[Penetrating Lung Injury Complicated by Hemodynamic Cerebral Infarction].

We encountered a case in which emergency surgery was performed for a penetrating lung injury complicated by a hemodynamic cerebral infarction. A 45-year-old man sustained a chest injury due to a scattered piece of metal and was admitted to a nearby hospital. He was confirmed to have hemorrhagic shock due to a right hemopneumothorax, and a chest tube was inserted he was transferred to our hospital. Chest radiography and computed tomography (CT) revealed a metal fragment in the right lung and confirmed the diagnosis of a penetrating lung injury due to a foreign body. The patient also presented with total blindness of an unknown etiology. Emergency surgery was performed to treat the injury and remove the foreign body. A large amount of blood and hematoma were removed from the right thoracic cavity, and a metal fragment was found in the lower lobe of the right lung. After removing the foreign body, pulmonary suturing was performed. On the following day, head magnetic resonance imaging revealed multiple cerebral infarctions in the bilateral occipital lobes, left frontal lobe, and left cerebellar hemisphere. However, no vascular occlusion or thrombus was found, and the patient was diagnosed with hemodynamic cerebral infarction due to hemorrhagic shock.

[Pulmonary Congestion and Stump Bleeding after Wedge Resection].

A 50's-year-old woman was pointed out an abnormal shadow in the right lung field on chest X-ray. Chest computed tomography revealed a nodule in the upper lobe of the right lung. No specific finding was shown by bronchoscopy. A thoracoscopic operation was performed. Wedge resection was performed using automatic suturing devices. Intraoperative pathology revealed the lesion to be necrotizing granuloma, and the operation was finished without resection of the residual upper lobe. After surgery, the upper right lung field shadow and intrathoracic hematoma were observed, and reoperation was performed. The residual upper lobe was highly congested with bleeding from the stump, requiring lobectomy. It was possibly caused by a deep cut of the lung parenchyma with automatic suturing devices at lung wedge resection, resulting in obstruction of the drainage vein.

Effect of Charge Groups Immobilized in Hydrogel Microspheres during the Evaporation of Aqueous Sessile Droplets.

In contrast to conventional dispersions of solid microspheres, dilute dispersions containing soft hydrogel microspheres (microgels) exhibit unique drying behavior due to their selective adsorption at the air/water interface of sessile droplets. So far, the impact of the size, chemical composition, and softness (degree of cross-linking) of microgels has been investigated. In the present study, we present the impact of charged groups introduced in the microgels on the adsorption and assembly behavior of these microgels at the air/water interface using a series of microgels with different amounts and distribution of charged groups. A series of experiments under different conditions (pH value and ionic strength) afforded information that clarified the adsorption, interpenetration, and deformation behavior of such charged microgels at the air/water interface. The results indicate that the adsorption and the deformation of charged microgels at the air/water interface are suppressed by the presence of charged groups. Moreover, charged microgels adsorbed at the interface are more dynamic and not highly entangled with each other; i.e., even though the more dynamic charged microgels are arranged at the interface, these arranged structures are disrupted upon transferring onto the solid substrates. Our findings of this study can be expected to promote the further development of applications, e.g., foams and emulsions stabilized by microgels, that crucially requires an in-depth understanding of the adsorption behavior of charged microgels at the air/water interface such as coatings.

Self-Organization of Soft Hydrogel Microspheres during the Evaporation of Aqueous Droplets.

The unique drying behavior of aqueous droplets that contain soft hydrogel microspheres (microgels) upon evaporation was systematically investigated. Compared to the ring-shaped deposits that are obtained from drying solid microsphere dispersions, we have previously reported that uniformly ordered thin films are obtained from drying ∼1.2 µm-sized poly( N-isopropyl acrylamide) microgel dispersions. In the present study, we thoroughly investigated several hitherto unexplored aspects of this self-organization, such as the effect of the size, chemical structure, and "softness" of the microgels (or rigid microspheres). For the macro- and microscopic observation of the drying behavior of various microsphere dispersions, an optical microscope and a digital camera were employed. The results suggested that the convection in the aqueous droplets plays an important role for the transportation of the microgels to the air/water interface, where the softness and surface activity of the microgels strongly affects the adsorption of the microgels. On the basis of these discoveries, a design concept for the rapid formation of uniform thin films of soft microgels was proposed.

[Solitary pulmonary metastasis of low-grade uterine endometrial stromal sarcoma resected 31 years before].

A 74-year-old female underwent hysterectomy and bilateral ovariectomy for uterine endometrial stromal sarcoma( ESS), low grade, at another hospital 31 years previously. When the patient was admitted for pneumonia, a lung tumor was pointed out on her chest X-ray and computed tomography( CT) scan. Chest X-ray showed an oval figure shadow of about 3.5 cm in diameter in the right lower lung field.Chest CT scan revealed an irregular form tumor of 3.5 cm in diameter in the right S8 of the lung. Fluorodeoxyglucose-positron emission tomography (FDG-PET) scan identified an abnormal accumulation of FDG at the tumor site. A pulmonary metastasis of the ESS was suspected by transbronchial lung biopsy, and the patient underwent the thoracoscopic partial resection of the right lower lobe of the lung.Histologically, the tumor was diagnosed as metastasis of the ESS, low grade.

Needlescopic video-assisted wedge resection combined with the subcostal trans-diaphragmatic approach for undetermined peripheral pulmonary nodules.

BACKGROUND: Reduced mortality from lung cancer by computed tomography (CT) screening facilitates the use of video-assisted thoracic surgery (VATS) lung wedge resection to obtain a definite diagnosis and to treat tiny nodules. The authors evaluated their initial experience using novel needlescopic VATS wedge resection combined with the subcostal trans-diaphragmatic (SCTD) approach for managing undetermined peripheral pulmonary nodules. METHODS: Between 2009 and 2012, 35 patients who had 36 operations underwent needlescopic VATS wedge pulmonary resection with the SCTD approach. Preoperative percutaneous CT-guided marking of the nodule was performed. Two 3-mm miniports were placed in the thorax for the thoracoscopic camera and minigrasper. Just anterior to the 10th rib, a 2-cm subcostal incision was made, and a 12- or 15-mm port was placed trans-diaphragmatically into the chest cavity. Wedge resection of the lung was performed with endostaplers introduced through a subcostal port. RESULTS: The median tumor size was 1.1 cm. Localization of the tumor was widely distributed. The mean operation time was 51 min, and the mean blood loss was 4.2 mL. No patients required conversion to thoracotomy, and one patient required conversion to conventional VATS. Additional thoracic ports were placed in five patients, and the needlescopic incision was extended to 15 mm in one patient. The median duration of chest drainage was 1 day. Additional analgesia was not required for 22 patients and was used for less than 1 day for three patients, less than 2 days for seven patients, and less than 3 days for seven patients. The pathologic diagnosis of the nodules was malignant for 28 patients and benign for 8 patients. On postoperative day 7 or at admission, 34 patients were free of postoperative neuralgia. CONCLUSIONS: Needlescopic VATS wedge pulmonary resection combined with the SCTD approach is both safe and feasible and offers the specific advantages of minimal invasiveness and good cosmetic outcomes.

U-clip for airway reconstruction: an experimental study of the feasibility of a robot-assisted endoscopic procedure.

BACKGROUND: The U-clip anastomotic device was developed to facilitate interrupted anastomoses without the need to tie sutures. Recently, this technology has been expanded into various fields of surgery. However, in the field of airway reconstruction, there have been no previous reports of this technology being used. The present study examined the technical feasibility of performing safe and efficient robot-assisted endoscopic airway reconstruction using nitinol U-clips in rabbits. METHODS: A total of six tracheal anastomoses with S60 U-clips were performed using the da Vinci Surgical System. Anastomosis time and complications were recorded. The effectiveness of anastomoses was evaluated by postoperative observation of rabbits for 8 weeks and measurement of anastomotic strictures and pathological findings. RESULTS: All procedures were completed safely. Mean procedure time was 14 ± 1.8 min (mean ± SD). There were no perioperative complications; however, all animals died between postoperative days 14-27, and anastomotic stricture was the likely cause of death. All anastomoses had severe strictures; the mean stricture rate was measured as being 51.1 ± 33.3 (%). CONCLUSIONS: Although the technical feasibility of robot-assisted endoscopic airway reconstruction using U-clips has been demonstrated in rabbits, the safety of this technique has not been evaluated. Our data suggest that U-clips are not a feasible approach for airway reconstruction surgery because of the occurrence of severe postoperative anastomotic stricture.

[Total port-access robot-assisted lobectomy for lung cancer].

We reported 2 cases of total port-access right lower lobectomy with hilar and mediastinal lymph nodal dissection using the da Vinci surgical system through subcostal trans-diaphragmatic approach. In case 1, the operating time was 6 hours 00 minutes, and the total blood loss was little. In case 2, the operating time was 6 hours 30 minutes, and the total blood loss was little. The da Vinci surgical system provides a high-resolution stereoscopic image and allows remote, tremor-free, and scaled control of endoscopic surgical instruments with 7 degrees of freedom. Minimally invasive robot-assisted lobectomy is an effective procedure and may add benefits for both surgeon and patients.

[Rapid multidisciplinary therapy for an advanced lung cancer patient with severe tracheal stenosis resulting in long-term survival].

A 61-year-old female was admitted to our hospital due to dyspnea and facial edema. A chest CT scan showed stenosis of the trachea and superior vena cava due to a tumor around the trachea. She underwent partial resection of the tracheal tumor via a rigid bronchoscope introduced into the trachea, and placement of a Dumon Y-stent. Undifferentiated non-small cell lung cancer was diagnosed. After airway management, she underwent cisplatin-based chemoradiotherapy and total 56 Gy stereotactic radiotherapy for the tumor. The tumor size was reduced by 40% immediately after chemoradiotherapy. Six months after the tracheal stent insertion, bone metastases were pointed out, and we changed the chemotherapy regimen to gefitinib. She has been in good condition without tumor growth for more than six years after tracheal stent insertion.

Durable gelfoams stabilized by compressible nanocomposite microgels.

Although hydrogel microspheres (microgels) are useful as emulsion stabilizers, typical microgels cannot stabilize foams over a prolonged period of time. Here, we found that compressible nanocomposite microgels with solid nanoparticles can overcome undesired desorption of microgels from the air/water interface of bubbles, and form highly durable, microgel-surrounded foams (gelfoams).

Non-close-packed arrangement of soft elastomer microspheres on solid substrates.

Unlike rigid microparticles, soft and deformable elastomer (rubber) microspheres were found to exhibit a non-close-packed arrangement on solid substrates after the evaporation of water from their dispersions. The microscopic observation revealed that individual microspheres are ordered in regular intervals at the air/water interface of a sessile droplet and remain fixed on the substrate without being affected by the capillary forces during evaporation due to their deformability. Moreover, using the Langmuir-Blodgett method, thin films of non-close-packed structures could be successfully generated over large areas. Our findings may potentially help to control the arranged structures of elastomer microspheres, which can be expected to improve the nano-science and technology for the precise control for e.g. surface patterning.

Hydrophobized nanocomposite hydrogel microspheres as particulate stabilizers for water-in-oil emulsions.

Hydrophobized nanocomposite microgels can serve as particulate emulsifiers for water-in-oil (W/O) emulsions with different types of oils, including non-polar oils, which usually do not form W/O emulsions with conventional microgels. The emulsion type can be controlled via the amount or type of hydrophobic polymer formed within the microgels.

The deformation of hydrogel microspheres at the air/water interface.

The deformation of soft hydrogel microspheres (microgels) adsorbed at the air/water interface was investigated for the first time using large poly(N-isopropyl acrylamide)-based microgels synthesized by a modified aqueous precipitation polymerization method. The deformation of the micron-sized soft microspheres could be visualized clearly and analyzed quantitatively at the air/water interface.

Atherosclerotic aneurysm of the right subclavian artery: report of a case.

Subclavian artery aneurysms are uncommon. The most common causes of these aneurysms are atherosclerosis and traumatic pseudoaneurysm. We report on a case of an atherosclerotic aneurysm of the right subclavian artery. The aneurysm was resected with a combined supra-infraclavicular approach, and a primary end-to-end anastomosis was performed. The postoperative course was uneventful. In arteriosclerotic cases, the axillobrachial artery is frequently tortuous, and the proximal axillary artery can be mobilized. If possible, a direct end-to-end anastomosis is recommended for the aneurysm of the distal part of the subclavian artery.

In vitro sensitivity to platinum-derived drugs is associated with expression of thymidylate synthase and dihydropyrimidine dehydrogenase in human lung cancer.

Thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) are critical enzymes in nucleic acid metabolism. Proliferating cell nuclear antigen (PCNA) is a specific protein that is correlated with proliferative activity of cells. The TS gene has a variable number of tandem repeats (VNTR) in its 5'-untranslated region and a single nucleotide polymorphism (SNP) in the VNTR area. We examined the association of in vitro sensitivity to anticancer drugs with TS polymorphism, TS, DPD, and PCNA mRNA expression using human lung cancer tissues. Seventy-eight surgically resected lung cancer tissues were tested for in vitro sensitivity to 5-fluorouracil, cisplatin (CDDP), carboplatin (CBDCA), irinotecan, docetaxel, and gemcitabine by histoculture and MTT assay. The TS polymorphisms were analyzed by PCR and PCR-RFLP. TS, DPD, and PCNA mRNA expression levels were quantified by real-time RT-PCR and normalized relative to beta-actin mRNA expression. The inhibition rates (IRs) of CDDP and CBDCA were significantly correlated with TS/PCNA, the ratio of TS/actin and PCNA/actin, and DPD/PCNA, the ratio of DPD/actin and PCNA/actin. This correlation was further explored by subgroup analyses according to TS VNTR or TS functional type, in which 2R/3G, 3C/3G, or 3G/3G were classified into H-type group and 2R/2R, 2R/3C, or 3C/3C into L-type group. The associations of TS/PCNA and DPD/PCNA with the IRs of CDDP, CBDCA remained significant in the 3R/3R group and H-type group. These results suggest that in vitro sensitivity to platinum-derived drugs, CDDP and CBDCA, is associated with PCNA-normalized mRNA expression of TS and DPD in human lung cancer tissues, as affected by the TS polymorphism. The clinical significance of these pharmacogenomic markers for chemotherapy regimens with platinum-derived drugs should be investigated further for personalized treatment of lung cancer.

Postoperative bronchial stump fistula responding well to occlusion with metallic coils and fibrin glue via a tracheostomy: a case report.

An 80-year-old man underwent middle and lower lobectomy of the right lung to treat squamous cell carcinoma (SCC) (4 cm in diameter) originating from the right B4 bronchus. On the 4th postoperative day, a massive air leak from the thoracic drain was noted. At that time, a diagnosis of bronchial stump fistula was made on the basis of the bronchoscopic findings. Continuous thoracic drainage, aspiration of sputum via a tracheostomy and intravenous administration of antibiotics were performed immediately after the diagnosis. However, the patient's condition was complicated by aspiration pneumonia. On the 11th postoperative day, bronchoscopic procedure to close the bronchial fistula was performed via the tracheostomy. During this procedure, metallic coils were first inserted into the fistula to serve as the core for occlusion. Then, instead of directly infusing fibrin glue, several small beans-sized pieces of Surgicell cotton (Johnson & Johnson Co., Cincinnati, OH) soaked in fluid A (concentrated fibrinogen) and the same number of Surgicell cotton pieces soaked in fluid B (thrombin) were alternately inserted into the fistula, to allow closure of the bronchial fistula. After this procedure, the embolus created remained in place without being expectorated, and the aspiration pneumonia entered remission, allowing the patient to be discharged from the hospital on the 24th postoperative day. At preset, 14 months after surgery, the patient is in good condition. This technique allows simple and reliable closure of a fistula if a tracheostomy is available. It should be selected as a therapy of first choice when dealing with patients with a postoperative bronchial stump fistula in poor general condition. Patients undergoing right pneumonectomy or middle and lower lobectomy of the right lung should be considered as belonging to a high risk group for bronchial fistula and as requiring preventable measures (e.g., covering the stump with an intercostal muscle flap).

[Perioperative targeting brachytherapy for lung cancer invading the chest wall].

We evaluated the efficacy of perioperative targeting brachytherapy for lung cancer invading the chest wall. Between 1998 and 2003, 7 patients underwent perioperative targeting brachytherapy for lung cancer invading the chest wall. There were 5 male and 2 female patients. The mean age was 63.3 years, with a range of 45 to 77 years. All patients underwent complete resection including the chest wall combined resection. During the operation, plastic afterloading catheters fixed on the Vicryl mesh at interval of 1 cm were placed on the site of chest wall resection. From the third to sixth day after the operation, 15 to 32 Gy of radiation was delivered over 3 or 4 days using a high dose rate remote afterloading system. The area targeted for brachytherapy was determined by a computed tomography (CT) scanner translator with a computer program for radiation planning. The median postoperative hospital stay was 35 days. Local recurrences were observed in 2 patients, but there was no evidence of recurrence in the margin of the resected chest wall. We believe that this short period of treatment and the low side effects enhances the quality of the patients. Prevention of local recurrence was achieved in short term follow-up.

[A case of recurrent gastric cancer that responded dramatically to docetaxel and 5'-DFUR combination chemotherapy].

A 54-year-old man suffering from Borrmann type 4 advanced gastric cancer with pancreatic invasion and paraaortic lymph node metastases underwent a total gastrectomy, which was a radical C operation. From postoperative month 4, he visited our hospital with multiple liver metastases and increased lymph node metastases. After chemotherapy with CDDP and 5-FU, CDDP and UFT was administered on an outpatient basis. The effect of this therapy was PD, therefore, docetaxel and 5'-DFUR combination chemotherapy was performed as second line therapy. After 2 courses of this therapy, the size of liver and lymph node metastases was reduced and the effect of this therapy was PR. The patient has undergone 4 courses of this therapy and is maintaining a clinical PR. It is conceivable that docetaxel and 5'-DFUR combination chemotherapy is useful for patients with advanced and recurrent gastric cancer, even if they had been treated with 5-FU administration as first line therapy.

A novel fluorescence technique for identification of the pulmonary segments by using the photodynamic diagnosis endoscope system: an experimental study in ex vivo porcine lung.

OBJECTIVE: Photodynamic diagnosis is a technique that has been proposed to enhance tumor detection and resection. We modified this technique to identify pulmonary segments and examine the feasibility of this technique in ex vivo porcine lungs. METHODS: The photodynamic diagnosis endoscope system consisted of the D-Light system as the excitation light source and a TRICAM camera as the fluorescence sensing endoscope (Karl Storz GmbH & Co, Tuttlingen, Germany). Vitamin B2 was used as the fluorescence substance. Two kinds of segmentectomy were performed in right porcine lung. After identification of the segmental bronchus, the fluorescent substance was injected transbronchially. The fluorescent segment was observed using the photodynamic diagnosis endoscope system, and the identified intersegmental plane was cut using scissors. The operative data collected were the success rate of accurately identifying the pulmonary segments. The duration and light intensity of fluorescence of the target segment were recorded to provide an objective measurement of success. The same parameters were also measured for the adjacent segment. RESULTS: Overall, 20 segmentectomies were performed, 10 of each kind--cranial segmentectomy and L2 segmentectomy. In all procedures, it was possible to identify the target segment by its yellow-green fluorescence. No unexpected injuries of the major segmental bronchi and vessels nor incorrect recognition of target segments occurred. The success rate of accurately identifying pulmonary segments was 100%. The duration and light intensity of this fluorescence technique was enough to perform pulmonary segmentectomy. CONCLUSIONS: This florescence technique using vitamin B2 and the photodynamic diagnosis endoscope system is useful to identify the target pulmonary segment easily and clearly in ex vivo porcine lung.

Usefulness of fluorine-18 fluorodeoxyglucose-positron emission tomography in management strategy for thymic epithelial tumors.

BACKGROUND: This study investigated the usefulness of fluorine-18 fluorodeoxyglucose-positron emission tomography (FDG-PET) during the treatment of thymic epithelial tumors in combination with Ki-67 evaluation based on surgical cases in our department. METHODS: Between November 2003 and May 2011, 39 patients with thymic epithelial tumor underwent preoperative FDG-PET. The maximum standardized uptake value (SUVmax) of each category within Masaoka stage, World Health Organization classification, tumor diameter, myasthenia gravis, and Ki-67 label index were compared. To examine risk factors for relapse, SUVmax, age, sex, and surgical radicality were investigated in addition to those items. RESULTS: The mean SUVmax was 4.5 (range, 1.2 to 14.6) and was significantly higher for Masaoka stage IV than for I and II (all p < 0.008) and for World Health Organization classified thymic cancer compared with all other types (all p < 0.0001). Mean SUVmax revealed significantly higher values for large tumors than for small tumors (p = 0.02). Mean SUVmax was significantly higher for high Ki-67-positive samples (p = 0.0004), indicating a strong correlation between SUVmax and the Ki-67 label index (ρ = 0.77, p = 0.0001). SUVmax accurately reflected therapeutic efficacy in patients with induction therapy. Univariate analysis revealed Masaoka stages III and IV and pathologically incomplete resection as risk factors for relapse. On multivariate analysis, independent risk factors for relapse comprised only Masaoka stages III and IV. CONCLUSIONS: FDG-PET SUVmax does reflect proliferation and invasiveness of thymic epithelial tumors and can provide an index for diagnosis and treatment, although it is not a risk factor for relapse. FDG-PET is also useful for evaluating induction therapy efficacy and detecting relapse.