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Scientific letter
Robotic segmentectomy for pulmonary sequestration complicated with aspergilloma
Segmentectomía robótica como tratamiento de un secuestro pulmonar complicado con un aspergiloma
Clara Forcadaa, Mehlika Iscanb, María Teresa Gómez-Hernándeza,c,d,
Corresponding author
mtgh@usal.es

Corresponding author.
, Cristina E. Rivasa,c,d, Marcelo F. Jiméneza,c,d
a Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
b Department of Thoracic Surgery, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
c Salamanca Institute of Biomedical Research, Salamanca, Spain
d University of Salamanca. Salamanca, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary sequestration &#40;PS&#41; is a rare congenital malformation characterized by nonfunctional lung parenchyma isolated from the normal tracheobronchial tree that receives aberrant blood supply from the systemic arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Intralobar sequestrations &#40;ILS&#41; are the more common type&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in which the abnormal tissue is embedded within the visceral pleura of the normal lung&#46; Superimposed aspergillus fungal infections have rarely been reported in ILS&#44; consisting of 39 isolated case reports&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Surgical resection of the sequestrated lung and shutting off aberrant arteries is the standard treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Resection typically consisted of lobectomy&#46; However&#44; sublobar resection may be preferable since parenchymal preservation is desirable&#46; Here&#44; we report the first case described in the literature of an ILS complicated with aspergilloma&#44; which was successfully resected by robot-assisted segmentectomy using fluorescence image guided by indocyanine green &#40;ICG&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 63-year-old woman with no relevant medical history had been incidentally diagnosed with left lower lobe ILS 10 years earlier&#44; which was managed conservatively since she was asymptomatic&#46; In recent years&#44; symptoms had begun to manifest&#44; and she had several episodes of pneumonia and expectoration with haemoptysis&#46; Chest computed tomography demonstrated a cystic lesion with a 2&#46;2-cm mobile&#44; nodular content at the base of the left lower lobe&#44; compatible with ILS complicated with mycetoma &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Systemic blood supply was provided by the splenic artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Bronchoscopy was performed&#44; and microbiological cultures of the bronchial suction sample showed evidence of <span class="elsevierStyleItalic">Aspergillus fumigatus</span>&#46; Pulmonary function tests were within normal ranges &#40;FEV1&#37;&#58; 105&#37;&#44; and DLCO&#37;&#58; 96&#37;&#41;&#46; Therefore&#44; the patient was diagnosed with ILS complicated with aspergilloma&#44; treated with voriconazole and scheduled for robotic resection of the pulmonary sequestration&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A 4-arm technique with one additional assistant port was used with the da Vinci X surgical system &#40;Intuitive&#44; Sunnyvale&#44; CA&#44; USA&#41;&#46; The camera port was situated in the eighth intercostal space&#46; No significant pleural adhesions were found&#46; A systemic arterial branch to the sequestration originating below the diaphragm was first isolated &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and divided with a robotic stapler &#40;white cartridge&#44; 2&#46;5-mm staple height&#41;&#46; Venous drainage of the sequestration was diminutive&#44; and therefore Maryland bipolar coagulation forceps were used&#46; There was no other vascular or bronchial abnormality&#46; Thirteen milligrams of ICG &#40;0&#46;15&#8201;mg&#47;kg&#41; were injected intravenously after ligation of the arterial blood supply&#44; permitting demarcation of the sequestration from the normal lung&#46; The boundary around the sequestration was marked with electrocautery&#46; However&#44; the sequestrated parenchyma was quite extensive and central&#44; and left lower lobe basilar segmentectomy was therefore performed to ensure complete resection of the abnormal tissue&#46; ICG was administered again to define the borderline between the segment 6 and basilar segments&#46; Parenchymal transection was then performed with robotic staples &#40;blue and green cartridges&#44; 3&#46;5-mm and 4&#46;3-mm staple heights&#44; respectively&#41;&#46; The specimen was removed with a polytetrafluoroethylene bag&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Pathology confirmed the diagnosis of aspergilloma within ILS&#46; The postoperative period was uneventful&#44; and the patient was discharged home on postoperative day 2 after chest tube removal&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">PS is a relatively unusual condition comprising 0&#46;15&#8211;6&#46;4&#37; of congenital lung malformations&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Superinfections of PS by fungal pathogens are extremely rare&#46; Some authors support the hypothesis that some ILS may be acquired lesions associated with chronic infection&#44; such as aspergillosis&#44; instead of congenital abnormalities related to anomalous lung development&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In the current case&#44; the patient was diagnosed with ILS several years before developing the fungal infection&#46; We hypothesize that pulmonary aspergilloma developed in preexisting cavities formed by underlying pulmonary lesions&#46; The occurrence of a fungal mycetoma within ILS indicates that the ILS must have communications with the tracheobronchial tree&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Surgical resection is considered the optimal treatment for both PS and aspergilloma in order to prevent life-threatening symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7</span></a> Although ILS have been classically treated with lobectomy&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> successful cases of sublobar resections&#44; including wedge resection and segmentectomy&#44; have been reported for localized ILS&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8</span></a> We believe that sublobar resection should be preferred when the sequestration is limited to a segment&#44; since it allows for complete removal of the benign lesion and limits the loss of normal-functioning lung&#46; Whether patients with pulmonary aspergillomas should receive lobectomy or sublobectomy is also debatable&#46; A retrospective research study revealed that sublobar resections were recommended for small&#44; peripheral&#44; and simple pulmonary aspergillomas &#40;&#60;3&#8201;cm&#41; to preserve lung function and enhance recovery&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> These procedures are usually technically demanding&#44; mainly due to difficult operating conditions&#44; including massive pleural adhesions or damaged lung parenchyma&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Robotic-assisted resection of ILS has been recently reported&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10</span></a> while minimally invasive surgery has been described in selected cases of pulmonary aspergilloma&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The robotic approach offers the advantages of minimally invasive surgery&#44; superior visualization in the 3-dimensional view setting&#44; higher instrument precision with 7 degrees of motion resulting in improved dexterity and fluorescence imaging vision&#46; These advantages are particularly useful during anatomical pulmonary segmentectomy&#44; which requires meticulous intraparenchymal dissection and precise delimitation of the intersegmental plane&#44; and also in ILS&#44; where identification of aberrant arteries and demarcation of the sequestration margin is crucial for resection&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">This case demonstrates that the robotic approach with fluorescence image guidance can be helpful for sublobar resection of ILS complicated with aspergilloma&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding statement</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no financial support was received regarding the content of this manuscript&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest regarding the content of this manuscript&#46;</p></span></span>"
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