Keywords
thoracic aorta - cardiopulmonary bypass - vascular surgical procedure - esophagoplasty
- thoracic malignancies
Introduction
Simultaneous thoracic aorta, lung, and esophagus resection remain quite a rare procedure,
mainly because of the high technical complexity of the surgery and the need for cardiopulmonary
bypass (CPB) or extracorporeal membrane oxygenation.[1] Most articles are dedicated to concomitant lung resection surgeries and anatomic
aortic replacement.[2]
[3]
[4]
We propose a unified surgical approach we have called “Penza's Surgical Maneuver (PSM).”
The main purpose of this technique is to prepare an aortic segment that is safe for
surgery and includes the following: (1) aortic arch, (2) aortic isthmus, and (3) beginning
segment of descending aorta. We have called such a segment “defunctionalized aortic
zone” (DAZ).
Clinical Experience
Patient 1, a 28-year-old male, intravenous drug-dependent patient, presented with
an infected aortic graft with recurrent pulmonary bleeding and esophagus fistula.
Five years before, he underwent thoracic aorta resection and replacement with a synthetic
graft due to aortic coarctation. Over the 5 years, the graft became infected and a
paraprosthetic cavity connected to the esophagus with a fistula of 8 mm in diameter
was formed ([Fig. 6]). Additionally, there were multiple fistulas connecting the paraprosthetic cavity
to the left lung parenchyma, which allowed for pulmonary bleeding.
Fig. 6 Schematic illustration of the disease in patient 1: 1, the esophagus; 2, the paraprosthetic
pyogenic cavity; 3, the fistula connecting the paraprosthetic cavity to the esophagus.
The patient underwent the following 11-hour surgical procedure. After the PSM and
gastric mobilization were finished, a right-sided thoracotomy was performed. The esophagus
was mobilized and transected 2-cm proximal to the fistula. An en block resection of
the upper part of the DAZ, including the graft, the infected paraprosthetic fibrous
capsule, and the esophagus was done ([Fig. 7]). The pulmonary fistulas were stitched with reverse U-shaped pledget sutures. Ivor–Lewis
type esophagoplasty was performed. The zone of the paraprosthetic cavity and lung
fistulas was filled with the omentum.
Fig. 7 Right-sided thoracotomy. Defunctionalized aortic zone (DAZ) and the esophagus are
resected: 1, tracheal bifurcation; 2, zone of the left lung with fistulas that have
to be sealed; 3, the distal aortic stump after DAZ resection.
The postoperative period was complicated by stroke causing right-sided hemiparesis.
The patient was transferred to the neurology department on the postoperative day 12.
The patient was followed up for 7 years ([Fig. 8]). Neurology deficit is completely resolved, and patient has returned to his work
and stop narcotic use.
Fig. 8 Computed tomography volume rendering lateral view (A) and frontal view (B) of patient 1. Seven years after surgery: 1, the distal aortic stump, 2, the graft
to the abdominal aorta anastomosis, 3, the graft to the ascending aorta anastomosis.
Patient 2, a 44-year-old male presented with left-sided pulmonary central adenocarcinoma,
T3N0M0, and midthoracic esophageal squamous cell cancer, T3N1M0, with para-aortic
metastatic invasion into the thoracic aorta ([Fig. 9]). He underwent surgery that lasted 10 hours. After PSM and gastric mobilization
were finished, left-sided thoracotomy and combined pneumonectomy with esophageal and
DAZ, resection to the inferior pulmonary vein level were performed. Ivor–Lewis type
esophagoplasty was done ([Fig. 10]).
Fig. 9 Computed tomography (CT) scan (A) and CT volume rendering (B) of patient 2. Arrows point to the tumor mass.
Fig. 10 Stages of the operation via the left-sided thoracotomy with patient 2. (A) Left-sided pneumonectomy with the pericardium, left atrium, defunctionalized aortic
zone, and esophagus resection: 1, the distal aortic stump; 2, the running suture of
the left atrium; 3, the bronchial stump; 4, the proximal aortic (aortic arch) stump;
5, the clumped esophageal stump. (B) The final view of the operation: 1, the proximal aortic (aortic arch) stump; 2,
the left-sided Ivor–Lewis esophagoplasty with the hand-made esophagogastric anastomosis.
The postoperative period was uneventful. The patient was discharged on postoperative
day 14. Three courses of adjuvant chemotherapy were performed. The patient was followed
up for 6, 12, 18, 24, 32, and 40 months ([Fig. 11]). Radiological computed tomography (CT) follow-up did not reveal any signs of recurrent
tumors in the tumor bed. The patient's condition was stable with very good social
activity. CT after 40 months disclosed numerous metastases. The patient died 44 months
after our operation due to lung cancer progression.
Fig. 11 Computed tomography volume rendering of patient 2. Forty months past surgery: 1,
the ascending aorta to the graft side-to-side anastomosis; 2, the end-to-side anastomosis
of the graft to the abdominal epigastric aorta; 3, the stomach in the vast empty pleural
cavity.
Patient 3, a 56-year–old male, 35 years after thoracic aorta grafting due to aortic
coarctation, presented with the rupture of aortic graft pseudoaneurysm, which caused
hemothorax and pulmonary bleeding ([Fig. 12]).
Fig. 12 Computed tomography (CT) scan (A) and CT volume rendering (B) of patient 3: 1, zone of the aortic graft pseudoaneurysm; 2, the hemothorax mass;
3, the prosthesis.
He underwent an 11-hour emergency surgery. After PSM, DAZ (including “old” graft and
aneurysm) resection through left-sided thoracotomy was also done. Because of the left-lung
destruction caused by extensive parenchymal hematoma, pneumonectomy was performed
([Fig. 13]).
Fig. 13 Computed tomography volume rendering frontal view (A) and lateral view (B) of patient 3. Third postoperative day: 1, the anastomosis of the graft to the abdominal
epigastric aorta; 2, the ascending aorta to the graft anastomosis; 3, debranched left
subclavian and carotid arteries.
The postoperative period was complicated by severe pulmonary and cardiac failure.
Intensive care unit stay lasted for 26 days. The patient was discharged on postoperative
day 33. After 35 months of follow-up, the patient's condition is stable, he is mobile,
and his complete social adaptation has been achieved.
Discussion
We have named the surgical technique described above “maneuver” because we consider
it as a complete, undivided, conceptual procedure that is sure to include an approach,
off-pump ascending-to-descending aortic grafting, debranching of two left arch branches,
and an aortic arch transection. While every item is well-known, we have never met
an intention to join them into an essential procedure. To emphasize this, we have
permitted ourselves the proper name “Penza surgical maneuver.”
We think that the PSM has several advantages, including no need in CPB and circulatory
arrest, which are important to maintain hemostasis during further surgery stages,
and performance in an anatomically intact region, which facilitates surgical manipulations.
Aortic arch and aortic isthmus surgery is complicated, unsafe, and ambiguous in terms
of approaches, even with CPB.[4] Cervical end-to-side debranching of the left subclavian artery into the left carotid
artery with the further on-pump intrathoracic orthotopic vascular interventions has
been proposed as a technical approach to solve this problem.[5] We believe that PSM and DAZ creations make all thoracic aorta segments approachable
from any thoracotomy and render aortic resection much easier and safer, as there is
no need to mobilize the aortic arch and the aortic isthmus through thoracotomy.
The first side-to-side anastomosis between the ascending aorta and the bifurcation
graft is left open from both sides, which, we feel, permits anatomically correct graft
positioning at both ends later in the case. We anastomosed the graft’s distal end
to the epigastric segment of aorta as it was described by Wukasch et al.[6] Such an approach is especially reasonable in concomitant esophagoplasty, since the
access to the mentioned aortic segment is facilitated when esophageal and gastric
mobilization is done. Right sided crurotomy, sagittal diaphragmotomy, periaortic fat,
and lymph node excision are the common procedures in lymph node dissection for esophageal
cancer. We have always managed to mobilize at least 10 cm of the anterolateral wall
of the epigastric aorta, which was enough to form an anastomosis. Moreover, it is
technically much easier to create a vascular anastomosis with the epigastric aortic
segment under the diaphragm through sternolaparotomy than with the thoracic aorta.
In this case, there is no need to rotate the heart cranially, which could require
CPB. The latter is especially important when the heart is dilated.[7] Besides, forming an anastomosis with the epigastric aortic segment allows keeping
the pleural cavity intact in case of pleural infection, avoiding lung injury if there
are severe pleural adhesions, and preventing dangerous transthoracic manipulations
in the presence of intrapleural bleeding. Stitching the graft's distal end to the
epigastric aortic segment permits forming a more physiological anastomosis at acute
angle compared with the anastomosis with the thoracic aorta, where a right angle is
created.
The clear-cut advantage of the PSM is that it allows a graft to be fully isolated
within the pericardium and the abdomen, which prevents its contact with the area of
the main pathological process. This is highly important when the consequent lung,
esophagus, or thoracic aorta surgery carries a risk for the graft to become infected.
When carrying out concomitant esophageal resection, we preferred performing primary
esophagoplasty. Since sternolaparotomy is done by two surgical teams working simultaneously,
gastric transplant preparation does not take additional time. We have always finished
gastric mobilization before the PSM is done. The quality of life of a patient after
primary esophagoplasty is, undoubtedly, higher. Delayed restoration of gastrointestinal
continuity after PSM with esophageal and DAZ resection seems to be difficult. The
distinct advantage of concomitant esophagoplasty permits the use of the transposed
omentum as a plastic material with unique biological properties. This matters especially
when there is a risk for the aortic graft to be infected.
DAZ allows us to choose either side to perform the required thoracotomy. The aorta
with the transected aortic arch becomes accessible from both sides to safely conduct
the surgery. In the first presented case, we chose right-sided thoracotomy to resect
the thoracic aorta, since we did not want to do a traumatic left-sided pneumolysis
and take down connective-tissue adhesions. The right-sided approach was performed
through the intact pleural cavity in comfortable anatomical conditions. Keeping the
left lung safe and plugging the infected graft area with the omentum let us immediately
achieve complete aerostasis avoidance of air leak and prevention of infection dissemination.
In the second and third cases, the benefits of left-sided thoracotomy are clear. Creation
of DAZ facilitated the left-sided Ivor–Lewis procedure in patient 2.
The obvious disadvantages of PSM are the need for three different surgical approaches
and the long surgery duration. It is notable that 10 to 11 hours of operation are
a total time including either DAZ preparation or difficult resection and reconstruction.
Thereafter, we may not estimate whether surgery duration decreased under the conditions
of CPB. Probably these changes might be insignificant. Sternotomy and continuing upper
laparotomy, anastomosing of the prosthesis to the epigastric segment of an aorta give
an ability to reduce wound length, and prepare gastric and omental transplants perfectly
well without an additional time. This may be considered as an advantage of our technique.
We suppose thoracotomy to be obviously essential. The steps sequence described above
meets principles of patient's safety, an efficient surgical control during resection
of the aorta, and a proper hemostasis.
CPB is a routine and harmless procedure nowadays. But all our patients underwent a
complex surgery in the area of the aortic arch and isthmus. So, CPB has to be used
with hypothermia and circulatory arrest.[8] Such approach cannot be considered very safe in the context of brain and visceral
organs protection. Moreover, hemostasis may be very doubtful in this scenario.
Some authors reported different techniques that may be positioned as alternatives
to PSM. Arakelyan et al[9] proposed ascending-to-descending aortic bypass via right thoracotomy without establishment
of CPB. We believe such an approach is irrelevant for our patients because in every
case there was a severe complication of disease and not only shunting but challenging
resection of the aortic arch and isthmus was of demand. Moreover, esophagoplasty was
performed in two cases. Safe and handy surgery was impossible via right thoracotomy
without prior preparing of DAZ, stomach, and omental transplants.
Said et al[10] described ascending-to-descending posterior pericardial aortic bypass via sternotomy
with usage of CPB and hypothermia. This technique is regarded unfit for the foregoing
reasons: esophagoplasty is impossible via sternotomy (patients 1 and 2), and infected
prosthesis should not be excised via the pericardium due to the risk of infection
spread (patient 1). Pneumonectomy is possible via sternotomy. Nevertheless, simultaneous
complex aortic resection was performed in all our patients. DAZ and thoracotomy provide
simplicity of surgery and the best surgical control.
Coselli and LeMaire[11] described classical “clamp and sew” technique, combined with left heart bypass (LHB).
LHB provides perfusion of a distal part of an aorta and decreases the risk of spinal
and visceral ischemia. In our technique, this risk is minimal. On the one hand, we
excise the proximal part of aorta only, but on the other hand, we never clamp it transversely
when forming a DAZ.
Therefore the clear advantages, for example, universal technical simplicity in its
every step, complete surgical control, convenience during all the surgery stages,
and the possibility to solve the whole variety of concomitant medical problems (i.e.,
hemostasis, infection isolation, esophagoplasty, and bleeding prevention) allow stable
long-term surgery outcomes. We consider the PSM to be a conceptually new approach
to aortic arch and thoracic aorta surgery in the most severe complex diseases with
a possible involvement of respiratory organs and the esophagus.
