Surgery for non-small cell lung cancer in patients with a history of cardiovascular surgery.

PURPOSE: To clarify if previous cardiovascular surgery (CVS) affects the postoperative outcome of surgery for non-small cell lung cancer (NSCLC). METHODS: We reviewed, retrospectively, the medical records of 36 patients with a history of CVS, who underwent lung cancer surgery at a single institution (study group; SG) and compared their characteristics and postoperative outcomes with those of patients without a history of CVS history (control group; CG), and also with those of patients with coexisting cardiovascular diseases in the CG (specified control group; SCG). Finally, we used a thoracic revised cardiac risk index (ThRCRI) to evaluate the risk of perioperative cardiovascular events. RESULTS: There was a significant difference in the ThRCRI classifications between the SG and the SCG (p < 0.0001). There were no significant differences in the incidence of intraoperative and postoperative complications between the SG and CG, or between the SG and SCG. The 5-year survival rates of the SG, CG, and SCG were 69.3, 73.9, and 65.4 % in all stages, and 83.5, 82.2, and 70.4 % in stage I, respectively. CONCLUSIONS: Previous CVS did not increase the number of perioperative cardiovascular events in this study and had no significant influence on the prognosis of patients undergoing resection of NSCLC.

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

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

[SIMULATION AND NAVIGATION OF PULMONARY SEGMENTECTOMY WITH HOMEMADE SOFTWARE].

Pulmonary segmentectomy-level variations in the three-dimensional (3D) architecture of the bronchi and pulmonary vessels are much wider than those at the lobectomy level. Presurgical simulation with sharing of necessary information is believed to reduce the surgical time and number of detachment procedures required. For such simulations, the author's group developed homemade software that: 1) reconstructs the shapes of the bronchi, vessels, lung, and tumors as simplified 3D images such as sequentially connected cylinders with branches and membranes from digital-imaging data on a personal computer screen; 2) allows surgeons to input data on the initial and terminal points, diameters of cylinders, etc. continuously by moving computed tomography (CT) images up and down; and 3) permits these data to be read by modeler shareware on the Internet. Although conventional 3D images from CT data are reconstructed by a volume-rendering method, those of the software developed by the author's group are made using a surface-rendering method. This article explains the present status of and future trends in the actual processes of simulated surgery including segmentectomy and navigation, applications of newly developed operative procedures, and results of data analysis of more than 500 cases.

[Outcomes of Surgical Treatment by Modified Transmanubrial Approach].

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

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

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

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

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

[Hemoptysis caused by bleeding into a bleb].

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

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

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

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

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

[Surgical treatment for mediastinal cysts].

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

[Adenocarcinoma developed in the pulmonary giant bulla; report of a case].

A 56-year-old man was point out chest abnormal shadow in the left lung by chest X-ray for routine follow-up of diabetes. Chest computed tomography (CT) revealed emphysematous changes in the bilateral lung, and showed an approximately 23 x 20 mm tumor in the giant bulla of the left upper lobe. Left S(1+2) segmentectomy was performed as the diagnosis of adenocarcinoma was established by intra-operative biopsy. The lesion was diagnosed as poorly differentiated adenocarcinoma (pT1N0M0P0D0PM0E0, stage IA). The frequency of lung cancer within a bulla is reported as high as 14-29% in Japan. Therefore, it is thought to be necessary that the pulmonary bullous lesion must be followed-up for a long period because of the possibility of development of malignancy.

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

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

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

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

Anatomical analysis of the left upper lobe of lung on three-dimensional images with focusing the branching pattern of the subsegmental veins.

BACKGROUND: A clear understanding of the anatomical characteristics of the pulmonary veins (PVs) is essential for the successful performance of segmentectomy and important to avoid intraoperative pulmonary vessels injury. However, there is no report showing the relations between the branching patterns of PVs and pulmonary arteries (PAs). Moreover, internationally accepted symbols for describing PVs remain unavailable. For anatomically assessing the branches and courses of the subsegmental veins in the left upper lobe (LUL), the diverse branching patterns of blood vessels and bronchi should be investigated. METHODS: The branching patterns and intersegmental courses of PVs were assessed by performing three-dimensional image analysis of the bronchi, and PAs and PVs in the LUL in 103 patients who were scheduled to receive segmentectomy in LUL from January 2008 through August 2012. RESULTS: Branching types of the bronchi and pulmonary vessels failed to be independent each other. Although the combinations of anterior extension type of bronchus with the inter-lobar type (IL-type) of arterial branching pattern were often observed, but those with the mediastinal type (M-type) were rarely observed. The combinations of apical vein dominant type with the IL-type of arteries, and intermediate and central vein types with the M-type were often observed. Since LUL was adjoined by various subsegments, and the intersegmental pulmonary veins showed diverse patterns. CONCLUSIONS: This study found the relationship among PA, PV, and bronchus patterns, in the subsegment where the branching patterns were fixed in 103 cases. This study discovered PVs that was difficult to be named by the conventional naming systems because of the diversity of the locations in the subsegment.

[Virtual reality in video-assisted thoracoscopic lung segmentectomy].

The branching patterns of pulmonary arteries and veins vary greatly in the pulmonary hilar region and are very complicated. We attempted to reconstruct anatomically correct images using a freeware program. After uploading the images to a personal computer, bronchi, pulmonary arteries and veins were traced by moving up and down in the images and the location and thickness of the bronchi and pulmonary vasculture were indicated as different-sized cylinders. Next, based on the resulting numerical data, a 3D image was reconstructed using Metasequoia shareware. The reconstructed images can be manipulated by virtual surgical procedures such as reshaping, cutting and moving. These system would be very helpful in complicated video-assisted thoracic surgery such as lung segmentectomy.

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

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

Long-term clinical outcome after extended thymectomy combined postoperative high-dose steroid therapy for juvenile myasthenia gravis.

Myasthenia gravis (MG) is considered to be an autoimmune disorder of neuromuscular transmission and is rare in childhood. We report 3 juvenile MG (JMG) cases of extended thymectomy (ETMX) combined postoperative high-dose steroid therapy. All patients developed MG symptoms under the age of 14 years and were given cholinergic drugs and had generalized MG: the Myasthenia Gravis Foundation of America classification II was present in 1 case and classification III was in 2. All patients were taking pyridostigmine before surgery; none was treated with prednisone preoperatively. All patients performed the ETMX combined postoperative high-dose steroid therapy. Muscle weakness of extremities and bulbar symptoms improved in all patients, but not all exhibited an unstable phase in their clinical course as a result of combined therapy. There was no postoperative morbidity or mortality. All patients had follicular lymphoid hyperplasia without thymoma. Follow-up for more than 5 years has shown one to be in complete remission and the others to have improved symptoms. Although our results are inconclusive because we used only a few JMG patients, the ETMX combined postoperative high-dose steroid therapy appeared to provide a better chance of remission or control of symptoms.

Dynamic sealing of lung air leaks by the transplantation of tissue engineered cell sheets.

Current methods including the use of various biological and synthetic sealants are ineffective in the closure of intraoperative air leaks that often occur during cardiothoracic surgeries, resulting in a decreased quality of life for patients. We present the development of a novel lung air leak sealant using tissue engineered cell sheets. In contrast to previous materials such as fibrin glue, these bioengineered cell sheets immediately and permanently seal air leaks in a dynamic fashion that allows for the extensive tissue contraction and expansion involved in respiration, without any postoperative recurrences. Additionally, we demonstrate that mesothelial cells migrate to cover the transplanted cells sheets, thereby confirming excellent biocompatibility and integration with the host tissues. Finally, we present the use of skin fibroblasts as an effective and readily available autologous cell source that can be easily applied. This study shows for the first time, the development of an immediate and permanent lung air leak sealant, suitable for future clinical applications.

Bronchial artery embolization: first-line option for managing massive hemoptysis.

Background Today, treatment for hemoptysis is not limited to surgery, and among the various options, bronchial artery embolization is regarded as an effective approach. Methods In this retrospective study, 179 of 389 patients with massive hemoptysis were treated with bronchial artery embolization, without taking into account the underlying pathological lesions responsible (bronchiectasis in 41, aspergilloma in 29, lung cancer in 25, old tuberculosis in 23, pyothorax in 19, others in 23). Results Bronchial artery embolization failed in 12 cases. In the 167 successful cases, surgery was required in 16 and bronchial occlusion was performed in 4; 3 patients died due to recurrent massive hemoptysis. After bronchial artery embolization, thoracic surgery for reasons other than hemostasis was carried out in 15 patients. Bronchial artery embolization was performed in 31 patients with hemoptysis who had a history of chest surgery. Four patients underwent bronchial occlusion, and immediate hemostasis was achieved in all of them. Conclusions For treatment of hemoptysis, bronchial artery embolization is a safe and minimally invasive technique that can be performed repeatedly, and provides not only short-term but also prolonged effectiveness; thus it can be used as a first-line treatment irrespective of the underlying pathological lesion. Bronchial occlusion may be useful for emergency hemostasis, but it warrants careful follow-up with consideration of additional elective treatment such as bronchial artery embolization.