[Usefulness of Continuous Suction Unit in Detecting Air Leakage for Pneumothorax].

A 66-year-old male with spontaneous pneumothorax underwent chest tube drainage in other hospital. After tube drainage, chest X-ray showed that the lung fully expanded and an air leakage was not visible. However, clamping the chest tube led to the collapse of the lung, and he transferred to our hospital. A continuous suction unit with pressure and bubbling time history monitoring system was used to detect intermittent air leakages( MS-009T). He underwent video-assisted thoracoscopic surgery. An air leakage from the right lung successfully closed. A new continuous suction unit was useful in detecting an air leakage which could not be confirmed by visual inspection.

Effect of collagen vascular disease-associated interstitial lung disease on the outcomes of lung cancer surgery.

PURPOSE: This study compared the effect of collagen vascular disease-associated interstitial lung disease (CVD-ILD) with that of idiopathic interstitial pneumonias (IIPs) on the outcomes of lung cancer surgery. METHODS: This study retrospectively reviewed the medical records of patients who underwent surgery for non-small cell lung cancer (NSCLC) and compared the data of 16 patients with CVD-ILD with those of 70 patients with IIPs. The patterns of interstitial lung disease (ILD) on chest computed tomography were classified into usual interstitial pneumonia (UIP) and non-specific interstitial pneumonia (NSIP) patterns. RESULTS: The numbers of UIP and NSIP patterns were 10 (62.5%) and 6 (37.5%) patients in CVD-ILD group, and 62 (88.6%) and 8 (11.4%) patients in IIPs group, respectively. A postoperative acute exacerbation (AE) appeared in 1 patient (6.3%) in the CVD-ILD group and 6 patients (8.6%) in the IIPs group. No significant differences in the incidence of postoperative AE and mortalities were observed between the two groups. The five-year overall survival rates of the CVD-ILD and IIPs groups were 37.5 and 49.2%, respectively. CONCLUSIONS: Surgery for NSCLC in CVD-ILD patients appear to cause no increase in postoperative AE and mortality in comparison to that seen in IIPs patients. Similar to IIPs, CVD-ILD might therefore affect the prognosis of resected NSCLC.

[Outcomes of Surgical Treatment by Modified Transmanubrial Approach].

OBJECTIVE: The aim of this study is to evaluate the useful and safety of surgical treatment by modified transmanubrial approach(MTA). METHODS: Between January 2000 and May 2014, 10 patients underwent surgical treatment by MTA. Among these patients, we retrospectively reviewed the medical records of 6 patients who had vascular invasion of tumor. We evaluated postoperative outcomes of MTA. RESULTS: All patients were men, with a median age of 56 years. Pathological diagnoses were as follows:thymic carcinoma in 2, thyroid cancer in 2, primary lung cancer in 1, mediastinal lymph node metastasis of thyroid cancer in 1 patient. The median operative time was 468 minutes. The median bleeding was 1,723.5 ml. Four patients underwent angioplasty, including direct suture in 1, graft replacement artificial blood vessel in 3 patients. Right auricle-innominate vein bypass was performed in 3 patients. The median hospitalization term was 29 days. R0 resection was archived in all cases. CONCLUSION: The surgical treatment by MTA is useful and safety for anterior apical tumor and mediastinal tumor invading adjacent vessels. Because of a small number of sample size, further investigation well be needed.

Binocular stereo-navigation for three-dimensional thoracoscopic lung resection.

BACKGROUND: This study investigated the efficacy of binocular stereo-navigation during three-dimensional (3-D) thoracoscopic sublobar resection (TSLR). METHODS: From July 2001, the authors' department began to use a virtual 3-D pulmonary model on a personal computer (PC) for preoperative simulation before thoracoscopic lung resection and for intraoperative navigation during operation. From 120 of 1-mm thin-sliced high-resolution computed tomography (HRCT)-scan images of tumor and hilum, homemade software CTTRY allowed sugeons to mark pulmonary arteries, veins, bronchi, and tumor on the HRCT images manually. The location and thickness of pulmonary vessels and bronchi were rendered as diverse size cylinders. With the resulting numerical data, a 3-D image was reconstructed by Metasequoia shareware. Subsequently, the data of reconstructed 3-D images were converted to Autodesk data, which appeared on a stereoscopic-vision display. Surgeons wearing 3-D polarized glasses performed 3-D TSLR. RESULTS: The patients consisted of 5 men and 5 women, ranging in age from 65 to 84 years. The clinical diagnoses were a primary lung cancer in 6 cases and a solitary metastatic lung tumor in 4 cases. Eight single segmentectomies, one bi-segmentectomy, and one bi-subsegmentectomy were performed. Hilar lymphadenectomy with mediastinal lymph node sampling has been performed in 6 primary lung cancers, but four patients with metastatic lung tumors were performed without lymphadenectomy. The operation time and estimated blood loss ranged from 125 to 333 min and from 5 to 187 g, respectively. There were no intraoperative complications and no conversion to open thoracotomy and lobectomy. Postoperative courses of eight patients were uneventful, and another two patients had a prolonged lung air leak. The drainage duration and hospital stay ranged from 2 to 13 days and from 8 to 19 days, respectively. The tumor histology of primary lung cancer showed 5 adenocarcinoma and 1 squamous cell carcinoma. All primary lung cancers were at stage IA. The organs having metastatic pulmonary tumors were kidney, bladder, breast, and rectum. No patients had macroscopically positive surgical margins. CONCLUSIONS: Binocular stereo-navigation was able to identify the bronchovascular structures accurately and suitable to perform TSLR with a sufficient margin for small pulmonary tumors.

New findings on the three-dimensional anatomical relations between the bronchi and pulmonary blood vessels at the pulmonary hilum.

During the 1940s, considerable knowledge was acquired about the anatomy of pulmonary segments, and anatomical terms were proposed and have been widely accepted. In recent years, minimally invasive and thoracoscopic segmentectomy has been performed with a versatile sublobar resection approach on patients with early peripheral lung cancer, metastatic lung tumors, and undiagnosed nodules. The three-dimensional (3D) anatomy of the bronchi and the pulmonary vessels has also been studied in individual patients. Three-dimensional models of the bronchi and pulmonary vessels were prepared using homemade software from computed tomograms (CT) of the chests of patients scheduled to undergo surgical procedures. Using these models, the authors examined the 3D positional relationships of the segmental broncho-arterial triangle (SBAT) created by three points defined by the origins and courses of the bronchi and the pulmonary arteries, which are located apart from each other at the pulmonary hilum, and the segmental pulmonary veins (SPV), which run near the SBAT. In the left and right upper lobes, many branches of the pulmonary arteries and parallel bronchi in subsegments were widely separated at the origin of the pulmonary hilum, creating a relatively large SBAT. However, as an exceptional case, an SPV passed through an SBAT in only one of 158 patients. To our knowledge, no similar findings have been documented previously. Our findings could help to determine resection surfaces for thoracoscopic segmentectomy in the future, and provide new insights into the 3D anatomy and development of the lung.

[Hemoptysis caused by bleeding into a bleb].

A man in his 40s was admitted to our hospital for hemoptysis. A chest computed tomography showed a mediastinal mass adjacent to the left side wall of the ascending aorta with infiltrative shadows of the left upper lobe. In spite of medical treatment, hemoptysis continued, and the surgery was performed. The thoracoscopic findings showed hematoma in the bullous cavity. Partial resection of the left upper lobe was performed. Histopathological findings in the resected specimen revealed a bleb that was filled with blood.

Presurgical planning using a three-dimensional pulmonary model of the actual anatomy of patient with primary lung cancer.

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) for both lobectomy and segmentectomy has been used widely for early stage nonsmall cell lung cancer (NSCLC). The objective of this study was to investigate the clinical feasibility of surgical planning using patient's actual three-dimensional (3D) pulmonary model for the thoracoscopic surgical treatment of early stage NSCLC. METHODS: We examined 57 patients with stage IA NSCLC ≤ 2 cm in diameter. Based on patient's actual 3D pulmonary model created by using a homemade software program called CTTRY (Tokyo Women's Medical University, Tokyo, Japan), both the location of and extent of tumor invasion were assessed, and a suitable type of VATS lung resection for an individual was selected. RESULTS: By the 3D models, tumors in 47 patients were localized within one segment, and other tumors (10 patients, 18%) were involved in multiple segments. VATS lung resections consisted of a single segmentectomy were performed in 25 patients; upper division resections, 9; lingulectomy, 5; extended segmentectomy, 7; single subsegmentectomy, 6; and multiple subsegmentectomy, 5. All 57 patients underwent successful VATS lung resection without massive bleeding. CONCLUSION: Presurgical planning based on patient's actual 3D pulmonary model is useful for patients with stage IA NSCLC ≤ 2 cm in diameter and for selecting an appropriate VATS lung resection for an individual.

[Surgery for metastatic lung tumor from malignant tumor of liver, biliary duct and pancreas].

BACKGROUND: Resection of lung metastasis from malignant tumor of liver, biliary duct and pancreas has various controversial problems. These problems are that many patients have a progressive disease and there are few patients who can have resectable lesion. Generally the prognosis of these diseases is poor. In addition, the effect of pulmonary resection for lung metastasis from malignant tumor of liver, biliary duct and pancreas is unclear. We set out to investigate the outcome and usefulness of surgery in this group. PATIENTS AND METHODS: From January 1999 to November 2012, 18 patients underwent a total of 21 surgeries. There were 11 men and 7 women with mean age of 66.6±10( range, 43 to 78). Primary diseases of these patients were hepatocellular carcinoma in 5, cholangiocellular carcinoma in 1, cholangiocarcinoma in 2 and pancreatic cancer in 10 patients. RESULTS: Disease-free interval from 1st local therapy such as surgical treatment for primary lesion was 50.8±28.7(range, 19 to 107) months. Numbers of lung metastasis were 1 in 15, 2 in 4 patients and 3 in 1 patient. Many metastasis were in right lower lobe. Numbers of wedge resection were 13, segmentectomy were 4, lobectomy were 2 in these patients. Average of total survival time was 38±34 months. Four patients were dead. The 14 patients are alive and 7 patients had no recurrence. Adjuvant therapy such as chemotherapy was important. One-year all over survival rate after 1st pulmonary resection was 88%, 3 or 5-years was 73%. We think that it's was good result. CONCLUSION: There is a possibility that surgery for metastatic lung tumor from malignant tumor of liver, biliary duct and pancreas is useful by control of primary lesion and selecting of patients and adjuvant therapy such as chemotherapy.

[Surgical treatment for mediastinal cysts].

BACKGROUND: Since most of mediastinal cysts are benign tumors, video-assisted thoracic surgery (VATS) is optimal surgical procedure in recent years. It is important to select an appropriate approach accordance with the various locations of the cysts. METHODS: This is a retrospective review between 2005 and 2011 included 42 cases who had been undergone surgery for mediastinal cysts at the department. RESULTS: There were 19 males and 23 females, mean-age 58.9±11.8 year. The cysts in superior portion of the mediastinum, anterior and middle mediastinum were 2, 31, and 9 patients, respectively. Operative procedures included 3 or 4 ports in 11, mini-thoracotomy and 2 or 3 ports in 28, cervical incision and mini-thoracotomy and 2 ports in 1, median sternotomy in 2. Mean operative time was 128.8±62.8 minutes. The mean postoperative stay was 5.6±2.1 days. There was hardly a perioperative complication, excepting only 1 case of intraoperative hemorrhage. CONCLUSION: VATS allows various surgical approach to each location of mediastinal cysts, and less invasive procedure.

[Three-dimensional display simulation of lung surgery using "active shutter glasses"].

We have reported preoperative 3-dimensional (3D) simulation of thoracoscopic lung surgery using self-made software and internet shareware of 3D-modeler. Using "active shutter glasses", we have tried the "3D display simulation" of lung surgery. 3D display was more effective to grasp clear 3D interrelation between the bronchii and pulmonary vascular system than those in images of currently in use with the same information volume.

[Thoracoscopic subsegmental and segmental resection for postoperative local recurrence of lung cancer based on the three-dimensional structure after lung resection].

After lung cancer surgery, because chest computed tomography (CT) examinations are conducted frequently, recurrent cancer is often discovered at an early stage. In postoperative cases, because the lung volume has already decreased, radical limited surgery is therefore required. Before performing lung resection, we create a three-dimensional image of the lung, using CTTRY, on a personal computer and conduct a simulation of the resection range before moving on to surgery and accurately and smoothly performing thoracoscopic segmental and subsegmental resection. In the past 2 years, we have treated 5 cases of ipsilateral cancer and surgery for recurrence using this surgical technique. This case was a 66-year-old female. Right lower lobectomy was performed to treat primary squamous cell carcinoma of the lung. Recurrence was observed in CT examinations during the follow-up, and right S2 segmentectomy was performed. For performing radical limited surgery for recurrent lung cancer, avoiding completion pneumonectomy, it is therefore very useful to review the surgical procedures using CTTRY.

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.

Venous Branching Pattern in a Patient with Hemorrhagic Infarction in the Lingula after the Upper Division Resection of the Left Lung.

BACKGROUND: Because left upper division resection is similar to right upper lobectomy, this procedure is frequently employed. Few studies have used the anatomic courses of veins evaluated on preoperative computed tomography (CT) imaging to determine what types of patients are at the highest risk for hemorrhagic pulmonary infarction. CASE: We describe our experience with a patient in whom hemorrhagic pulmonary infarction occurred at 6 days after transecting two superior branches (V1 and V3) of the three branches of the left superior pulmonary vein. We preoperatively confirmed that small-caliber lingular veins were perfused by V3. However, the patient had a poor pulmonary function, and the tumor was located distal to V3. Left upper division resection was therefore performed. CONCLUSION: The division of V3 could be the cause of hemorrhagic infarction in the lingular segment after upper division segmentectomy.

A successful surgical repair of intraoperative pneumothorax and the diffuse dissection of visceral pleura during liver transplantation surgery via trans-diaphragmatic approach.

BACKGROUND: Pneumothorax during surgery under general anesthesia is a life-threatening situation for the patient because it can progress easily to the tension pneumothorax due to positive pressure ventilation unless appropriate treatments such as inserting a drainage tube in the thoracic cavity are initiated. The authors experienced a case of intraoperative pneumothorax and the diffuse dissection of visceral pleura during liver transplantation surgery, and achieved successful repair by a trans-diaphragmatic approach without changing patient's body position. CASE PRESENTATION: A 66-year-old male with multiple liver and renal cysts caused by autosomal dominant polycystic kidney disease (ADPKD) was admitted to the authors' hospital for treating the infection of the liver cysts. The infection was unable to be controlled by conservative treatments. Therefore, the patient was planned to undergo living-donor liver transplantation. Intraoperatively, the liver was found to swell markedly and to firmly adhere to the right diaphragm. After the extraction of the liver, because the right diaphragm swelled markedly, pneumothorax was suspected. Chest tube was inserted immediately, and the small incision was made in the right diaphragm. Thoracoscopic observation revealed that (1) the visceral pleura of the bottom of the right lung widely expanded like a giant cyst due to the dissection from the lung parenchyma and (2) a large air leakage from a pin hole appeared in the dissected pleura. After the completion of the liver transplantation, the thoracoscopic leakage-closing operation was performed through the right diaphragm incision. Because the dissection of visceral pleura was too wide to perform plication or cystectomy by a stapler or sutures, the dissected pleura was opened, and absorbable fibrin sealant patches and fibrin glue were put or injected between the lung parenchyma and the pleura. Although, after being observed postoperatively, prolonged minor air leakage disappeared by a conservative drainage treatment, and the cyst on the bottom of the right lung disappeared on chest computed tomography (CT). CONCLUSIONS: Although intraoperative pneumothorax and broad dissection of visceral pleura during laparotomy is a complicated situation, the authors successfully repaired air leakage via a trans-diaphragmatic approach without changing the patient's body position.

A novel and simple method for identifying the lung intersegmental plane using thermography.

Identifying the intersegmental plane is very important for successful lung segmentectomy. Although several methods are available, they require specialized skills and pose a potential risk of losing sight of the correct intersegmental planes. Therefore, easier and more reliable methods are required. In this study, we hypothesized that surface temperatures of resecting segments or lobes decrease because of blood flow suppression after the ligation of target arteries and veins, and intersegmental planes can be visualized using a thermography. To test this hypothesis, we performed six lung resections (two lobectomies and four segmentectomies) on three pigs and, using a handheld thermography, we monitored the lung surface temperatures to identify intersegmental planes. We demonstrated that thermal imaging sharply demarcated intersegmental planes soon after the ligation of vessels in all procedures. Compared with other methods, thermography requires no special technical skills, drug injection and lung inflation. Therefore, we believe that the thermographic method described in this study will be a powerful option to identify intersegmental planes during anatomical lung segmentectomy.

Do the lung segments exist continuously from the early stage of the embryonic period as units?

OBJECTIVES: Although various types of segmentectomy are frequently performed for resecting lung tumours at present, there is no clear answer to the question what kind of segmentectomy would be more efficient for performing lymphadenectomy. Learning the embryological mechanism of the segment formation could be one of the methods for selecting the surgical procedure. To investigate the developmental mechanism of the lung, this study focused on 'sharing structure', a unique 3D structure consisting of the bronchi and pulmonary arteries. In the structure, two arteries from different directions, after straddling the bronchus in the central part, share one bronchial tree at the peripheral part. METHODS: Using computed tomography data obtained before segmentectomy, this study observed the 'sharing structure' in 193 left and right upper lobe cases. This study investigated the relationship between the segmental arterial types and the straddled bronchi, which were straddled by the pulmonary arteries found in the centre of the sharing structure. RESULTS: In the right upper lobes, the straddled bronchi were anterior segmental bronchi. In the left upper lobes, however, the straddled bronchi of the lingular interlobar pulmonary artery type contained no anterior segmental bronchi. But, the straddled bronchi of lingular mediastinal pulmonary artery type contained anterior segmental bronchi in all cases. CONCLUSIONS: Although pulmonary arteries in almost all sharing structures in the right upper lobes straddled anterior bronchi, those in mediastinal type and interlobar type in the left upper lobe were found to straddle the anterior and apicoposterior bronchi, respectively. These findings indicated that the interlobar type was speculated to be rotating mediastinal type backward in the embryonic period. This study strongly suggested a new concept that 'the lung segments never continuously exist from the early stage of the embryonic period as units, but they are only simple units artificially named by their prevailing bronchial branching patterns'. Therefore, during segmentectomy including lymphadenectomy for pulmonary tumours, the retrieval of the branching patters of pulmonary arteries could allow the segmentectomy to become more efficient with considering the formations of lung lobes.

Video-assisted thoracoscopic surgery after renal transplantation: A single-institution experience.

INTRODUCTION: The number of renal transplantations performed for patients with chronic kidney disease has increased in Japan, but little is known about the outcomes in those who subsequently undergo video-assisted thoracoscopic surgery (VATS). We therefore investigated the outcomes of consecutive patients requiring VATS after renal transplantation at our institute. METHODS: We retrospectively collected the clinical data for patients undergoing VATS after renal transplantation between January 2003 and September 2014. Specifically, we compared the serum creatinine level and estimated glomerular filtration rate preoperatively and postoperatively, and investigated the postoperative complications. RESULTS: In total, 12 patients underwent VATS after renal transplantation during the study period. All patients received two or three immunosuppressive agents. Operative methods used included VATS wedge resection (n = 4), segmentectomy (n = 4), lobectomy (n = 2), mediastinal tumor resection (n = 1), and chest wall tumor resection (n = 1). No patients required perioperative hemodialysis. There were no intraoperative complications, but one patient developed postoperative hemorrhagic cystitis and another developed pneumonia. One patient developed pneumocystis pneumonia 2 months after left lower lobectomy and required hemodialysis. No further hemodialysis was required by any patient. Of note, no statistically significant differences were observed between the preoperative and postoperative serum creatinine level (P = 0.666) and estimated glomerular filtration rate (P = 0.388). There were no in-hospital deaths. Univariate analysis revealed no significant risk factors for postoperative complications. CONCLUSION: This report showed favorable results for VATS after renal transplantation. However, clinicians must remain vigilant for complications because transplant recipients remain permanently immunocompromised.

Noninvasive thymoma in the middle mediastinum.

We present a rare case of thymoma that developed entirely in the middle mediastinum. A 60-year-old woman was referred to our hospital with a mediastinal mass. The mass was located in the visceral compartment of Shields' mediastinal classification. Intraoperative pathologic evaluation revealed a thymoma, whereupon total thymectomy was performed. The postoperative course was uncomplicated and the patient received no postoperative adjuvant radiotherapy.

Bronchoplasty with plication of the proximal bronchial membranous portion.

Bronchoplasty originally designed for patients with inadequate pulmonary function who cannot tolerate pneumonectomy, has recently yielded good results as well as offering an alternative to pneumonectomy. We describe a technique for plication of the proximal bronchial membranous portion when there is significant discrepancy in lumen size between the main and the segmental bronchi to allow precise end-to-end anastomosis. Plication helps prevent postoperative anastomotic stenosis and obstruction.

Early endoscopic treatment of chylothorax develops after surgical treatment of lung cancer patients.

OBJECTIVE: Chylothorax which occasionally develops after surgical treatment of lung cancer is generally treated conservatively, and surgical treatment is limited to patients who do not respond well to conservative treatment. SUBJECTS AND METHODS: Of the 941 lung cancer operation, 6 patients in whom Chylothorax developed after surgical treatment of lung cancer were evaluated for its characteristics and outcome. RESULTS: Two patients underwent thoracoscopic treatment. The duration of drainage was shorter for the 2 patients undergoing chylothorax operation than for the 4 patients who underwent conservative treatment. The mean duration of hospitalization after surgical treatment of lung cancer was 24 days for the patients who underwent conservative treatment alone and 12.5 days for the patients who underwent chylothorax operation. CONCLUSION: Patients in whom chylothorax develops after surgical treatment of lung cancer should promptly undergo operation when the volume of chylous fluid is not decreased by conservative treatment.