 21.3)ml.Also,within 90 patients who underwent bullectomywithout dissection of pulmonary ligament, 9 patients whose pleural effusion, at 1 st postoperative day, were less than 300ml(10％ ,9/90);81 patients whose pleural effusion were greater than or equal to 300ml (90％, 81/90);the mean drainage for 90 patients was(65.1 ± 28.0)ml.At the 3rd day, 40 patients' pleural effusion were greater than or equal to 300ml (44.4％,40/90) , and the mean drainage was(40.2 ± 25.5) ml.2 of 7 hemopeumothorax patients bled for the vessels injury during pulmonary ligament avulsion.Conclusion There was significant difference in clinical outcomes between two groups, and the dissection of pulmonary ligament was able to reduce the pooling of pleural effusion, facilitate the drainage of pleural effusion, and prevent pneumothorax recurrence, but there is no convincing evidence that dissection of pulmonary ligament can lead to bronchial deformation, stenosis, and reduce the free thoracic space.

Dissection of the pulmonary ligament during upper lobectomy: is it necessary?

A best evidence topic was written according to a structured protocol. The question addressed was whether dissection of the pulmonary ligament during an upper lobectomy would result in improved outcomes. A total of 85 articles were found using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were complications associated with dissection (atelectasis, bronchial stenosis, bronchial obstruction and bronchial deformation) and preservation (insufficient lung expansion, pooling of effusion and atelectasis) of the pulmonary ligament, ratio (%) of dead space in longitudinal axis (movement of nonoperated lobes), change in the angle (degrees) of main bronchus on the operated side, overall morbidity and mortality, overall survival and conversion rates. In a randomized control trial, the dissection of the pulmonary ligament revealed no significant difference in the dead space ratio or change in the angle of the main bronchus when compared with preservation. Dissection of the ligament, in theory, reduces the free space in the upper thorax by increasing the mobility of the residual lobes. Dissection of the ligament may lead to bronchial deformation, stenosis, obstruction or lobar torsion. Preservation of the ligament may prevent this complication by suppressing the upward movement of residual lobes. However, this may result in pleural effusion in the free thoracic space that may potentially become infected resulting in an empyema or bronchial fistula. Five large case series were analysed; three routinely dissected the pulmonary ligament and two did not. There was no observed difference in clinical outcomes between the two groups. There is no convincing evidence that dissection of the pulmonary ligament in an upper lobectomy significantly improves outcomes and reduces complications.

Massive hemoptysis from pulmonary ligament artery supplying abnormal basal segments of the lower lobe.

BACKGROUND: Non-bronchial systemic arteries can be a significant source of massive hemoptysis in patients with marked pleural involvement. However, in some cases without pleural involvement, the pulmonary ligament artery (PLA) can also enter the abnormal lung parenchyma and be responsible for hemoptysis. PURPOSE: To discuss the factors influencing the development of a blood supply from the PLA in patients with hemoptysis. MATERIAL AND METHODS: Seventy-five consecutive patients who underwent bronchial artery embolization (BAE) for massive hemoptysis were evaluated between January 2006 and December 2011 retrospectively. Selective arteriography showed an enlarged and tortuous PLA in five patients. CT was done to determine the site and extent of the underlying diseases before BAE in all patients. Angiographic and CT images were analyzed to determine if there was a relationship between PLA supply and location of the underlying disease or mediastinal pleural involvement. RESULTS: The underlying lesions of six patients involved the basal segments of the lower lobe without marked mediastinal pleural thickening or adhesion, but diaphragmatic and lateral pleural thickening was observed in one case. Of these six patients, the PLA supplied blood to the lesions related to the hemoptysis in five patients. No patient with massive hemoptysis whose underlying lesions involved other segments of lung had a PLA supplying the lesions. CONCLUSION: Even though pleural involvement is absent, underlying lesions involving the basal segments of the lower lobe could be a good indicator that the PLA is the cause of bleeding in patients with massive hemoptysis.