The patient is male, 73 years old, admitted to hospital mainly because of recurrent blood in sputum for 9 months, blood in sputum appeared in the neurology department for cerebral infarction 9 months ago, the symptoms disappeared after symptomatic treatment for more than 10 days, a chest CT examination revealed lesions in the lower lobe of the right lung, fiberoptic bronchoscopy showed “inflammation”, blood in sputum appeared again for no apparent reason 2 months ago The patient was diagnosed with right lower lung hilar occupancy and central lung cancer by chest CT and fiberoptic bronchoscopy, and was admitted to the thoracic surgery department for further examination and treatment. On admission: BP 165/74 mmHg, no enlarged lymph nodes were palpated in the supraclavicular and cervical areas bilaterally, and the breath sounds in the right lower lung were reduced. Auxiliary examination: CEA: 5.76ng, electrocardiogram: sinus bradycardia with atrioventricular block, non-specific ST-segment and T-wave abnormalities, Shen Zhenyun, Department of Thoracic and Cardiovascular Surgery, Aviation General Hospital of China Medical University
Blood gas analysis: see attached chart
Chest CT: bronchial stenosis in the middle segment and middle and lower lobes of the right lung, with right lower lobe atelectasis.
Fiberoptic bronchoscopy: right lower lobe bronchial opening stenosis, dorsal segment and basal segment subridge congestion and edema, partial mucosal granuloma-like growth, pathology: intermediate differentiated squamous cell carcinoma. See attached figure
Pulmonary function conclusion: obstructive ventilation disorder. See accompanying figure
Diagnosis: lung cancer of the right lower lung, stage 3 hypertensive disease, old cerebral infarction, and post-gastrectomy.
Preoperative discussion.
The patient was an elderly male with a past history of smoking for many years, concomitant hypertensive disease, a history of cerebral infarction before September, and a previous major gastrectomy 7 years ago. The diagnosis of right lower lung cancer was clear. The current ECG showed sinus bradycardia and 1st degree atrioventricular conduction organization, and pulmonary function measurements were obstructive ventilation disorder, FEV1 (L): 1.07, FEV1 (%) 47%, FEV1/FVC: 67%. The patient had arrhythmias and low pulmonary function. Preoperative staging was T2N2M0, as judged from chest CT and fiberoptic bronchoscopy, and right middle and lower lobectomy could be considered. The chest CT showed complete pulmonary atelectasis in the right lower lobe, and it was expected that the loss of pulmonary function after right lower middle lobe lobectomy would be low compared to the preoperative stage, and the lung function could tolerate the expected extent of surgical resection. However, the patient’s concomitant disease and cardiopulmonary status increase the risk of surgery, and preoperative lung function should be adequately improved and rehabilitation should be performed. Surgery should avoid simple exploration and total pneumonectomy.
Surgical findings and steps: left lateral recumbent position, imitating French-window through the 6th intercostal approach: no obvious pleural fluid in the chest, right lower lobe near the hilar mass, nearly 4 cm in diameter, hard texture, obvious wrinkling of the surface pleura, complete oblique fissure, incomplete upper middle lobe fissure, right lower lobe pulmonary atelectasis, right middle and lower lobe lobectomy was performed after exploration to remove the right middle segment parabronchial lymph nodes and the subrhomboid The right middle and lower lobes were resected and the bronchial stump was closed with 3-0 absorbable braided sutures with interrupted 8-way sutures, and the right middle and lower lobes were resected. Several lymph nodes of R3, R4 and 7 groups were removed, and the right middle bronchial stump was reinforced with free tissue flap covered sutures, and a chest tube was left in place to close the chest. Intraoperatively, the bronchial stump was sent to fast freezing pathology with net bronchial margin cut.
Postoperative pathology: see the attached figure
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