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Completion pneumonectomy (CP) is a technically demanding procedure associated with significant morbidity and mortality, primarily due to dense hilar adhesions and anatomical distortions from previous surgeries. Right CP is particularly hazardous given potential intrapericardial involvement. Comprehensive preoperative planning and multidisciplinary collaboration are essential to mitigate the risk of catastrophic intraoperative hemorrhage. A 57-year-old woman with a history of right middle lobectomy for lung cancer nine years prior presented with a local recurrence necessitating a right CP. Given the anticipation of intrapericardial adhesions and the potential need for cardiopulmonary bypass (CPB), a meticulous preoperative strategy was devised. The patient was placed in a modified left lateral decubitus position with a 45° posterior pelvic rotation, allowing simultaneous access for a posterolateral thoracotomy and femoral CPB cannulation. Strategic central venous access was established to ensure adequate venous return in the event of superior vena cava (SVC) clamping. Intraoperatively, dense adhesions involving the extrapericardial SVC were identified. In contrast, the pericardial space was relatively free of adhesions, allowing for the safe intrapericardial control of the pulmonary vessels. By establishing proximal control within the pericardium and distal control at the brachiocephalic veins, the SVC was safely managed. The procedure was completed without the need for CPB initiation. The postoperative course was uneventful, and the patient remained recurrence-free at the one-year follow-up. Successful CP requires more than surgical technicality; it demands a robust multidisciplinary strategy. Meticulous preparation regarding standby CPB, optimized patient positioning, and proactive vascular control are critical components in ensuring safety and achieving favorable outcomes in high-risk thoracic procedures.
Oki et al. (Sun,) studied this question.