A case of delayed bleeding of the chest wall after VATS treated with transcatheter arterial embolization.

We report a case of delayed bleeding after video-assisted thoracic surgery (VATS) that was successfully treated with transcatheter arterial embolization. An 81-year-old woman underwent a pleural biopsy via VATS for pleural dissemination of lung cancer. The postoperative course was good, but 8 days later she was hospitalized for swelling in the right axilla and was admitted to our hospital with a diagnosis of delayed postoperative hemorrhage. Gauze compression was performed, and the patient was discharged without exacerbation of hematoma. However, 4 days later, she was hospitalized for rapidly worsening swelling and pain. Chest computed tomography at the time of rebleeding showed an increase in the hematoma and extravasation in the peripheral right lateral thoracic artery. The patient was immediately treated with emergency angiography, and coil embolization was performed. After this treatment, the patient has done well and there has been no subsequent recurrence of bleeding.

Impact of the first surge of the coronavirus disease pandemic on general thoracic surgery practices in Kanagawa: a questionnaire survey by the Kanagawa General Thoracic Surgical Study Group.

OBJECTIVES: The first surge in severe acute respiratory syndrome coronavirus 2 infection had a significant impact on health care institutions. Understanding how the pandemic affected general thoracic surgery would provide valuable data for establishing a health care protocol for upcoming surges. METHODS: A questionnaire survey on coronavirus disease-related patient statistics and health care was conducted between February 2020 and June 2020 across 14 facilities affiliated with the Kanagawa General Thoracic Surgery Study Group. RESULTS: The average number of newly referred patients from February to June 2020 was 65% of that during the same period in 2019. Six facilities placed restrictions on medical care services, among which four restricted surgeries. At all institutions and those placed on surgical restriction, the total number of surgeries under general anesthesia was 92% and 78%, the total number of primary lung cancers was 94% and 86%, and the total number of surgeries for pneumothorax was 71% and 77% of that in the preceding year, respectively. Infection control and insufficient resources of the medical material were the most influential factors impacting the medical institutions' decision to restrict the services provided. CONCLUSIONS: Restrictions on surgery had a significant impact on the care provided by general thoracic surgery departments. To avoid patient inconvenience, establishing a collaborative system that refers patients to operational medical institutions in case of medical treatment restrictions may be useful.

A prophylaxis study of acute exacerbation of interstitial pneumonia after lung cancer surgery.

INTRODUCTION: Acute exacerbation of interstitial pneumonia (AE-IP) is a lethal complication after lung surgery. We conducted a prospective, multi-institutional phase II trial to assess the efficacy and safety of prophylactic measures. METHOD: Patients with lung cancer with dorsal subpleural fibrotic changes occupying three or more segments of both lower lobes and planned anatomical lung resection were enrolled. Prior to surgery, patients received a 125-mg bolus injection of methylprednisolone and continuous intravenous infusion of sivelestat sodium hydrate (sivelestat) for 2 days. RESULTS: Sixty-nine patients were analysed. Preoperative high-resolution computed tomography (HRCT) showed 37 (53.6%) cases presented with usual interstitial pneumonia (UIP) and possible UIP pattern. There were 60 lobectomies and 9 segmentectomies. Thirty-eight cases were in clinical stage I. No adverse events associated with prophylaxis were observed. There were four cases of AE-IP (5.8%), higher than the expected 2.0%. Three of the four cases showed inconsistencies with the UIP pattern in preoperative HRCT and were pathologically diagnosed as UIP. All patients died of respiratory failure. Overall, 89.9% were diagnosed as idiopathic interstitial pneumonias; UIP was found in 48 patients (69.6%). Severe post-operative complications occurred in 11.6% of the cases. There were 35 deaths, 17 cases of lung cancer and 11 cases related to interstitial pneumonias. The overall survival rate at 3 years was 41.8% of the total and 47.2% of cases with clinical stage I. CONCLUSIONS: Perioperative use of sivelestat and low-dose methylprednisolone in patients with anatomical lung resection was safe but did not prove to be a prophylactic effect for AE-IP.

Retrospective study of efficacy of adjuvant chemotherapy using tegafur-uracil in patients with non-small cell lung cancer with primary tumor size of 4.1-5.0 cm.

BACKGROUND: The staging of patients with a tumor of diameter 4.1-5.0 cm and no lymphatic/distant metastases have been up-graded to stage IIA in the latest 8th edition of the TNM staging system. However, the efficacy of adjuvant tegafur-uracil (UFT) therapy in these patients, which has been recommended in the guideline issued by The Japan Lung Cancer Society, remains unclear. We evaluated the efficacy of adjuvant UFT therapy among a cohort by retrospective analyses of multicentric database. METHODS: In 2005-2007, 130 patients with p-stage IB non-small cell lung cancer (NSCLC) (diagnosed according to the 7th edition of the TNM staging system) and tumor size of ≥3.1 cm underwent anatomic complete resection at nine of our affiliated hospitals. We retrospectively reviewed the clinicopathological characteristics and the outcomes among these patients. RESULTS: Ninety-eight patients had tumor size of 3.1-4.0 cm (T2a group), whereas 32 patients had tumor size >4.0 cm (T2b group). Overall, patients who received adjuvant UFT showed a tendency of better outcomes than patients who did not [hazard ratio (HR) 0.564; 95% confidence interval (CI), 0.257-1.238, P=0.147]. In subgroup analyses, patients who received adjuvant UFT also tended to show better outcomes than those who did not in both T2a group and T2b group (HR 0.504; 95% CI, 0.202-1.255, P=0.132 in T2a group and HR 0.855; 95% CI, 0.181-4.033, P=0.843 in T2b group, respectively). CONCLUSIONS: Our results suggest that adjuvant UFT therapy have the potential to improve postoperative outcomes even in patients with p-stage IIA disease, as classified according to the 8th edition of the TNM staging system.

Isolated unilateral absence of the pulmonary artery.

Isolated unilateral absence of the pulmonary artery (UAPA) is a rare malformation. It is associated with respiratory symptoms, such as dyspnea or hemoptysis. We suggest that surgical treatment should be positively considered in patients with UAPA who are severely symptomatic and who have no other cardiovascular or respiratory comorbidities.

Gender Differences in the Recurrence Timing of Patients Undergoing Resection for Non-Small Cell Lung Cancer

Objective: This study was designed to visually represent postoperative recurrence patterns using event dynamics and to assess sex-based differences in the timing of recurrence for non-small cell lung cancer. Methods: We studied 829 patients (538 men, 291 women) with NSCLC who underwent complete pulmonary resection in 9 hospitals. Event dynamics with the use of life-table methods were evaluated, and only first events (distant metastases or local recurrence) were considered. The effects of sex, histological type, pathological stage, and smoking history were studied. Result: The resulting smoothed hazard rate curves indicated that the recurrence risk pattern definitely correlated with sex, with a sharp peak in the first year in men and a broad peak during the first 2 to 3 years in women. These findings were also confirmed by analyses according to pathological stage, histological type, and smoking history. Conclusion: The peak times of recurrence differed considerably between men and women. The delayed time of peak recurrence in women, associated with a longer disease-free interval within subsets of patients with similar disease stage, histological type, and smoking status, might account for the better survival in women.

Lobe-Specific Lymph Node Dissection as a Standard Procedure in Surgery for Non-Small Cell Lung Cancer: A Propensity Score Matching Study.

INTRODUCTION: Systematic lymph node dissection (SND) is the standard procedure in surgical treatment for NSCLC, but the value of this approach for survival and nodal staging is still uncertain. In this study, we evaluated the potential of lobe-specific lymph node dissection (L-SND) in surgery for NSCLC by using a propensity score matching method. METHODS: From 2005 to 2007, 565 patients with cT1a-2b N0-1 M0 NSCLC underwent lobectomy with lymph node dissection at our 10 affiliated hospitals. Patients were classified into groups that underwent nodal sampling, L-SND, and systematic dissection SND on the basis of pathological data for the number and extent of nodal resection. A total of 77 patients with insufficient pathological data were excluded from the study. RESULTS: Overall, survival did not differ significantly among the groups (p = 0.552), but the rate of detection of pN2 in the SND group (13.1%) was significantly higher than in the nodal sampling (3.3%) and L-SND (9.0%) groups (p = 0.010). However, given the many confounding factors in the patient characteristics in each group, outcomes were reevaluated using a propensity score matching method for the L-SND and SND groups. After matching, the two groups had no significant differences in 5-year overall survival (73.5% for L-SND versus 75.3% for SND, p = 0.977) and pN2 detection (8.2% in both groups, p = 0.779). CONCLUSIONS: These results suggest that lobe-specific lymph node dissection has the potential to be a standard procedure in surgical treatment for NSCLC.

Postoperative follow-up strategy based on recurrence dynamics for non-small-cell lung cancer.

OBJECTIVES: Our study was designed to visually represent recurrence patterns after surgery for non-small-cell lung cancer (NSCLC) with the use of event dynamics and to clarify postoperative follow-up methods based on the times of recurrence. METHODS: A total of 829 patients with NSCLC who underwent complete pulmonary resection from 2005 to 2007 in 9 hospitals affiliated with the Yokohama Consortium of Thoracic Surgeons were studied. Event dynamics, based on the hazard rate, were evaluated. Only first events involving the development of distant metastases, local recurrence or both were considered. The effects of sex, histological type, pathological stage and age were studied. RESULTS: The hazard rate curve displayed an initial surge that peaked about 6-8 months after surgery. The next distinct peak was noted at the end of the second year of follow-up. On non-parametric kernel smoothing, the maximum peak was found 6-8 months after surgery in men. In women, the highest peak occurred 22-24 months after surgery, which was about 16 months later than the peak in men. The peak timing of the hazard curve was not affected by histological type, pathological stage or age in either sex. CONCLUSIONS: Our results suggest that the timing of recurrence after surgery for lung cancer is characterized by a bimodal pattern, and the times with the highest risk of recurrence were suggested to differ between men and women. Postoperative follow-up strategies should be based on currently recommended follow-up programmes, take into account the recurrence patterns of lung cancer, and be modified as required to meet the needs of individual patients.

Combined Video-Assisted Thoracic Surgery and Posterior Spinal Surgery for the Treatment of Dumbbell Tumor of the First Thoracic Nerve Root.

Although several cases of a dumbbell tumor of thoracic nerve roots have been reported, reports on the surgical procedures for a dumbbell tumor of the first thoracic (T1) nerve root are rare. Surgeons should be cautious, especially when performing a surgical procedure for a dumbbell tumor of the T1 nerve root because the tumor is anatomically located adjacent to important organs and because the T1 nerve root composes the lower trunk of the brachial plexus with the eighth cervical nerve root. We present cases with dumbbell tumors of the T1 nerve root that were treated with combined surgical treatment to remove the tumor. We first performed video-assisted thoracic surgery (VATS) to release the organs anteriorly and then performed posterior spinal surgery in the prone position. The combined VATS and posterior spinal surgery may become a standard surgical procedure for the treatment of dumbbell tumors of the T1 nerve root.

Pulmonary Resection for Lung Cancer in Patients With Idiopathic Interstitial Pneumonia.

BACKGROUND: After pulmonary resection, patients with lung cancer who have idiopathic pulmonary fibrosis (IPF) have been reported to have higher pulmonary morbidity and mortality and poorer outcomes than patients without IPF. However, whether morbidity, mortality, and outcomes differ according to the subtype of idiopathic interstitial pneumonia (IIP) remains unclear. METHODS: The clinical records of 678 patients with non-small cell lung cancer who underwent pulmonary resection were reviewed retrospectively. A total of 103 patients had IIP and were classified into an IPF group and a non-IPF group in accordance with the 2011 statement. RESULTS: The IPF group comprised 46 patients, and the non-IPF group comprised 57. The 5-year survival rate was significantly higher in the non-IPF group (53.2%) than in the IPF group (22.1%; p = 0.0093). Cause of death was IIP-related respiratory failure in 26.1% (12 of 46) of the patients in the IPF group as compared with 7.0% (4 of 57) of patients in the non-IPF group (p = 0.008). Multivariate Cox analysis indicated that IPF was a significant predictor of long-term survival (hazard ratio 1.910, 95% confidence interval: 1.102 to 3.313; p = 0.021). CONCLUSIONS: Idiopathic pulmonary fibrosis is independently associated with poorer overall survival in patients with lung cancer who undergo pulmonary resection. The decision whether to perform surgery in patients who have lung cancer with IIP should therefore take into account the subtype of IIP and the poorer outcomes associated with IPF.

Intraoperative core needle biopsy under complete video-assisted thoracic surgery for indeterminate tumor of lung.

BACKGROUND: The accuracy, feasibility, and safety of intraoperative core needle biopsy under complete video-assisted thoracic surgery (VATS) (V-CNB) for indeterminate tumors are examined retrospectively, as well as the possibility of pleural dissemination. METHODS: The diagnostic yield and complications of V-CNB were evaluated for a total of 95 patients who underwent V-CNB for indeterminate tumor during the period of April 2002 through March 2012. Moreover, operation time, number of auto-suture instruments used for resection of the lung, and pleural dissemination were compared between the patients who underwent V-CNB (n = 44) and those who did not (n = 87, non-V-CNB) among stage I primary lung cancer patients, for whom lobectomy was performed under complete VATS during the same period. RESULTS: Of the 95 patients, eighty three had primary lung cancer, four had metastatic lung cancer, and eight had benign tumor. Sensitivity, specificity, and accuracy were 94.3, 87.5, and 93.7%, respectively. There were no complications associated with V-CNB. Among stage I primary lung cancer, for which lobectomy and lymph node dissection were performed, there was no significant difference between the V-CNB group and the non-V-CNB group for tumor size (23.5 and 24.7 mm, p = 0.482), distance between pleura and tumor (3.4 and 5.0 mm, p = 0.202), operation time (228 and 217 min, p = 0.186), and number of auto-suture instruments used for resection of the lung (4.77 and 4.61, p = 0.533). There was no pleural dissemination in the V-CNB group, although there were two cases (2.3%) in the non-V-CNB group. CONCLUSION: V-CNB diagnosed small-sized indeterminate lung tumors accurately during complete VATS operation, without any complications. V-CNB can reduce the use of auto-suture instruments necessary for performing wedge resection on frozen section diagnosis prior to lobectomy without increasing operation time and the risk of pleural dissemination.

Influence of visceral pleural invasion on survival in completely resected non-small-cell lung cancer.

OBJECTIVES: Although the prognostic implications of visceral pleural invasion (VPI) are well established, it remains controversial whether the extent of VPI affects survival in patients with completely resected non-small-cell lung cancer (NSCLC). In addition, the impact of VPI according to nodal status is unclear. We evaluated the influence of the extent of pleural invasion on survival by analysing a multicentre retrospective database of patients who had undergone surgery for NSCLC. METHODS: We retrospectively reviewed the clinicopathological characteristics and outcomes of 639 patients with NSCLC who underwent anatomic complete resection from 2005 to 2007 at nine hospitals affiliated with the Yokohama Consortium of Thoracic Surgeons. RESULTS: The median follow-up was 65.0 months. The extent of pleural invasion was PL0 in 462 patients, PL1 in 135 and PL2 in 42. The 5-year overall survival rate was significantly higher in patients with PL0 tumours (75.9%) than in those with PL1 (63.6%) or PL2 tumours (54.1%). On subgroup analysis according to nodal status, PL0 was associated with a higher survival rate than that of PL1 or PL2 tumours in patients with N0 or N1 metastasis, but not in those with N2 metastasis. There was no difference between PL1 and PL2 in any subgroup. CONCLUSIONS: Our results suggest that the presence of VPI, rather than the extent, has an impact on postoperative survival in patients with NSCLC who have N0 or N1 metastasis. Because very few previous studies have addressed the effects of VPI in patients with N1 disease, further re-evaluation of the prognostic impact of VPI is necessary in this subgroup of patients.

Assessment of spontaneous hemopneumothorax: Indications for surgery.

BACKGROUND: Although spontaneous hemopneumothorax is rare, emergency surgery may be necessary if massive bleeding is present. METHODS: We examined therapeutic strategies and outcomes as well as background factors in 16 patients with spontaneous hemopneumothorax treated at our hospital between April 2002 and August 2013. RESULTS: Emergency surgery was performed in 3 patients, all of whom were hemodynamically unstable. Elective surgery was performed in 7 patients, all of whom showed continuous bleeding from a pleural cavity drain. The surgery consisted of intrapleural hematoma removal, hemostasis, and bullectomy; 3-port thoracoscopy was used in all of the surgical cases. Six patients, none of whom showed continuous bleeding, recovered with conservative therapy. Comparing the conservative therapy and surgery groups revealed the mean continuous bleeding volume and total blood loss to be significantly greater in the latter, but no significant difference was noted between the two groups in terms of the initial bleeding volume following tube thoracostomy. None of the cases required a blood transfusion. CONCLUSIONS: Spontaneous hemopneumothorax is not necessarily an indication for surgery, and even when the initial volume of blood drained through the chest tube is large, some patients can still be treated conservatively with careful monitoring of vital signs and continuous bleeding volumes. However, it is important not to miss the optimal timing of surgery in order to avoid administering unnecessary blood transfusions to young patients.

Renal infarction in a patient with pulmonary vein thrombosis after left upper lobectomy.

A 43-year-old male experienced renal infarction (RI) following left upper lobectomy for lung cancer. The patient complained of acute-onset severe left flank pain on the 14th postoperative day. A contrast-enhanced computed tomography (CT) of the abdomen revealed RI by a large wedge-shaped defect in the left kidney. A chest CT scan located the thrombus in the stump (a blind-ended vessel) of the left superior pulmonary vein. Therefore, thromboembolic RI caused by pulmonary vein thrombosis was suspected. Anticoagulation therapy was initiated with heparin and warfarin to treat RI and to prevent further embolic episodes. Two months later, pulmonary vein thrombosis had resolved without the appearance of additional peripheral infarction. This case emphasizes the need to consider thrombus in the stump of the pulmonary vein as a cause of RI.

Pulmonary arterial sampling was useful for localizing ectopic ACTH production in a patient with bronchial carcinoid causing Cushing syndrome.

OBJECTIVE: We report a 44-year old man with ectopic adrenocorticotropic hormone (ACTH) syndrome caused by bronchial carcinoid that developed Cushing syndrome. METHODS: We performed several imaging studies, including chest and abdominal CT, for exploration of nodules and selective pulmonary arterial sampling for localizing a source of ectopic ACTH production. RESULTS: The patient was diagnosed as Cushing syndrome due to ectopic production of ACTH without identification of its source(s). After 2 years' follow-up with repeated CT scans every 6-12 months and treatment with metyrapone, chest CT revealed two small nodules respectively in the segment (S) 4 and 10 of the right lung. We performed selective pulmonary arterial sampling from branches of the right pulmonary artery to obtain blood from the nodules in a reverse flow fashion: wedged sampling from the basal branch (A8, 9 and 10) revealed significant elevation of ACTH, whereas sampling from the lateral branch (A4) did not, indicating that the S10 nodule produced ACTH ectopically. The video-assisted thoracoscopic surgery removing the right inferior lobe normalized plasma ACTH, serum cortisol and 24-hour urinary free cortisol. The S10 nodule was histologically diagnosed as atypical bronchial carcinoid containing immunoreactive ACTH. CONCLUSIONS: Selective pulmonary arterial sampling was useful for localizing the lesion of ectopic ACTH production and helped make the decision for its surgical removal. This procedure should be considered once lung nodules suspicious for ectopic ACTH production are identified in patients with EAS.

Intrapleural analgesia using ropivacaine for postoperative pain relief after minimally invasive thoracoscopic surgery.

PURPOSE: to evaluate the efficacy and safety of intrapleural analgesia (IPA) using ropivacaine after thoracoscopic surgery, compared with thoracic epidural analgesia (TEA) using ropivacaine. METHODS: forty patients undergoing thoracoscopic bullectomy for spontaneous pneumothorax were randomly assigned to one of two groups. IPA group (n = 20) received intermittent bolus injection of 0.375% ropivacaine into intrapleural space two times; at the end of operation and one more time as the pain increased. TEA group (n = 20) received continuous epidural analgesia with 0.375% ropivacaine. Transrectal diclofenac was administered as an additional analgesic. Pain was assessed on the basis of additional analgesics requirements and by using a visual analog scale (VAS). RESULTS: the time courses of VAS scores along the postoperative time course were not significantly different (p = 0.175). Consumption of transrectal diclofenac was significantly smaller in IPA group (p = 0.025). No major complications appeared in both groups, and incidence of adverse symptoms was not different. CONCLUSIONS: in IPA group, pain was managed with less consumption of additional analgesics. IPA could be one of the good choices after thoracoscopic surgery for its efficacy, safety, and benefit of easy placement of the catheter.

Intralobar pulmonary sequestration supplied by an anomalous aneurysmal artery.

Pulmonary sequestration is a relatively rare condition in which a systemic artery supplies blood to an abnormal lung tissue. Pulmonary sequestration with an aneurysmal systemic artery is extremely rare. We describe the case of a 52-year-old man with intralobar pulmonary sequestration supplied by an aneurysmal systemic artery. Because the nomenclature of pulmonary sequestration is still not clear, we propose that type 1 intralobar pulmonary sequestration be called "systemic arterial supply to the normal lung," as named by many professionals, and for this to be distinguished from pulmonary sequestration.

Video-assisted thoracoscopic surgery for pulmonary arteriovenous malformations: report of five cases.

We experienced five cases of pulmonary arteriovenous malformations (PAVMs) that were successfully treated by video-assisted thoracoscopic surgery. Four malformations were treated by local wedge resection and one was treated by segmentectomy. Criteria for patient selection for surgery were peripheral and solitary lesions, with feeding arteries larger than 3 mm. Postoperative hospital stays were 1-7 days (median, 2 days). All patients showed unchanged or increased values of PaO(2) in arterial blood after operation. No major postoperative complication occurred in any patient, but a persistent air leak for 5 days occurred in the one patient who was treated by segmentectomy. No growth of accessory vessels or untreated malformations were seen in any patient throughout the follow-up period of 14-54 months. Thoracoscopic surgical resection for well-selected patients provides a high certainty of eliminating fistulae and was associated with lower morbidity, lower mortality, and shorter hospital stays.