Video-assisted thoracoscopic surgery for intralobar pulmonary sequestration
© Avgerinos et al; licensee BioMed Central Ltd. 2008
Received: 22 September 2008
Accepted: 24 October 2008
Published: 24 October 2008
Intralobar pulmonary sequestration is a rare congenital abnormality of the lower respiratory system, which becomes symptomatic early in life. Standard treatment consists of wedge resection or lobectomy through a thoracotomy.
We report on an unusual case of a 36-year-old female patient with intralobar pulmonary sequestration on the right lower lobe, which was treated with video-assisted thoracic surgery. The case is presented along with literature review.
VATS wedge resection is a great alternative to the traditional thoracotomy for the treatment of intralobar pulmonary sequestrations.
Pulmonary sequestration is a rare congenital abnormality of the lower respiratory system, consisting of about 0.15–6.4% of all pulmonary malformations . The standard treatment of this entity used to be either wedge resection or lobectomy through a thoracotomy, after identification and ligation of the aberrant artery of the mass. However, recent advancements in technology have permitted a more minimally invasive approach by using video-assisted thoracoscopic surgery (VATS). This report illustrates a case in which a VATS wedge resection was employed successfully to treat intralobar pulmonary sequestration in an adult. A Medline search of the English literature revealed that this is only the second published case in the United States of intralobar pulmonary sequestration in an adult that was treated with VATS.
After closing the port sites and inserting a chest tube, the patient was extubated and was transferred to the surgical intensive care unit for observation. Her recovery was uneventful and the chest tube was put on water seal the next morning and removed on post-operative day 2. The patient was discharged the third post-operative day and until today, about five months after the operation, remains in excellent condition. Final pathology revealed intralobar pulmonary sequestration.
Pulmonary sequestration is a rare lesion of the lung parenchyma of unknown etiology that lacks normal connection with the tracheobronchial tree and has a blood supply directly from the descending aorta . There are two basic types: extralobar (25% of all cases), which have their own pleura, and intralobar (75% of all cases), which are surrounded by visceral pleura [3, 4]. Patients with pulmonary sequestration tend to present early in life with symptoms of recurrent infections of the lower respiratory system. As a result, they undergo definitive operative treatment at a young age. Work-up to investigate the etiology of the repeated episodes of pneumonia should include a thorough history and physical investigation, usual labs (complete blood count and basic metabolic panel), chest x-ray, and, ultimately, CT scan of the chest with intravenous contrast. The last modality makes the diagnosis and is regarded as the imaging test of choice for pulmonary sequestration.
The definitive treatment of every patient with pulmonary sequestration, both intralobar and extralobar, is surgical resection of the mass. Traditionally, the open approach through posterolateral thoracotomy has been employed, as it offers adequate exposure. Because pulmonary sequestration is a benign disease, it is believed that partial lung resection is more appropriate than lobectomy , especially if the mass is confined within a lung segment . Special attention needs to be paid to the aberrant artery, since its path through the diaphragm needs to be identified before it is ligated and divided. The advent of minimally invasive techniques made VATS gain special role in the treatment of this pathologic entity. VATS offers an important alternative to the open approach for pulmonary sequestration, with minimum surgical trauma morbidity, post-operative pain, and hospitalization. It is characteristic that our patient was discharged home on the second post-operative day in an excellent condition. Our experience has shown that patient undergoing thoracotomy for the same disease usually stay in the hospital from 3 to 5 days, mainly for surgical site pain management. Also, VATS has been shown to better preserve lung function during the recovery period [7, 8]. An important note, if VATS is employed for the resection of intralobar pulmonary sequestration, is that extensive pre-operative work-up is needed for the identification of the aberrant artery. Its connection to the thoracic or abdominal aorta can be identified with the use of computed tomography (CT) with intravenous contrast or even CT angiography.
We believe that VATS wedge resection is a great alternative to the traditional thoracotomy for the treatment of intralobar pulmonary sequestrations.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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