Uniportal VATS Lung Sparing Resection with Radial Stapler for Unknown Post-COVID-19 Lesions

The pathophysiology and evidence in terms of long-term management of post-COVID-19 respiratory symptoms and pulmonary sequelae remain poorly understood and data regarding thrombotic lung lesions are still lacking.

Patients with post-COVID-19 pulmonary fibrosis may present with dyspnea, dry cough, and oxygen desaturation. Reduced diffusion capacity for carbon monoxide and a restrictive pattern are the most common functional abnormalities that may be found in the long-term period (1, 2).

The use of a chest CT scan is considered to be complementary to COVID-19 diagnosis and helps in severity of analysis of viral pneumonia. The CT may demonstrate the presence of architectural distortion, reticular opacities, traction bronchiectasis, ground-glass opacities, mosaic attenuation, and honeycombing. A predominance of upper and central distribution may be observed (3, 4).

Although the main histopathological patterns identified in post-COVID-19 pulmonary fibrosis have not been completely determined, they are probably associated with an organizing and fibrotic phase of diffuse alveolar damage, nonspecific interstitial pneumonitis pattern, and organizing pneumonia (5-7).

As far as pathogenesis of such pulmonary lesions is concerned, the mechanisms include the linkage with angiotensin converting enzyme receptor 2, epithelial and endothelial to mesenchymal transition, and cytokine storm that lead to activation and migration of inflammatory cells (8, 9). Excessive production of reactive oxygen species and nonprotective mechanical ventilation could also be involved (10).

Clinicians and surgeons should always be aware of these post-COVID-19 atypical benign lesions, mimicking lung tumors, to avoid unnecessary extensive pulmonary resections. To pursue this aim, the radial stapler is a valid and useful tool for lung sparing lung resection.

Makey et al. established a thoracoscopic simulation lab to compare the radial and linear stapler in the execution of thoracoscopic wedge resection (11). They noticed that a radial stapler allows for a better mass to margin resection of a small target from a broad surface of the lung. To the authors of this article’s knowledge, only one other case of lung resection by radial reload with single port VATS access has been described in literature by Sano et. Al. (12).

This case supports the use of radial stapler for lung sparing surgery, even by uniportal VATS approach. Although technically challenging because of the dimensional bulk of the radial reload inserted into the small single incision, a radial stapler may be pivotal to perform lung preserving wedge resections, as in this case.

The Patient

A seventy-year-old man was incidentally discovered to have two right pulmonary lesions. The patient was a former light smoker affected by systemic arterial hypertension who underwent SARS-Cov2 infection in December 2021, developing an interstitial pneumonia. A chest computed tomography (CT) angiography was taken, which revealed a concomitant pulmonary embolism. Therefore, the patient was admitted to the pulmonology department and underwent noninvasive ventilation (NIV). The patient was discharged after a complete recovery with no apparent sequelae. 

In April 2022, a first chest CT was displayed as follow-up to the former infection and pulmonary embolism, which showed the appearance of two right pulmonary lesions. The main lesion straddled the oblique fissure between the middle and lower lobes, and another, smaller nodule affected the apical segment of the right lower lobe. A total body positron emission tomography (PET) was then programmed in May 2022, showing a suspicious uptake at the level of known lung lesions with an SUVmax of 1.6. Because of this, a further chest CT control was displayed in July 2022. The pulmonary lesions were still present, and increased dimensionally: 31 x 25 mm ex 24 x 18 mm, 14 x 11 mm ex 13 x 8 mm. A CT-guided needle aspiration biopsy was then performed, which found no atypical cells. Following the procedure, the patient developed right pneumothorax, which was treated with pleural drainage placement. Given the growth of the lesions, the case was discussed in a multidisciplinary board and made a candidate for surgical excision with diagnostic and therapeutic intent.

The Surgery

The procedure was conducted using video-assisted thoracic surgery (VATS) with a uniportal access. A 3.5 cm incision was performed at the fifth right intercostal space and a wound protector-retractor was applied. The major lesion straddled the oblique fissure between the middle and lower lobes. Some adhesions were present at the fissure level, probably because of the previous COVID-19 pneumonia. The adhesions were partially dissected for a better mobilization of the lung. Then, a wedge resection was performed comprehending this nodule. 

First, two linear mechanical staplers were used, one on the middle lobe and another on the lower lobe. A radial mechanical reload was then employed to join the previous resection line. The radial mechanical stapler was used to complete a lung sparing resection. The resection was successful despite the dimensional bulk of the radial reload, which was inserted in a uniportal VATS access.

Another linear mechanical stapler was needed to complete the resection. The suture was then checked and showed no active bleeding. The specimen was extracted with an endobag and a collagen-based device was applied on the suture line with hemostatic and aerostatic intent. The smaller nodule on the inferior lobe was then identified, and another wedge resection was performed by linear mechanical stapler. 

Postoperative Course

The postoperative course was uneventful. The pleural drainage was removed on POD II, in absence of air-leak. The chest X-ray taken after the drainage removal showed complete expansion of the two lungs, with no pleural effusion. Pathologic examination revealed pulmonary parenchyma with occlusive thrombi partially organized into ectasic vessels with subverted architecture, most likely arterial. This histological pattern was peculiar and very likely related to the previous Sars-Cov2 infection. A radiological follow-up was then set out, considering the benign nature of the lesions.

References

1. Yu M, Liu Y, Xu D, et al. Prediction of the development of pulmonary fibrosis using serial thin-section ct and clinical features in patients discharged after treatment for COVID-19 pneumonia. Korean J Radiol. 2020 Jun;21(6):746–755
2. Daher A, Balfanz P, Cornelissen C, et al. Follow up of patients with severe coronavirus disease 2019 (COVID-19): pulmonary and extrapulmonary disease sequelae. Respir Med. 2020Nov-Dec ;174:106197
3. Marvisi M, Ferrozzi F, Balzarini L, et al. First report on clinical and radiological features of COVID-19 pneumonitis in a Caucasian population: factors predicting fibrotic evolution. Int J Infect Dis. 2020Oct;99:485–488
4. Ai T, Yang Z, Hou H, et al. Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases. Radiology. 2020 Aug;296(2):E32–E40
5. Adachi T, Chong JM, Nakajima N, et al. Clinicopathologic and immunohistochemical findings from autopsy of patient with COVID-19, Japan. Emerg Infect Dis. 2020 Sep;26(9):2157–2161
6. Zhang H, Zhou P, Wei Y, et al. Histopathologic Changes and SARS-CoV-2 immunostaining in the lung of a patient with COVID-19. Ann Intern Med. 2020 May 5;172(9):629–632
7. Rodrigues TS, Ksg DS, Ishimoto AY, et al. Inflammasomes are activated in response to SARS-CoV-2 infection and are associated with COVID-19 severity in patients. J Exp Med. 2021 Mar 1;218(3): e20201707
8. Ojo AS, Balogun SA, Williams OT, et al. Pulmonary fibrosis in COVID-19 survivors: predictive factors and risk reduction strategies. Pulm Med. 2020;2020:6175964
9. Bharat A, Querrey M, Markov NS, et al. Lung transplantation for patients with severe COVID-19. Sci Transl Med. 2020 Dec 16;12 (574):eabe4282
10. Ferrara F, Granata G, Pelliccia C, et al. The added value of pirfenidone to fight inflammation and fibrotic state induced by SARS-CoV-2: anti-inflammatoryand anti-fibrotic therapy could solve the lung complications of the infection? Eur J Clin Pharmacol. 2020 Nov;76(11):1615–1618
11. Makey IA, El-Sayed Ahmed MM, Jacob S. The Radial Stapler Facilitates Lung-Conserving Wedge Resections. Innovations (Phila). 2020 Sep/Oct;15(5):463-467.
12. Sano A, Yotsumoto T. Single-port thoracoscopic lung wedge resection using the Endo GIA Radial Reload. Surg Today. 2018 Feb;48(2):248-251.

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