Improvement in respiratory function and exercise tolerance following video-assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation.

Hemidiaphragm paralysis, a complication of catheter ablation for atrial fibrillation, can severely affect respiratory function and can lead to paradoxical breathing and dyspnea on exertion. A 75-year-old woman with iatrogenic diaphragm paralysis showed improved symptoms, respiratory function, and exercise tolerance after video-assisted thoracoscopic diaphragm plication.

[Indication of limited pulmonary resection for small-sized lung cancer based on preoperative clinical data].

Limited pulmonary resection is performed mostly based on the size of lung cancer and ground-glass opacity (GGO). It has been proposed to determine the indication of segmentectomy according to hilar lymph node involvement. There is a potential risk of underestimation for lymph node involvement since there may be a skip mediastinal lymph node metastasis without hilar involvement. We propose to use standardized uptake value( SUV) max of primary lung cancer as an indicator of non-invasive lung cancer. None of 44 small-sized lung cancers with SUVmax lower than 1 had lymph node metastasis or vessel invasion. A small-sized lung cancer ≤ 2 cm with SUVmax ≤ 1 is indicated wedge resection if GGO area is greater than 75% of tumor. Segmentectomy is indicated if the GGO area is less than 75%. We also propose selective lymphadenectomy for small-sized lung cancer. The lower mediastinal lymphadenectomy may be omitted if a small-sized tumor is located in the right upper lobe or the left upper segment. The upper mediastinal lymphadenectomy may be omitted if a small-sized lung cancer is located in the lower lobe and if the lower mediastinal lymph node involvement is excluded.

Laparoscopic approach as a safe and effective option for incarcerated femoral hernias.

INTRODUCTION: The laparoscopic approach for elective femoral herniorrhaphy is well established. However, femoral hernias often present as incarcerations and require emergency repair surgery, mainly using the open approach. This study aimed to retrospectively analyze the efficacy of the laparoscopic approach for incarcerated femoral hernias. METHODS: Data of patients who underwent emergency surgery for incarcerated femoral hernia between April 2016 and August 2021 were retrospectively analyzed. Laparoscopy was performed whenever possible; however, conversion to an open approach remained a fallback option for when laparoscopic repair was not possible. In laparoscopic repair, incarcerated femoral hernias reduced using traction, water pressure, and preperitoneal methods. Data of patients who underwent open repair and laparoscopy were then compared. RESULTS: During the observation period, 20 patients underwent emergency surgery for incarcerated femoral hernia. Eleven patients subsequently underwent repair using a laparoscopic approach, and eight underwent repair using an open approach. Only one patient underwent intestinal resection without hernia repair due to perforated bowel. Operative time for laparoscopic repair was longer. Mesh repair was performed in 18 patients. Four patients each in the laparoscopic repair and open group required intestinal resection. CONCLUSION: Incarcerated femoral hernias can be safely repaired using the laparoscopic approach.

Perforation of small intestinal metastasis of lung adenocarcinoma treated with pembrolizumab: a case report.

BACKGROUND: Pembrolizumab is an immune checkpoint inhibitor and is an anti-human programmed cell death-1 (PD-1) monoclonal antibody. Pembrolizumab is used for non-small cell lung carcinoma with high programmed cell death ligand-1 (PD-L1) expression. It has been found that better overall survival can be obtained using pembrolizumab compared to the existing chemotherapy. We report a case of perforation of small intestinal metastasis after pembrolizumab treatment. CASE PRESENTATION: A 62-year-old man was treated by pembrolizumab for PD-L1 highly expressed lung adenocarcinoma, with multiple metastasis (small intestinal, lymph nodes, and bone). The treatment was stopped owing to drug-induced pneumonitis. One month after drug withdrawal, the patient visited the emergency department of our hospital with the complaint of severe stomachache. He had a rigid abdomen and generalized tenderness, and computed tomography scans showed free air within the abdomen. We diagnosed bowel perforation and performed emergency surgery. Surgical findings revealed multiple small intestine metastasis and mesenteric lymph node metastasis. Perforation was found in the metastatic site in the jejunum located around 40 cm anal to Treitz's ligament. This perforated part was resected, and functional end-to-end anastomosis was performed using linear staplers. The post-operative course was uneventful. Pathological examination revealed lung adenocarcinoma metastasis at the perforation site, and the effectiveness of pembrolizumab was grade 1b (Japanese Classification of the Colorectal Carcinoma, seventh edition). CONCLUSIONS: This is the first report of perforation of small intestinal metastasis of lung adenocarcinoma after pembrolizumab treatment. Because pembrolizumab causes some side effects, particularly autoimmune side effects, careful attention during treatment is warranted.

Long-term survival after repeated resection of metachronous lung metastases from pStage IA pancreatic adenocarcinoma.

CASE REPORT: A 70-year-old woman with pancreatic ductal adenocarcinoma was initially treated by distal pancreatectomy (DP). Thirty-five months later, another tumor appeared in the pancreatic head and was treated by pancreaticoduodenectomy. Histopathological findings identified both tumors as pancreatic ductal adenocarcinoma pStage IA. Computed tomography (CT) of the chest 16 months after the second pancreatectomy revealed a ground-glass opacity in segment 3 of the right lung. Chest CT 23 months after the second pancreatectomy revealed a nodular shadow in segment 1a of the right lung. Chest CT 39 months after the second pancreatectomy revealed a nodular shadow in segment 5 of the left lung. These lesions were treated by video-assisted thoracoscopic surgery partial resection. Histopathological and immunohistochemical features (positive for cytokeratin (CK)7 and CK20, negative for transcription factor-1) for these three lesions and the secondary pancreatic ductal adenocarcinoma were similar, indicating a diagnosis of lung metastasis from the second pancreatic ductal adenocarcinoma. The patient has remained alive and free of new metastases for 8 years after initial DP, 3 years after the last lung resection. CONCLUSION: This patient has survived over the long term after undergoing three resections of lung metastases from resected pancreatic ductal adenocarcinoma.

Pigment epithelium-derived factor gene therapy inhibits human pancreatic cancer in mice.

PURPOSE: Pigment epithelium-derived factor (PEDF), which has recently been shown to be the most potent inhibitor of angiogenesis in the mammalian eye, is also expressed in the pancreas. Previously, we have screened the expression of PEDF by immunohistochemical analysis and showed that low expression of PEDF is associated with increased risk of hepatic metastasis and short survival. The purpose of this study was to investigate whether PEDF gene is a potent tumor suppressor and a potential candidate for cancer gene therapy. EXPERIMENTAL DESIGN: We investigated both in vitro and in vivo growth characteristics of human pancreatic adenocarcinoma cell lines that were stably transfected to overexpress human PEDF and therapeutic effects of lentivirus-based vectors expressing PEDF on tumor growth in murine s.c. tumor model. RESULTS: We discovered that cells secreted PEDF protein in the media and this exhibited strong inhibitory effects on proliferation and migration of human umbilical vein endothelial cells. The size of PEDF-overexpressing pancreatic adenocarcinoma tumors was significantly smaller than that of control tumors in s.c. tumor models. Moreover, the growth of PEDF-overexpressing pancreatic adenocarcinoma cells was significantly suppressed in comparison with control cells in peritoneal metastasis models. In gene transfer models, intratumoral injection of a lentivirus vector encoding PEDF (LV-PEDF) caused significant inhibition of tumor growth. The antitumor effect observed after treatment with LV-PEDF was associated with decreased microvessel density in tumors. CONCLUSION: Our data suggest that PEDF may exert a biological effect on tumor angiogenesis and PEDF gene therapy may provide a new approach for treatment of pancreatic adenocarcinoma.

Clinical outcomes following extended thymectomy for myasthenia gravis: report of 17 cases.

PURPOSE: This retrospective study was undertaken to assess the changes in the clinical status of patients with generalized myasthenia gravis (MG) treated with extended thymectomy and to identify prognostic variables that may be of significance in optimizing patient selection. PATIENTS AND METHODS: We reviewed the clinical outcomes of 17 patients who underwent extended thymectomy for MG. Main factors influencing the outcome are changes in clinical stage and medication requirement before and after thymectomy, age, sex, duration of disease, stage of disease, antibody status, histological characteristics of the thymus, and duration of follow-up. RESULTS: There was remission in 4 patients (23.5%), improvement in 9 patients (53%), and no change in 4 patients (23.5%). Patients in Osserman stage IIB and with a higher rate of decrease in acetylcholine receptor (AchR) antibody ratio showed a greater degree of postoperative improvement. Age of the patient, sex, presence or absence of thymoma, and time elapsed between diagnosis and operations were not found to be significant prognostic factors. CONCLUSION: The present study demonstrated that extended thymectomy for MG is an effective therapy with no great morbidity or mortality. Patients in preoperative stage IIB and with higher rate of change in the AchR antibody titer showed the greatest degree of postoperative improvement.

Expression of pigment epithelium-derived factor decreases liver metastasis and correlates with favorable prognosis for patients with ductal pancreatic adenocarcinoma.

Pigment epithelium-derived factor (PEDF) is expressed in several normal organs and identified as an inhibitor of neovascularization. In the present study, we screened the expression of PEDF immunohistochemically and investigated its correlation with clinicopathological features in patients who underwent surgery for ductal pancreatic adenocarcinoma. Of the 80 patients, 22 cases (27.5%) were positive for PEDF. A significant association was found between the PEDF expression and low microvessel density (P = 0.0003). No correlation was found between PEDF expression and age, gender, depth of invasion, tumor diameter, lymphatic invasion, venous, invasion or histopathological grading. The patients in pathological stage II had a significantly higher incidence of PEDF-positive expression than those in pathological stage III or IVA (P = 0.0418). PEDF immunoreactivity was inversely associated with liver metastasis (P = 0.0422). The survival of patients that were PEDF positive was significantly longer than that of those with negative expression (P = 0.0026). Multivariate analysis using the Cox regression model indicated that PEDF-positive expression was an independent favorable prognostic factor (risk ratio, 0.394; P = 0.0016). We conclude that PEDF expression suggests a more favorable prognosis than in patients whose carcinomas lack PEDF expression.

Noninvasive management for iatrogenic splenic injury caused by chest tube insertion: a case report.

Splenic injury is one of the most critical complications of chest tube insertion and often requires invasive emergency management. However, noninvasive management such as delayed removal of the malpositioned tube may be considered for a stable patient without severe adverse event.

Endobronchial closure of a bronchopleural fistula using a fibrin glue-coated collagen patch and fibrin glue.

Bronchopleural fistulas associated with empyema can occur as life-threatening sequelae after pulmonary resection, occurring most frequently after pneumonectomy. Three bronchopleural fistulas, 5-6 mm in diameter, were successfully treated using a fibrin glue-coated collagen patch (FGCCP) and fibrin glue (FG) at the site of a bronchopleural fistula. Through the clinical experiences, we introduce the methodology to perform the endobronchial closure of bronchopleural fistulas.Data were collected by reviewing the clinical charts of patients diagnosed with post-lobectomy bronchopleural fistula at Sapporo Minami-Sanjo Hospital from June 2004 to December 2010. Bronchopleural fistula was diagnosed by means of endoscopic visualization. Three cases of post-lobectomy and one case of post-pneumonectomy bronchopleural fistula were collected.A FGCCP fragment was packed within the fistula, and the fragment grasped with the forceps was kept in this position for approximately a minute, a time during which a FGCCP becomes adhesive, and the patch fragment was released. After releasing the patch fragment, the FG was applied directly on the FGCCP using a two-channel catheter.There have been few reports of the bronchoscopic closure of bronchopleural fistulas using a FGCCP and FG. Closure of small bronchopleural fistulas with the application of a FGCCP and FG may offer a valuable therapeutic alternative.

Video-assisted thoracoscopic left lower lobectomy in a patient with lung cancer and a right aortic arch.

A right aortic arch is a rare congenital anomaly, with a reported incidence of around 0.1%. A patient with a right aortic arch underwent video-assisted thoracic surgery left lower lobectomy and mediastinal lymph node dissection for squamous cell carcinoma. There was no aortic arch or descending aorta in the left thoracic cavity, but the esophagus. There was no anomaly in the location or branching of the pulmonary vessels, the bronchi, and the lobulation of the lungs. The vagus nerve was found at the level of the left pulmonary artery. The arterial ligament was found between the left subclavian artery and the left pulmonary artery. The recurrent laryngeal nerve was recurrent around the left subclavian artery. A Kommerell diverticulum was found at the origin of the left subclavian artery. The patient experienced no complications. We conclude that video-assisted thoracoscopic lobectomy with mediastinal dissection is feasible for treating lung cancer with a right aortic arch.

DRD2/DARPP-32 expression correlates with lymph node metastasis and tumor progression in patients with esophageal squamous cell carcinoma.

BACKGROUND: Dopamine receptors (DRs) are members of seven transmembrane domain trimeric guanosine 5'-triphosphate (GTP)-binding protein-coupled receptor family. Through dopamine receptor activation, dopamine plays a significant role in regulating gene expression, such as induced tumor cell migration. MATERIALS AND METHODS: We investigated DRD1 and DRD2 expressions in patients with esophageal squamous cell carcinoma (ESCC) for immunohistochemistry and analyzed differences between DRD1, DRD2, and DARPP-32 expressions of clinicopathological features in 122 patients with ESCC. RESULTS: DRD1 immunostaining correlated with the pathologic grade (P = 0.0127), and DRD2 immunostaining correlated with the pathologic stage (P = 0.0432) and pN classification (P = 0.0112). A significant correlation was found between DRD1 and DRD2 expression (P = 0.0292). However, no correlation was observed between DRD1/DRD2 expression and DARPP-32 expression (P = 0.4555 and 0.4774, respectively). No correlation was observed between the DRD1/DRD2 expression and patient prognosis. To find the cooperative role between DRD1, DRD2, and DARPP-32 expressions, patients were classified into the different groups. In the DRD2/DARPP-32 combination, the (+/-) group was significantly correlated with pathologic stage (P = 0.0006), lymph node metastasis (P = 0.0001), pT (P = 0.0287), and tumor size (P = 0.0202). Moreover, patients with this combination showed a lower survival rate compared with the other three groups (P = 0.0287). CONCLUSIONS: We conclude that DRD2/DARPP-32 expression is associated with tumor progression and that DRD2/DARPP-32 expressions may help predict prognosis in patients with ESCC.

Long-term efficacy of distal splenorenal shunt with splenopancreatic and gastric disconnection for esophagogastric varices in patients with idiopathic portal hypertension.

Idiopathic portal hypertension (IPH) requires invasive measures to prevent rupture and bleeding of esophagogastric varices. However, the long-term results of shunt surgery for IPH have not been reported. In particular, the pros and cons of surgery that preserves the spleen and its long-term hematologic effects have not been described. The records of 15 patients who underwent distal splenorenal shunt with splenopancreatic and gastric disconnection (DSRS with SPGD) for IPH between 1983 and 1998 was reviewed retrospectively. One patient died within 3 years of surgery, for a 3-year survival rate of 93%; the 10-year survival rate was 64%. Three patients (18%) suffered rebleeding from esophagogastric varices. The white blood cell and platelet counts were higher 3-5 years and 7-13 years postoperatively compared with preoperative values. Four of five patients who underwent postoperative computed tomography had a smaller spleen postoperatively. DSRS with SPGD provides long-term hemostasis for esophagogastric variceal bleeding in IPH and alleviates hypersplenism. DSRS with SPGD is an effective treatment for patients with IPH in whom long-term survival is expected.