[Assessment of Fat-free Diet for Postoperative Chylothorax].

BACKGROUND: Chylothorax after lung cancer surgery is relatively rare but must be considered as a complication of thoracic surgery. METHOD: Between January 2012 and June 2017, 818 patients underwent lung cancer surgery at our hospital. Among them, 14 (1.7%) patients with chylothorax were retrospectively reviewed. Three patients were treated with oral intake cessation except water and total parental nutrition( TPN)[TPN group], 11 patients were treated with a fat-free diet( fat-free diet group). RESULTS: The drainage period was similar in both group [group TPN;13 (12~14) days and group fat-free diet;15.7 (6~42) days]. In the TPN group, 3 patients underwent pleurodesis and no patient needed surgical intervention. In the fat-free diet group, 5 patients improved only with diet management. Pleurodesis was necessary in 5 of which 3 underwent surgical intervention. CONCLUSIONS: A fat-free diet is useful in treating chylothorax after lung cancer surgery.

Size-capacity mismatch in the lung: a novel predictor for complications after lung cancer surgery.

BACKGROUND: The aim of the present study was to make a combined pulmonary functional and anatomical assessment using spirometry and computed tomography (CT) to clarify the best predictor for cardiopulmonary complications after thoracoscopic major lung resection for cancer. METHODS: We retrospectively reviewed our prospective database of 304 patients undergoing thoracoscopic major lung resection for cancer. The total lung volume (TLV) was measured preoperatively using deep-inspiratory CT by summing the voxels representing -600 to -1024 Hounsfield units. Forced vital capacity (FVC) was measured by spirometry. FVC/TLV was used to diagnose a lung size-function mismatch. We compared among FVC/TLV, conventional spirometric parameters, and the risk of postoperative cardiopulmonary complications. RESULTS: Postoperative cardiopulmonary complications developed in 25 of 304 patients (8.2%). There were no cases of operative mortality. A stepwise logistic regression analysis revealed that a history of smoking and low FVC/TLV were independent risk factors for postoperative cardiopulmonary complications in various preoperative measurements. According to a receiver-operating characteristic analysis, FVC/TLV was the only variable that was statistically useful for predicting complications (area under the receiver-operating characteristic curve > 0.7). CONCLUSIONS: Lung size-function mismatch was identified as the best predictor for cardiopulmonary complications after major lung resection for cancer among various spirometry- and CT-derived parameters. The usefulness of this parameter in screening for patients who are at risk of complications should be validated by a multicenter, large-scale study because it can be obtained through routine preoperative work.

Pulmonary emphysema and tumor microenvironment in primary lung cancer.

BACKGROUND: To clarify the relationship between the presence of pulmonary emphysema and tumor microenvironment and their significance for the clinicopathologic aggressiveness of non-small cell lung cancer. METHODS: The subjects included 48 patients with completely resected and pathologically confirmed stage I non-small cell lung cancer. Quantitative computed tomography was used to diagnose pulmonary emphysema, and immunohistochemical staining was performed to evaluate the matrix metalloproteinase (MMP) expression status in the intratumoral stromal cells as well as the microvessel density (MVD). RESULTS: Positive MMP-9 staining in the intratumoral stromal cells was confirmed in 17 (35%) of the 48 tumors. These 17 tumors were associated with a high MVD, frequent lymphovascular invasion, a high proliferative activity, and high postoperative recurrence rate (all, P < 0.05). The majority of the tumors (13 of 17) arose in patients with pulmonary emphysema (P = 0.02). Lung cancers arising from pulmonary emphysema were also associated with a high MVD, proliferative activity, and postoperative recurrence rate (all, P < 0.05). CONCLUSIONS: The MMP-9 expression in intratumoral stromal cells is associated with the clinicopathologic aggressiveness of lung cancer and is predominantly identified in tumors arising in emphysematous lungs. Further studies regarding the biological links between the intratumoral and extratumoral microenvironment will help to explain why lung cancers originating in emphysematous lung tissues are associated with a poor prognosis.

Enhanced tumor growth in the remaining lung after major lung resection.

BACKGROUND: Pneumonectomy induces active growth of the remaining lung in order to compensate for lost lung tissue. We hypothesized that tumor progression is enhanced in the activated local environment. METHODS: We examined the effects of mechanical strain on the activation of lung growth and tumor progression in mice. The mechanical strain imposed on the right lung after left pneumonectomy was neutralized by filling the empty space that remained after pneumonectomy with a polypropylene prosthesis. RESULTS: The neutralization of the strain prevented active lung growth. According to an angiogenesis array, stronger monocyte chemoattractant protein-1 (MCP-1) expression was found in the strain-induced growing lung. The neutralization of the strain attenuated the release of MCP-1 from the lung cells. The intravenous injection of Lewis lung cancer cells resulted in the enhanced development of metastatic foci in the strain-induced growing lung, but the enhanced development was canceled by the neutralization of the strain. An immunohistochemical analysis revealed the prominent accumulation of tumor-associated macrophages in tumors arising in the strain-induced growing lung, and that there was a relationship between the accumulation and the MCP-1 expression status. CONCLUSIONS: Our results suggested that mechanical lung strain, induced by pulmonary resection, triggers active lung growth, thereby creating a tumor-friendly environment. The modification of that environment, as well as the minimizing of surgical stress, may be a meaningful strategy to improve the therapeutic outcome after lung cancer surgery.

The Outcomes of a Limited Resection for Non-Small Cell Lung Cancer Based on Differences in Pathology.

OBJECTIVE: A precise preoperative diagnosis of in situ or minimally invasive carcinoma may identify patients who can be treated by limited resection. Although some clinical trials of limited resection for lung cancer have started, it will take a long time before the results will be published. We have already reported a large-scale study of limited resection. We herein report the data for a subclass analysis according to differences in pathology. METHODS: Data from multiple institutions were collected on 1710 patients who had undergone limited resection (segmentectomy or wedge resection) for cT1N0M0 non-small cell carcinoma. The disease-free survival (DFS) and recurrence-free proportion (RFP) were analyzed. Small cell carcinomas and carcinoid tumors were excluded from this analysis. Adenocarcinomas were sub-classified into four groups using two factors, the ratio of consolidation to the tumor diameter (C/T) and the tumor diameter alone. RESULTS: The median patient age was 64 (20-75) years old. The mean maximal diameter of the tumors was 1.5 ± 0.5 cm. The DFS and RFP at 5 years based on the pathology were 92.2 and 94.7 % in adenocarcinoma (n = 1575), 76.3 and 82.4 % in squamous cell carcinoma (SqCC) (n = 100), and 73.6 and 75.9 % in patients with other tumors (n = 35). The prognosis of adenocarcinoma in both groups A (C/T ≤0.25 and tumor diameter ≤2.0 cm) and B (C/T ≤0.25 and tumor diameter >2.0 cm) was good. In SqCC, only segmentectomy was a favorable prognostic factor. In the groups with other pathologies, large cell carcinomas were worse in prognosis (the both DFS and RFP: 46.3 %). CONCLUSION: Knowing the pathological diagnosis is important to determine the indications for limited resection. Measurement of the tumor diameter and C/T was useful to determine the indications for limited resection for adenocarcinoma. Limited resection for adenocarcinomas is similar with a larger resection, while the technique should be performed with caution in squamous cell carcinoma and other pathologies.

Prediction of postoperative dyspnea and chronic respiratory failure.

BACKGROUND: Even among patients considered to be functionally eligible for major lung resection, some experience postoperative dyspnea. Based on our previous study with quantitative computed tomography (CT), we hypothesized that postoperative dyspnea is associated with the collapse of the remaining lung, and thus, prediction of the postoperative lung volume may contribute to risk assessment for postoperative dyspnea. METHODS: We measured the emphysematous lung volume and functional lung volume (FLV) separately on whole lung CT using an image analysis software in 290 patients undergoing major lung resection for cancer between January 2006 and December 2012. The postoperative FLV was predicted by a stepwise multiple regression analysis. RESULTS: Fourteen patients complained of postoperative dyspnea (complicated group), five of them presented with chronic respiratory failure. The postoperatively measured FLV was significantly lower in the complicated group than in the control group (P < 0.01). The postoperative FLV could be calculated using preoperative variables, including the forced vital capacity, number of resected segments, FLV, and emphysematous lung volume. The predicted postoperative FLV was significantly lower in the complicated group than in the control group (P < 0.01, area under the curve = 0.78; sensitivity 86%; specificity 73%). The predicted postoperative FLV was also useful in distinguishing complicated patients from matched-control patients who had similar preoperative pulmonary function (P = 0.02). CONCLUSIONS: Postoperative dyspnea is likely accompanied by a collapse of the remaining lung. Quantitative assessment of the lung morphology on preoperative CT is useful to screen for patients at risk of postoperative dyspnea.

Assessment of volume reduction effect after lung lobectomy for cancer.

BACKGROUND: Lung lobectomy results in an unexpected improvement of the remaining lung function in some patients with moderate-to-severe emphysema. Because the lung function is the main limiting factor for therapeutic decision making in patients with lung cancer, it may be advantageous to identify patients who may benefit from the volume reduction effect, particularly those with a poor functional reserve. METHODS: We measured the regional distribution of the emphysematous lung and normal lung using quantitative computed tomography in 84 patients undergoing lung lobectomy for cancer between January 2010 and December 2012. The volume reduction effect was diagnosed using a combination of radiologic and spirometric parameters. RESULTS: Eight patients (10%) were favorably affected by the volume reduction effect. The forced expiratory volume in one second increased postoperatively in these eight patients, whereas the forced vital capacity was unchanged, thus resulting in an improvement of the airflow obstruction postoperatively. This improvement was not due to a compensatory expansion of the remaining lung but was associated with a relative decrease in the forced end-expiratory lung volume. According to a multivariate analysis, airflow obstruction and the forced end-expiratory lung volume were independent predictors of the volume reduction effect. CONCLUSIONS: A combined assessment using spirometry and quantitative computed tomography helped to characterize the respiratory dynamics underlying the volume reduction effect, thus leading to the identification of novel predictors of a volume reduction effect after lobectomy for cancer. Verification of our results by a large-scale prospective study may help to extend the indications for lobectomy in patients with oncologically resectable lung cancer who have a marginal pulmonary function.

Surgery for undiagnosed ground glass pulmonary nodules: decision making using serial computed tomography.

BACKGROUND: Although long-term observation of ground glass nodules on computed tomography facilitates the ability to distinguish malignant lesions from benign lesions, the resulting treatment delay can increase the rate of cancer recurrence. We reviewed our surgical cases of pathologically undiagnosed lung nodules possessing ground glass to clarify the clinical impact of selecting surgical candidates based on serial computed tomography, not preoperative biopsy results. METHODS: A consecutive series of 100 patients with clinically suspected lung cancer possessing ground glass among our prospective database of 262 surgical cases of suspected lung cancer were retrospectively reviewed. RESULTS: Surgical indication was determined based on the interval change in the outer diameter or internal attenuation of the lesions in 53 patients (increasing lesions), while that was determined based on the specific marginal or internal features of the lesions in 47 patients (non-increasing lesions). The length of preoperative follow-up was significantly longer in the patients with increasing lesions than in the patients with non-increasing lesions (27 vs. 3 months, P < 0.001). The final pathological diagnoses consisted of 97 adenocarcinomas and three non-malignant lesions. All increasing lesions were adenocarcinomas. Surgical biopsy contributed in avoiding futile lobectomy in patients with non-malignant lesions, while that caused false-negative result in one patient with an increasing lesion. Postoperative recurrence occurred in two patients. CONCLUSIONS: In a surgical series, serial computed tomography-diagnosed ground glass lesions are highly suggestive of adenocarcinoma, especially increasing lesions. Despite spending a long-term preoperative follow-up period without a pathological diagnosis, the surgical outcome is satisfactory. Surgical biopsy for increasing lesions is generally futile.

[Structural evaluation of the remaining lung after partial pulmonary resection by the stapling device].

The stapling device can excise the lung parenchyma without causing bleeding or air leak, while it causes shrinkage of the remaining lung. So, the stapling is thought to make the local pleura fragile due to excessive tension around the stump. However, little has been proven regarding these issues by experimental study. We evaluated morphologies in the remaining lung of pigs just after and 2 months after partial lung resection with stapler. As a result, the remaining lungs recovered their size to fill the thoracic cage in 2 months. Interestingly, the visceral pleura of the remaining lungs extended almost equally regardless of the distance from the stump, without causing bullous degradation. The alveoli proximal to the stump had higher alveolar density, shorter linear intercept, thicker alveolar wall than the ones distal to the stump just after resection, however, these differences were not found 2 months postoperatively. In summary, although lung excision by stapler results in shrinkage of the remaining lung temporally, it was found that the remaining lung recovered its size without adverse morphological change.

Intraoperative chylous leak diagnosis by preoperative oral administration of ice cream: a case report.

Background: Chylothorax is an intractable postoperative complication of thoracic surgery. Preventing postoperative chylothorax following initial surgery is important. Most cases of chylothorax are caused by injury to the thoracic duct or its branches. However, rare cases might result from injury to the lymphatic vessels in the chest wall. Preoperative oral administration of dairy products is widely recognized as a useful method for identifying the sites of chylous leaks during surgery for chylothoraces. Herein, we report a surgical case of a middle mediastinal tumor, wherein a chylous leak in the chest wall was intraoperatively detected due to scheduled preoperative oral administration of dairy products before the initial surgery, resulting in prevented postoperative chylothorax. Case Description: A 68-year-old male patient underwent computed tomography, revealing a cystic lesion in the middle mediastinum that was suspected to be a thoracic duct cyst or intrathoracic lymphangioma. A cup of ice cream was orally ingested 1 hour before entering the operating room to intraoperatively detect chylous leakage in case of injury to the lymphatic vessels, including the thoracic duct. The mediastinal tumor was removed via thoracoscopic surgery and histologically diagnosed as a schwannoma with cystic degeneration. Intraoperatively, chylous leakage was observed due to injury to a lymphatic vessel in the chest wall, which was repaired by clipping. The postoperative course was uneventful. Conclusions: Preoperative oral administration of dairy products was verified to be a useful method not only at the time of re-operation for postoperative chylothoraces but also at the time of initial surgery in cases where chylothorax is of high concern. Although relatively infrequent, chylothorax due to lymphatic vessel injury in the chest wall should be kept in mind.

Right middle lobe transposition after upper lobectomy: influence on postoperative pulmonary function.

BACKGROUND: The aim of the present study was to determine the prevalence of anatomical transposition of the remaining right middle lobe after right upper lobectomy and the effect of this transposition on postoperative global pulmonary function. METHODS: We correlated the postoperative pulmonary anatomical change with the functional change in patients undergoing right upper lobectomy for lung cancer. To estimate the regional pulmonary function, we measured the regional volume of the lung using normal lung attenuation values (- 600 to - 910 Hounsfield units), known as the functional lung volume, by computed tomography. The position of the middle lobe was objectively evaluated using volume-rendering three-dimensional computed tomography lung models. Intraoperatively, middle lobes were not fixed with the lower lobes. RESULTS: Postoperatively, the middle lobe remained attached to the anterobasal segment in 24 patients, whereas it migrated cranially in the remaining 26 patients. The functional volume of the middle lobe changed by various degrees postoperatively (range: 9 to 171% of preoperative values, mean: 96 ± 34%), and this change was significantly associated with the global pulmonary function (R = 0.5, p = 0.01). However, there were no significant differences between patients with and without middle lobe migration with respect to the postoperative functional volume of the middle lobe, the postoperative functional volume of the total lung, and global pulmonary function. CONCLUSION: Right middle lobe transposition after upper lobectomy is not associated with the deterioration of pulmonary function, but unexpected deflation of the right middle lobe is. Strategies for preventing middle lobe deflation should be explored in the clinical setting.

Thoracoscopic coaxial cutting needle biopsy for clinically suspected lung cancer: technical details, diagnostic accuracy, and probable complications.

BACKGROUND: Little has been described regarding the technical details, diagnostic accuracy, and probable complications of thoracoscopic cutting needle biopsy, which seems to be preferable to transthoracic needle biopsy for patients scheduled to undergo surgery for suspected lung cancer. METHODS: This study was a retrospective analysis of a prospective database of patients who underwent surgical biopsy for suspected lung cancer (n = 176). Sixty-two patients underwent thoracoscopic cutting needle biopsy, which was performed via thoracoport using a 16 gauge coaxial cutting needle; the remaining 114 patients underwent excisional biopsy, followed by curative intent surgery. RESULTS: The sensitivity and specificity of diagnosing lung cancer by thoracoscopic needle biopsy were 57/59 (96.6%) and 1/3 (33.3%), respectively. One false-negative result and one undiagnostic result occurred, but both lesions were correctly re-diagnosed by backup excisional biopsy during the same operation. When analysis was restricted to patients with lung lesions predominantly presenting with ground glass opacity, the sensitivity and specificity were 13/14 (92.9%) and 1/1 (100%), respectively. The sensitivity, specificity, and accuracy of diagnosing lung cancer by surgical biopsy in all patients were 164/165 (99.4%), 9/11 (81.8%), and 173/176 (98.3%), respectively. Pleural recurrence was identified in one patient after thoracoscopic needle biopsy whose pleural lavage cytology, performed before biopsy, was negative. CONCLUSIONS: Thoracoscopic cutting needle biopsy can be effectively applied to patients with an indeterminate lung tumor, especially those patients with lesions possessing ground glass opacity. However, further evaluation is necessary to confirm the risk of pleural dissemination induced by this procedure.

Verification of early removal of the chest tube after absorbable mesh-based pneumostasis subsequent to video-assisted major lung resection for cancer.

BACKGROUND: We previously reported that the combined use of absorbable mesh and fibrin glue is superior to the use of fibrin glue alone to stop intraoperative air leaks. However, concern remains about whether mesh-based pneumostasis can induce the recurrence of air leaks after chest tube removal. METHODS: We reviewed our prospective database of selected patients (n = 206) who underwent video-assisted major lung resection for cancer. Exclusion criteria included simultaneous combined resection, induction radiotherapy, entire intrathoracic adhesion, or a history of prior ipsilateral thoracotomy. We sealed any intraoperative air leaks with absorbable mesh and fibrin glue and then carried out prophylactic chest-tube drainage for 1 day. RESULTS: Intraoperative air leaks were detected in 133 (65%) patients. Overall, air leaks were not detected postoperatively in 186 (91%) patients, allowing chest tube removal on the day after the operation. The mean length of time for chest tube drainage was 1.2 days. A prolonged air leak (>7 days) was observed in one (0.5%) patient, and this leak resolved by itself. After chest tube removal, an air leak recurred in six (2.9%) patients during the 30 day follow-up period, necessitating chest tube reinsertion. Although the recurrence was observed more frequently after segmentectomy than after lobectomy (p = 0.04), the recurrence was not observed more frequently in patients who had an intraoperative air leak than in patients who did not (p = 0.3). CONCLUSION: Early removal of the chest tube after pneumostasis with absorbable mesh is verified in selected patients who underwent video-assisted major lung resection for cancer. However, further attempts should be made to prevent air leaks after anatomical segmentectomy.

[Three-port complete video-assisted thoracic surgery for mediastinal diseases].

Three port complete video-assisted thoracic surgery( 3-port cVATS) is our standard approach for primary lung cancers. The video image for the assistant is inverted, and the access ports are inserted at the best location decided by preoperative simulation surgery. Using this approach, the forceps of the operator are never interfered by the forceps of the assistant. We present 3-port cVATS applied to the mediastinal diseases difficult to be done via hybrid VATS mainly under direct vision. 1)The superior mediastinal tumor extending above the thoracic inlet. 2)The posterior mediastinal tumor extending to the other side behind the left atrium. 3)Surgical removal of non-traumatic mediastinal hematoma without capsule resection. 4)Simple thymectomy for the small anterior mediastinal tumor. We could carry through every operation via 3-port cVATS from one side of the chest. This is our minute report of 3-port cVATS applied to the mediastinal diseases.

Clinicopathological feature of a resected large mixed squamous cell and glandular papilloma: A case report.

INTRODUCTION AND IMPORTANCE: Solitary endotracheal papilloma is a rare benign lung tumor. It is classified into the following three histological subtypes: squamous cell papilloma (SP), glandular papilloma (GP), and mixed squamous cell and glandular papilloma (MSGP). MSGP is the rarest among them. Herein, we describe a case of a large MSGP. CASE PRESENTATION: A 59-year-old woman underwent computed tomography for the examination of cough, and an 8.2-cm-sized lung mass was noted in the left lingual segment. Bronchoscopy revealed that the left B5 lumen was completely occluded by a tumor. Transbronchial lung biopsy suggested GP; thereafter, a left upper lobectomy was performed. Macroscopic findings showed that the dilated B5 lumen was filled with cauliflower-like tumors. Histopathological findings showed that the majority of the tumors had pseudostratified columnar epithelium, while some had stratified squamous epithelium. The patient was diagnosed with MSGP. Although koilocytosis-like changes, such as perinuclear halo and nuclear deformation, were observed in some portions of the squamous epithelium, immunohistochemical staining was negative for human papillomavirus (HPV). CLINICAL DISCUSSION: HPV infection is reportedly associated with SP but not with GP and MSGP. Therefore, MSGP is considered to be caused by squamous metaplasia of a part of GP; this hypothesis is consistent with the present case. However, only one case of MSGP with HPV infection was recently reported, and the etiology and histological features of MSGP remain unclear. CONCLUSION: There are few reported cases of MSGP, and further case reports are needed to clarify its pathogenesis.

Mesh-based pneumostasis contributes to preserving gas exchange capacity and promoting rehabilitation after lung resection.

BACKGROUND: We recently introduced a technique of sutureless, mesh-based pneumostasis for preventing alveolar air leaks after lung resection. To verify the clinical usefulness of this technique, we examined if it can contribute to preserving gas exchange capacity and promoting postoperative rehabilitation. METHODS: We prospectively collected perioperative data, including arterial oxygen saturation on postoperative day (POD) 1 and the length of postoperative rehabilitation in 100 patients undergoing elective, video-assisted major lung resection for cancer. Before April, 2006, intraoperative air leaks were sealed with the conventional method (control group), and thereafter, with bioabsorbable mesh and glue, without suturing, (treated group). To reduce the bias in comparison of the nonrandomized control group, we paired the treated group with the control group using the nearest available matching method on the estimated propensity score. RESULTS: Thirty-five patients in the control group were matched to 35 patients in the treated group based on the estimated propensity score. The length of both chest tube drainage and postoperative rehabilitation were significantly shorter in the treated group than in the control group (median, 1 versus 1 d, P = 0.03; 2 versus 3 d, P = 0.01, respectively). The arterial oxygen saturation on POD 1 was significantly higher in the treated group than in the control group (median, 94.0 versus 92.5 %, P = 0.03). CONCLUSION: Mesh-based pneumostasis during video-assisted major lung resection enabled early chest tube removal, preserved postoperative oxygenation capacity, and promoted postoperative rehabilitation, which may facilitate fast-track surgery for patients undergoing video-assisted major lung resection for cancer.

Tegafur-uracil-induced pericardial effusion during adjuvant chemotherapy for resected lung adenocarcinoma: A case report.

In Japan, oral administration of tegafur-uracil is recommended as postoperative adjuvant chemotherapy for patients diagnosed with primary lung adenocarcinomas of >2 cm size and staged as IA, IB, and IIA. Reports on chemotherapy-induced pericardial effusion are rare. Herein, we report a rare case of tegafur-uracil-induced pericardial effusion during postoperative adjuvant chemotherapy for primary lung cancer. A 60-year-old man underwent left lower lobectomy and mediastinal lymph node dissection for left lower lung adenocarcinoma. Lung cancer was staged as IB, and tegafur-uracil was administered as postoperative adjuvant chemotherapy from 1 month after the surgery. A computed tomography (CT) scan revealed a pericardial effusion 5 months after the surgery. A malignant pericardial effusion was suspected, and tegafur-uracil was discontinued. Pericardiocentesis could not be performed owing to a small amount of pericardial effusion. An 18 F-fluorodeoxyglucose (FDG) positron emission tomography/CT scan revealed no abnormal FDG uptake. During a short follow-up period after discontinuation of tegafur-uracil, a CT scan revealed a decrease in pericardial effusion, suggesting that the pericardial effusion was induced by tegafur-uracil. Follow-up of pericardial effusion is required while administering tegafur-uracil. In cases of pericardial effusion without symptoms and no suspicious metastatic lesions in other organs, we should be concerned about tegafur-uracil-induced pericardial effusion.

Suspected fibrin glue-induced acute eosinophilic pneumonia after pulmonary resection: A case report.

Air leakage is a common complication after pulmonary resection, and fibrin glue is used as a sealant to reduce postoperative air leakage. It is generally recognized that fibrin glue-induced adverse events are rare. Herein, we report a rare case of suspected fibrin glue-induced acute eosinophilic pneumonia (AEP). A 72-year-old man underwent right lower lobectomy and mediastinal lymph node dissection for right lower lung cancer. Fibrin glue was sprayed to cover the interlobar surface of the right upper and middle lobes. On postoperative day 10, computed tomography (CT) revealed ground-glass shadows around the interlobar surface of the remaining lobes of the right lung. Although antibacterial drugs were administered for suspected bacterial pneumonia, fever spike, shortness of breath, and exacerbation of ground-glass shadows were observed. Peripheral blood and bronchoalveolar lavage fluid showed increased eosinophil count, supporting the diagnosis of AEP. Pneumonia resolved after prednisolone administration. At one-year follow-up, CT showed no AEP recurrence. Drug-induced pneumonia usually develops in the bilateral lung and rarely in the hemilateral lung. In this case, pneumonia was localized around the site covered with fibrin glue, suggesting fibrin glue-induced AEP. Thus, the use of fibrin glue should be carefully considered during pulmonary resection.

Intraoperative bronchial blood flow evaluation using indocyanine green fluorescence for bronchoplasty: A case report.

INTRODUCTION AND IMPORTANCE: Blood flow evaluation of bronchial arteries using indocyanine green fluorescence (ICG-FL) is rarely reported during pulmonary resection. We present the case of a patient with bronchiectasis and a history of bronchial artery embolization (BAE) for hemoptysis. Bronchial artery blood flow was evaluated using ICG-FL during lobectomy with bronchoplasty. CASE PRESENTATION: A 63-year-old woman presented with right middle lobe bronchiectasis (due to nontuberculous mycobacteriosis) and repeated hemoptysis, which had previously been corrected each time with hemostasis by BAE. Bronchoscopy revealed a swollen blood vessel proximal to the right middle lobe bronchus that was suspected of being the origin of bleeding. Right middle lobectomy with bronchoplasty was performed to prevent hemoptysis. ICG-FL was used to detect the patency of the right bronchial arteries, and the arteries surrounding the right middle lobe bronchus were ligated. The proximal side of the right middle lobe bronchus was cut in a deep wedge shape, and the bronchus was anastomosed. ICG-FL revealed that the blood supply was maintained at the bronchial anastomosis. No bronchial anastomotic leakage was observed after the surgery. CLINICAL DISCUSSION: The key to successful bronchoplasty is the maintenance of blood flow. Bronchial artery blood flow theoretically decreases after BAE. In this case, ICG-FL was able to detect bronchial artery patency before cutting the bronchus as well as the maintenance of blood flow at the bronchial anastomosis after bronchoplasty. CONCLUSION: Intraoperative blood flow evaluation of the bronchus using ICG-FL may reduce the risk of bronchial anastomotic leakage caused by ischemia after bronchoplasty.

Treatment strategy for primary lung cancer in a lung highly compressed by giant emphysematous bullae: A case report.

Lung cancer sometimes develops on the wall of a giant emphysematous bulla (GEB). Herein, we describe a rare case in which lung cancer developed in lung tissue compressed by GEBs. A 62-year-old man underwent a computed tomography (CT) scan that revealed two right GEBs. A tumor was suspected in the highly compressed right upper lobe. Since the right bronchus was significantly shifted toward the mediastinum, it was difficult to perform a bronchoscopy. We inserted thoracic drains into the GEBs, and a subsequent CT scan revealed re-expansion of the remaining right lung and a 3.3 cm tumor in the right upper lobe. The shift of the right bronchus was improved, and bronchoscopy was performed. The tumor was diagnosed as non-small cell lung cancer (NSCLC). Additionally, the GEBs were found to have originated from the right lower lobe. We performed a right upper lobectomy, mediastinal lymph node dissection, and bullectomy of the GEBs via video-assisted thoracoscopic surgery. In preoperative evaluation of a GEB, assessing re-expansion and lung lesions of the remaining lung is important, and intracavity drainage of a GEB may be useful. KEY POINTS: Significant findings of the study Cancer that develops in lung tissue highly compressed by a giant emphysematous bulla is difficult to diagnose. In the preoperative evaluation of a giant emphysematous bulla, assessing re-expansion and lung lesions of the remaining lung is important. What this study adds After performing intracavity drainage of a giant emphysematous bulla, the remaining lung re-expands, and the bronchial shift improves; subsequently, bronchoscopy makes it possible to diagnose lung cancer in the remaining lung.