Dual-color FISH analyses of xenogeneic human fibroblast sheets transplanted to repair lung pleural defects in an immunocompromised rat model.

BACKGROUND: Pulmonary air leaks (PALs) due to visceral pleura injury during surgery is frequently observed after pulmonary resections and the complication is difficult to avoid in thoracic surgery. The development of postoperative PALs is the most common cause of prolonged hospitalization. Previously, we reported that PALs sealants using autologous dermal fibroblast sheets (DFSs) harvested from temperature-responsive culture dishes successfully closed intraoperative PALs during lung resection. OBJECTIVE: In this study, we investigated the fate of human DFSs xenogenetically transplanted onto lung surfaces to seal PALs of immunocompromised rat. Dual-color FISH analyses of human fibroblast was employed to detect transplantation human cells on the lung surface. RESULTS: One month after transplantation, FISH analyses revealed that transplanted human fibroblasts still composed a sheet-structure, and histology also showed that beneath the sheet's angiogenesis migrating into the sheets was observed from the recipient tissues. FISH analyses revealed that even at 3 months after transplantation, the transplanted human fibroblasts still remained in the sheet. Dual-color FISH analyses of the transplanted human fibroblasts were sparsely present as a result of the cells reaching the end of their lifespan, the cells producing extracellular matrix, and remained inside the cell sheet and did not invade the lungs of the host. CONCLUSIONS: DFS-transplanted human fibroblasts showed that they are retained within cell sheets and do not invade the lungs of the host.

Intraoperative robotic surgical system-related problems in robot-assisted thoracoscopic surgery.

BACKGROUND: Malfunctions of robotic instruments during robotic surgery are well known to occur; however, detailed reports on the inherent problems associated with robotic instruments and robotic surgical systems are scarce. The objective of this study was to retrospectively investigate the intraoperative problems associated with robotic surgical systems and robotic instruments. MATERIALS AND METHODS: This was a single-center retrospective study. Between April 2012 and December 2022, 544 patients with consecutive lung malignancies and/or mediastinal tumors underwent robot-assisted thoracoscopic surgery. Among these, 15 cases had intraoperative problems associated with the robotic surgical system. Human error was defined as a problem caused by the incorrect operation of the robotic surgical system and human factors as problems in which the robotic surgical system stopped owing to damage to the instruments of the robotic surgical system or the self-diagnosis of the robotic surgical system. We retrospectively investigated the causes of intraoperative problems in these cases. RESULTS: There were 4 cases (0.7%) with problems related to the robotic surgical system, 2 of which were human errors, and 11 (2.0%) with problems related to robotic surgical instruments, 6 of these were related to instruments and 5 were related to robotic staplers. Five of these were related to human factors. CONCLUSION: Teams performing robot-assisted thoracoscopic surgery should be familiar with the features of robotic surgical systems and various robotic devices, be aware of reported problems during robot-assisted thoracoscopic surgery, and be prepared for emergencies.

[Improved Surgical Technique for Closing the Tracheocutaneous Fistula].

The tracheocutaneous fistula is a late complication after tracheotomy decannulation, which decreases the quality of life. Though several procedures to close tracheocutaneous fistula were reported, postoperative wound dehiscence was frequently noted. We developed new surgical technique to prevent this complication and report a case in which the technique was successfully applied. This surgical technique is useful simple method to be effective, and safe.

Comparison of different approaches in complete thoracoscopic segmentectomy of lung lower lobe.

Background: Safe and oncologically acceptable segmentectomy outcomes were reported for early-stage lung cancer. The high-resolution computed tomography allowed us to find detailed structures inside the lungs, such as the pulmonary ligaments (PLs). Hence, we have presented the relatively anatomically challenging thoracoscopic segmentectomy, for the resection of the lateral basal segment, the posterior basal segment, and both segments through the PL as a PL approach. This study aimed to retrospectively examine the lung lower lobe segmentectomy, excluding the superior and basal segments (from S7 to S10), using the PL approach as an option to treat the lower lobe tumors of the lung. We then compared the efficacy of the PL approach in terms of safety with the interlobar fissure (IF) approach. The characteristics of the patients, intra- and postoperative complications, and surgical outcomes were analyzed. Methods: Of the 510 patients who underwent segmentectomy for malignant lung tumors from February 2009 to December 2020, 85 were included in this study. Among them, 41 underwent a complete lung lower lobe thoracoscopic segmentectomy, excluding S6 and basal segments (from S7 to S10), using the PL approach, and the remaining 44 used the IF approach. Results: The median age in 41 patients in the PL group was 64.0 years (range, 22-82), and that in 44 patients in the IF group was 66.5 years (range, 44-88), with significant differences in gender between these groups. Video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery were performed on 37 and 4 patients in the PL group and 43 and 1 patient in the IF group, respectively. Postoperative complication frequency was not significantly different between these groups. The most common complications were the air leaks that persisted for over 7 days in 1 and 5 patients in the PL and IF groups, respectively. Conclusions: Complete thoracoscopic segmentectomy of the lower lobe, excluding S6 and basal segments, using the PL approach is a reasonable option for lung lower lobe tumors compared with the IF approach.

Complete thoracoscopic S9 and/or S10 segmentectomy through a pulmonary ligament approach: a retrospective study.

BACKGROUND: The high resolution of computed tomography has found the pulmonary ligaments that consists of a double serous layer of visceral pleura, forms the intersegmental septum, and enters the lung parenchyma. This study aimed to investigate the clinical feasibility of thoracoscopic segmentectomy (TS) of the lateral basal segment (S9), posterior basal segment (S10), and both through the pulmonary ligament (PL). METHODS: Between February 2009 and November 2021, 542 patients underwent segmentectomy for malignant lung tumors at Tokyo Women's Medical University Hospital (Tokyo, Japan). This study included 51 patients. Among them, 40 underwent a complete TS of the S9, S10, or both by the PL approach (PL group), and the remaining 11 by the interlobar fissure approach (IF group). RESULTS: Patients' characteristics did not significantly differ between the two groups. In the PL group, 34 underwent video-assisted thoracoscopic surgery (VATS), and 6 underwent robot-assisted thoracoscopic surgery. In the IF group, all 11 underwent VATS. Operation duration, estimated blood loss, and postoperative complication frequency were not significantly different between these groups, but the maximum tumor diameter showed a significant difference. CONCLUSIONS: Complete TS of the S9, S10, and both through the PL is a reasonable option for tumors located in such segments. This approach is a feasible option for performing TS.

[Outcomes of Surgical Cases of Solitary Rib Metastases in Renal Cell Carcinoma].

BACKGROUND: Aggressive surgical treatment for renal cell carcinoma (RCC) bone metastasis has shown good results. METHODS: Since January 1995, four patients underwent surgery at our institution for rib metastasis of operated RCCs. Of these patients, three were male and one was female. The patients had a mean age of 67.5 years. Except one patient who presented with rib metastasis at the time of diagnosis of RCC, the average period of metastasis to the ribs after RCC surgery was 24.3 months. All patients underwent resection of metastasized tumors involving the ribs, with or without chest wall involvement. The clinical features of the surgical treatment for RCC bone metastasis were retrospectively analyzed. RESULTS: The mean time to tumor recurrence was 22.3 months postmetastasectomy. All patients developed other bone metastases and underwent multidisciplinary therapy. After metastasectomy, the four patients survived for 19~93 months. CONCLUSION: Surgical treatment for patients with rib metastases of RCC may contribute in prolonging survival.

Papillary thyroid microcarcinoma with multiple pulmonary metastases following lung cancer surgery: a case report.

BACKGROUND: Distant metastasis is extremely rare for papillary thyroid microcarcinoma (PTMC) without lymph node metastasis or extrathyroidal extension, for which active surveillance (AS) is indicated. The evaluation of distant metastases in low-risk PTMC is controversial. A case of PTMC in which AS would have been performed if chest CT and lung surgery had not been performed is reported. CASE PRESENTATION: The patient was a 71-year-old woman undergoing follow-up in the Department of Thoracic Surgery at our hospital for multiple frosted glass shadows in both lung fields for one and a half years. To make a definitive diagnosis, thoracoscopic right middle lobectomy and left upper partial lobectomy were performed 4 and 6 months earlier, respectively. In both resected specimens, lung adenocarcinoma and small metastasis of papillary thyroid carcinoma (PTC) were found. The patient was transferred to our department for a thorough examination for PTC. Ultrasonography was performed to search for the primary lesion, and it showed an irregular hypoechoic mass of 4 mm and 6 mm in the middle of the right lobe of the thyroid gland. The patient was diagnosed with PTC. Its clinical stage was T1a (m) N0 M1 (stage IVC). Total thyroidectomy and prophylactic central node dissection were performed. The pathological diagnosis was PTC (typical type) pT1a (m) N0. Postoperatively, she received radioactive iodine therapy. CONCLUSIONS: We experienced an extremely rare case and struggled to determine a treatment plan. We might be aware that lung metastases could develop in low-risk PTMC.

Recurrent spindle cell carcinoma of the lung successfully treated by chemoimmunotherapy.

There is limited evidence for the treatment of sarcomatoid lung carcinoma, especially spindle cell carcinoma (SpCC) because of the rarity of disease. Although the efficacy of combination of chemotherapy and immunotherapy (i.e. chemoimmunotherapy) for non-small cell lung cancer (NSCLC) is well recognized, the effect for SpCC is not fully elucidated. A 72-year-old woman underwent surgical resection for the treatment of stage IIIA SpCC. Recurrence occurred three months after surgery, and then she received combination of carboplatin, paclitaxel, bevacizumab, and atezolizumab. A clinically favourable response was achieved by four cycles of chemoimmunotherapy and sequential maintenance therapy with bevacizumab and atezolizumab. The prognosis of advanced SpCC is generally poor, but chemoimmunotherapy can be a good therapeutic option for the first-line treatment of SpCC.

[Surgical Cases of Solitary Lesion after Surgery for Primary Lung Cancer].

Lung nodules during postoperative follow-up of lung cancer are generally suspected to be its recurrence, but some cases are diagnosed as non-malignant disease. From January 2001 to November 2018, we experienced 5( 4.5%) new non-malignant lesions in 112 lung cancer patients who underwent a lung resection. The average period from first to second lung surgery was 36.2 months (range:3-64), and computed tomography findings before the second surgery were solid nodules in four cases and groundglass opacity in one case. The average maximum standardized uptake value of the lesions on fluorodeoxyglucose positron emission tomography was 4.29 (range:0-10.85). The diagnosis after the second surgery was pulmonary cryptococcosis in 2 cases, nontuberculous mycobacteriosis in 1 case, inflammatory mass in 1 case, and pneumonia in 1 case. The differential diagnosis between these diseases and lung cancer recurrence is discussed in the present study.

Robot-assisted thoracoscopic surgery using a narrow-profile vascular stapler through an 8-mm robotic port.

The number of robot-assisted thoracoscopic surgery (RATS) procedures performed for thoracic disease has been increasing. Recently, a narrow-profile vascular stapler (Signia small-diameter reload, Covidien Japan, Tokyo, Japan) has been developed to provide superior access and precise staple placement in video-assisted thoracoscopic surgery (VATS) procedures. A 70-year-old man who was an exsmoker visited our hospital with a complaint of coughing. Chest computed tomography revealed a tumor with a cavity, ~55 mm in diameter, in the right-middle lobe. A 4-arm RATS right-middle lobectomy was performed with a 4-cm utility thoracotomy with da Vinci Xi (Intuitive Surgical, Sunnyvale, CA, USA). The pulmonary vessels were divided using a narrow-profile vascular stapler through an 8-mm port. No complications occurred in the postoperative course. With a narrow-profile vascular stapler, portal RATS can be performed after VATS lung biopsy using 8-mm ports.

A pulmonary ligament approach for portal robotic segmentectomy of the lateral and posterior basal segments: a case report.

BACKGROUND: Thoracoscopic segmentectomy of the lateral and posterior basal segments is extremely technically challenging. Appropriate segmentectomy requires exposure and recognition of the branches of the bronchi and pulmonary vessels deep in the lung parenchyma. Although various approaches for these segmentectomies have been reported, the use of a pulmonary ligament approach is rational because it does not require any interlobar separation. Here, we report a successful case of portal robotic segmentectomy of the lateral and posterior basal segments through the pulmonary ligament approach. CASE PRESENTATION: A 60-year-old Japanese man with a history of low anterior resection for rectal cancer was referred to our department because of a lung nodule. His chest computed tomography revealed a 15-mm tumor in the left posterior basal bronchus. Robotic left S9-10 segmentectomy through the pulmonary ligament was performed with five-port incisions. CONCLUSIONS: An extremely technically challenging thoracoscopic segmentectomy of the lateral and posterior basal segments was performed through the pulmonary ligament using a robotic surgical system.

Bio-artificial pleura using autologous dermal fibroblast sheets to mitigate air leaks during thoracoscopic lung resection.

Lung air leaks (LALs) due to visceral pleura injury during surgery are a difficult-to-avoid complication in thoracic surgery (TS). Reliable LAL closure is an important patient management issue after TS. We demonstrated both safeties of transplantation of a cultured human autologous dermal fibroblast sheet (DFS) to LALs. From May 2016 to March 2018, five patients who underwent thoracoscopic lung resection met all the inclusion criteria. Skin biopsies were acquired from each patient to source autologous dermal cells for DFS fabrication. During the primary culture, fibroblasts migrated from the dermal tissue pieces and proliferated to form cell monolayers. These fibroblasts were subcultured to confluence. Transplantable DFSs were fabricated from these subcultured fibroblasts that were trypsinized and seeded onto temperature-responsive culture dishes. After 10 days of fabrication culture, intact patient-specific DFS were harvested. DFSs were analyzed for fibroblast cell content and tissue contaminants prior to application. For closing intraoperative LAL, mean number of transplanted autologous DFS per patient was 6 ± 2 sheets. Mean chest drainage duration was 5.0 ± 4.8 days. The two patients with major LAL had a drainage duration of more than 7 days. All patients currently have no LAL recurrence after discharge. DFSs effectively maintain LAL closure via remodeling of the deposited extracellular matrix. The use of autologous DFSs to permanently close air leaks using a patient-derived source is expected to reduce surgical complications during high-risk lung resections.

Effects of robot- and video-assisted thoracoscopic lobectomy experiences on the learning curve of lobectomy.

BACKGROUND: This study aims to investigate the effects of robot- and videoassisted thoracoscopic lobectomy on the learning curve of lobectomy. METHODS: Between September 2013 and February 2020, the first 68 consecutive patients (28 males, 40 females; median age: 71 years; range, 33 to 86 years) who were operated for lung malignancies and scheduled for robot-assisted thoracoscopic lobectomy were retrospectively analyzed. The characteristics of the patients and operative data were analyzed, and the operation times of the first 51 cases of video-assisted thoracoscopic lobectomy were compared with those of robot-assisted thoracoscopic lobectomy performed by a single surgeon. RESULTS: Of the patients, 62 had primary lung cancer and six had metastatic lung tumors. The majority of primary lung cancer patients (87.1%) had an adenocarcinoma. The most common clinical stage was IA1 (30.9%). There was no emergent conversion to thoracotomy in any of the patients. The median operation time was 223.5 min, and console time was 151 min. The most common complication was an air leak. All patients were alive. Compared to video-assisted thoracoscopic lobectomy, the median operation time was significantly longer in the robot-assisted thoracoscopic lobectomy group (p=0.0002). Similar to the operation time learning curve of the video-assisted thoracoscopic surgery group, the operation time learning curve of the robotassisted thoracoscopic surgery group increased from the first to ninth case (Phase 1), plateaued from the 10th t o 14th c ase ( Phase 2 ), and decreased from the 15th case (Phase 3). There was a statistically significant decrease in the operation time between Phase 1 and Phase 3 (p=0.0063). CONCLUSION: The results of robot-assisted thoracoscopic lobectomy by a single surgeon show that this surgery has a longer operation time, but the perioperative outcomes are satisfactory. The learning curve of this surgery may be gradual for experienced video-assisted thoracoscopic surgeons.

Pleural changes in patients with pneumothoraces and Marfan syndrome.

BACKGROUND: Patients with Marfan syndrome (MFS) often develop pneumothorax, but the features of pneumothorax in the context of MFS have not been well described in the literature. We clarified the clinical and histopathological characteristics of this condition in these patients. METHODS: Patients with MFS were selected from among all patients who underwent surgery for pneumothorax, between December 1991 and January 2015, in our hospital. We studied the histopathological characteristics of the resected lungs as well as the clinical features of the selected patients, including surgical findings and postoperative recurrence status. RESULTS: There were 966 operations underwent pneumothorax-related surgeries in our hospital. A total of 16 operations (1.66%) were performed on patients with MFS in 11 cases. In this study, 9 patients (6 men, 3 women) were included. Clinically, 7 patients (77.8%) had bilateral pneumothoraces and 4 (44.4%) exhibited postoperative recurrent pneumothoraces. Pathologically, the resected pulmonary bullae exhibited blood vessel cystic medial degeneration (55.6% of cases), calcification (55.6% of cases), and demonstrated elastic fiber fragmentation and degeneration (all cases). CONCLUSIONS: As in few previous reports, many patients with MFS develop bilateral or postoperative recurrent pneumothoraces. In many patients, characteristic changes in the pulmonary bullae, possibly caused by degenerated elastic fibers, were observed.

Anatomical analysis of the left upper lobe of lung on three-dimensional images with focusing the branching pattern of the subsegmental veins.

BACKGROUND: A clear understanding of the anatomical characteristics of the pulmonary veins (PVs) is essential for the successful performance of segmentectomy and important to avoid intraoperative pulmonary vessels injury. However, there is no report showing the relations between the branching patterns of PVs and pulmonary arteries (PAs). Moreover, internationally accepted symbols for describing PVs remain unavailable. For anatomically assessing the branches and courses of the subsegmental veins in the left upper lobe (LUL), the diverse branching patterns of blood vessels and bronchi should be investigated. METHODS: The branching patterns and intersegmental courses of PVs were assessed by performing three-dimensional image analysis of the bronchi, and PAs and PVs in the LUL in 103 patients who were scheduled to receive segmentectomy in LUL from January 2008 through August 2012. RESULTS: Branching types of the bronchi and pulmonary vessels failed to be independent each other. Although the combinations of anterior extension type of bronchus with the inter-lobar type (IL-type) of arterial branching pattern were often observed, but those with the mediastinal type (M-type) were rarely observed. The combinations of apical vein dominant type with the IL-type of arteries, and intermediate and central vein types with the M-type were often observed. Since LUL was adjoined by various subsegments, and the intersegmental pulmonary veins showed diverse patterns. CONCLUSIONS: This study found the relationship among PA, PV, and bronchus patterns, in the subsegment where the branching patterns were fixed in 103 cases. This study discovered PVs that was difficult to be named by the conventional naming systems because of the diversity of the locations in the subsegment.

Manipulation of long-shaft stapler in robotic-assisted thoracoscopic surgery lung resection.

The number of robotic surgical procedures for thoracic disease is increasing. The automatic linear stapler has become a necessary device in endoscopic surgery. A 67-year-old man with a history of smoking was referred to our hospital for an abnormal finding on chest x-ray. Computer tomography of the chest revealed a ground glass nodule in the right middle lobe. We performed right middle wedge resection through the assistant port using a long-shaft stapler (LSS). Because the nodule was diagnosed as an adenocarcinoma on the intraoperative frozen section, the patient underwent robotic-assisted thoracoscopic surgery (RATS) right middle lobectomy using the da Vinci® Xi system. The pulmonary arteries, veins, right middle bronchus and minor fissure were divided using the LSS through the utility thoracotomy or assistant port. The postoperative course was uncomplicated. This case suggests that the LSS can be used in RATS lung resection for cancer.

[Usefulness of Long Shaft Stapler in Robot-assisted Thoracic Surgery Lung Resection].

Since national health insurance began to cover robot-assisted thoracoscopic surgery (RATS) for malignant lung tumors, malignant mediastinal tumors, and benign mediastinal tumors in Japan starting in 2018, the number of RATS performed domestically has increased rapidly. In the case of undiagnosed lung tumor, it is necessary to perform a thoracoscopic lung biopsy in the port arrangement for RATS lung resection in the case of undiagnosed lung tumor. The 2 ports are placed in the same 8th intercostal space and a 3 cm utility thoracotomy is added to the 4th or 5th intercostal space for the thoracoscopic lung biopsy. Because the assistant uses the stapler from the port, the distance to the target area increases. When it is converted to RATS for malignant lung diseases, the utility thoracotomy is often hidden by the robot arm and all ports placed in the 8th intercostal space are far from the target area. Furthermore, the assistant working space outside the patient's body is limited by the robot arms. The Signia stapling system has an adapter to extend the shaft. By attaching the adapter, the shaft can be extended by 10 cm. This permits easy handling of the stapler during both thoracoscopic biopsy and RATS lung resection.

Mediastinal paraganglioma successfully resected by robot-assisted thoracoscopic surgery with en bloc chest wall resection: a case report.

BACKGROUND: Robot-assisted thoracoscopic surgery (RATS) is useful for surgery in the apical region of the chest cavity, as it narrows towards the head. Here, we describe a nonfunctional, rib-invasive paraganglioma arising in the posterior mediastinum that was successfully removed using RATS combined with chest wall resection. CASE PRESENTATION: A 31-year-old woman presented with a posterior mediastinal mass on chest computed tomography (CT) scan during a medical check-up 2 years prior. Positron emission tomography/computed tomography scan with F-18 fluorodeoxyglucose revealed a mass associated with standardized uptake maximum value of 2.69. With a preoperative diagnosis of neurogenic tumor by CT-guided percutaneous fine-needle aspiration biopsy, we performed robot-assisted tumor resection combined with chest wall resection. The wristed instruments of the robotic surgical system have increased range of motion and enabled the tumor resection without organ injury in the thoracic cavity. Histopathology examination revealed a non-functional paraganglioma with rib invasion. CONCLUSIONS: RATS is a useful technique, enabling safer and easier resection of a mediastinal tumor adjacent to surrounding organs.

Thoracoscopic surgical case of an ectopic mediastinal parathyroid adenoma detected by chance: a case report.

BACKGROUND: Ectopic mediastinal parathyroid tumor (EMPT) is a rare cause of primary hyperparathyroidism (PHPT); it is difficult to resect using the cervical approach. We describe a case of using video-assisted thoracic surgery (VATS) for EMPT resection. CASE PRESENTATION: A 67-year-old woman with a history of postoperative thyroid cancer had no symptoms. She was diagnosed with PHPT and underwent thyroid cancer surgery. She had serum calcium and intact parathyroid hormone (PTH) levels of 11.1 mg/dL and 206 pg/mL, respectively. Chest computed tomography showed a 10-mm nodule in the anterior mediastinum. Technetium-99 m methoxyisobutyl isonitrile scintigraphy showed an abnormal uptake lesion in the anterior mediastinum. She was diagnosed with PHPT caused by EMPT and underwent VATS. The pathological examination confirmed parathyroid adenoma. Her serum calcium and intact PTH levels were normal from 15 min after tumor resection. She has had no recurrence of EMPT. CONCLUSIONS: The VATS approach was effective for the resection of EMPT.

Off-the-Shelf Cell Sheets as a Pleural Substitute for Closing Visceral Pleural Injuries.

During pulmonary resections, removal of visceral pleura is frequently required, resulting in lung air leakage (LAL) and bleeding. Especially persistent LAL after pulmonary surgery has negative consequences. Current surgical procedures are ineffective in closing these visceral pleural injuries. Previously, the authors' laboratory has developed a novel and effective LAL sealant using tissue-engineered cell sheets harvested from temperature-responsive culture dishes. The clinical application of fresh fibroblast sheets (FSs) is limited by several problems related to the cell culture period, mass production, preservation, and transportation. Therefore, cryopreservation of FSs and feasibility of off-the-shelf FSs for repairing visceral pleural defects were investigated. Over 3 to 6 months, harvested skin-derived FSs in Dulbecco's modified Eagle's medium supplemented with 10% dimethyl sulfoxide were stored in an atmosphere of liquid nitrogen. The amounts of cytokines (basic fibroblast growth factor [bFGF] and vascular endothelial growth factor) released from frozen-thawed FSs were determined. bFGF levels were significantly elevated in frozen-thawed FSs compared with fresh FSs. After a visceral pleural injury model was created, a frozen-thawed skin-derived FS was transplanted directly to the defect. One month after transplantation, the frozen-thawed FS remained on the pleural surface, resulting in permanent closure, suggesting that cells in the off-the-shelf FS had the ability to proliferate and release various cytokines. Frozen-thawed FSs were useful for closing LALs during pulmonary surgery as an off-the-shelf technique and would be used as a pleural substitute.