Nutrition-related factors associated with waiting list mortality in patients with interstitial lung disease: A retrospective cohort study.

Japanese patients with interstitial lung disease (ILD) sometimes die waiting for lung transplantation (LTx) because it takes about 2 years to receive it in Japan. We evaluated nutrition-related factors associated with waiting list mortality. Seventy-six ILD patients were hospitalized in Kyoto University Hospital at registration for LTx from 2013 to 2015. Among them, 40 patients were included and analyzed. Patient background was as follows: female, 30%; age, 50.3 ± 6.9 years; body mass index, 21.1 ± 4.0 kg/m2 ; 6-minute walk distance (6MWD), 356 ± 172 m; serum albumin, 3.8 ± 0.4 g/dL; serum transthyretin (TTR), 25.3 ± 7.5 mg/dL; and C-reactive protein, 0.5 ± 0.5 mg/dL. Median observational period was 497 (range 97-1015) days, and median survival time was 550 (95% CI 414-686) days. Survival rate was 47.5%, and mortality rate was 38.7/100 person-years. Cox analyses showed that TTR (HR 0.791, 95% CI 0.633-0.988) and 6MWD (HR 0.795, 95% CI 0.674-0.938) were independently correlated with mortality and were influenced by body fat mass and leg skeletal muscle mass, respectively. It is suggested that nutritional markers and exercise capacity are important prognostic markers in waitlisted patients, but further study is needed to determine whether nutritional intervention or exercise can change outcomes.

[Usefulness of Nutritional Enforcement by Percutaneous Gastrostomy in Successful Omentoplasty for Empyema with Fistula].

Omentoplasty has been accepted as an effective surgical procedure for fistulated empyema. However, it is difficult for patients with poor nutritional status because their omental volume is often too poor to be applied for omentoplasty. Percutaneous endoscopic gastrostomy(PEG) is useful for long-term nutritional management. There is no report on safety and usefulness of PEG before omentoplasty. We report a case of omentoplasty that was successfully performed after nutritional enforcement by using percutaneous endoscopic gastrostomy in a patient of postoperative empyema with fistula.

Development of a novel lung-stabilizing device for VATS procedures.

BACKGROUND: The use of video-assisted thoracoscopic surgery (VATS) has substantially increased in recent years. These procedures involve the insertion of specialized devices into the thoracic cavity via access ports. However, conventional devices such as cotton-tipped applicators and graspers can limit the field of view and injure the fragile lung tissue. The aim of this study was to develop a novel lung-stabilizing device for VATS that provides a good surgical field of view without causing lung injury. METHODS: We developed a novel suction-based lung-stabilizing device equipped with three hemispheric 20-mm-diameter silicon suction cups. The utility and safety of the novel device were evaluated using a resected pig lung and canine models. In order to assess potential organ damage arising from the use of the novel device, canine lung parenchyma and pleura were macroscopically and microscopically examined after the device had been continuously applied under negative pressure conditions of -400 or -540 mmHg for 1 h. RESULTS: To assess the utility of the novel device, we performed lobectomies in the resected pig lung and VATS in canine models. The device demonstrated sufficient power to stabilize the lungs and provided a clear field of view during surgery, which enabled us to perform VATS lobectomies more easily than conventional stabilizing forceps. Assessment of the dogs' lungs immediately after detaching the suction-based device revealed no complications such as hemorrhage, air leaks, and bullae formation. Pathological examination after 7 days also showed no substantial damage, except for a small impression in the parenchyma and pleura of the surface layer where the device had contacted the lung tissue. CONCLUSIONS: Although further validation studies in clinical settings are required, our study indicates that the novel lung-stabilizing device has potentially useful applications in VATS procedures.

Localizing small lung lesions in video-assisted thoracoscopic surgery via radiofrequency identification marking.

BACKGROUND: To facilitate accurate localization of small lung lesions in thoracoscopic surgery, we employed a micro-radiofrequency identification tag designed to be delivered through the 2-mm working channel of a flexible bronchoscope. This report presents the results of preclinical studies of our novel localizing technique in a canine model. METHODS: To evaluate functional placement, three types of tags [Group A, tag alone (n = 18); Group B, tag + resin anchor (n = 15); and Group C, tag + NiTi coil anchor (n = 15)] were bronchoscopically placed in subpleural areas and subsegmental bronchi via our new delivery device; tags were examined radiographically on days 0-7 and day 14. In addition, eight tags, which were placed at a mean depth of 13.3 mm (range 9-15.7 mm) from visceral pleura in bronchi with a mean diameter of 1.46 mm (range 0.9-2.3 mm), were recovered by partial lung resection under video-assisted thoracoscopic surgery using a 13.56-MHz wand-shaped probe with a 30-mm communication range. RESULTS: Peripheral airway placement: Group C had a significantly higher retention rate than the other two groups (retention rate at day 14: Group A, 11.1 %; Group B, 26.7 %; Group C, 100.0 %; P < 0.0001). Central airway placement: Overall retention rate was 73.3 % in Group C, and placement was possible in bronchi of up to 3.3 mm in diameter. Outcomes of partial resection: Tag recovery rate was 100 %, mean time required for tag detection was 10.8 s (range 8-15 s), and mean surgical margin from the delivered tag was 9.13 mm (range 6-13 mm). CONCLUSION: Radiofrequency identification marking enabled accurate localization with depth, which could ensure effective deep resection margins.

Physical activity level significantly affects the survival of patients with end-stage lung disease on a waiting list for lung transplantation.

PURPOSE: Our objective was to investigate the factors predicting the survival of patients on the waiting list for lung transplantation (LT) during the waiting period, with a special emphasis on the physical activity level. METHODS: The study included 70 patients with end-stage pulmonary disease who were on the waiting list for LT at Kyoto University Hospital. We examined the association between the baseline characteristics, including the body mass index and body composition, serum albumin, serum C-reactive protein (CRP), steroid administration, physical activity level (calculated by the food frequency questionnaire) and survival during the waiting period using Kaplan-Meier curves and Cox proportional hazard regression models. RESULTS: A physical activity level of ≤1.2 was correlated with significantly decreased survival (1-year survival: 68 vs. 90.9%, p = 0.0089), with a hazard ratio (HR) of 2.24 (95% confidence interval (CI) 1.22-4.19, p = 0.0001). Hypo-albumin (HR 2.024, 95% CI 1.339-6.009, p = 0.004), a high level of CRP (HR 2.551, CI 1.229-4.892, p = 0.02), and the administration of steroids (HR 2.258, CI 1.907-5.032, p = 0.024) were also significant predictors of survival. CONCLUSIONS: Low levels of physical activity during the waiting period for LT led to decreased survival times among LT candidates.

Severe underweight decreases the survival rate in adult lung transplantation.

PURPOSE: The body mass index (BMI) before lung transplantation (LT) is a benchmark of the post-LT survival. The aim of the study is to determine the BMI inadequate for the post-LT survival. METHODS: We examined the survival after LT in patients grouped into the following BMI categories: <18.5 kg/m2 (underweight), 18.5-24.9 kg/m2 (normal weight), 25-29.9 kg/m2 (overweight), and ≥30.0 kg/m2 (obese) according to the World Health Organization (WHO) criteria. A more detailed categorization was made for further evaluation of the underweight group: mild (17.0 ≤ BMI < 18.5 kg/m2) and severely underweight (BMI <17.0 kg/m2). RESULTS: There was no statistically significant difference in the post-LT survival between underweight and normal-weight patients (5-year survival: 78.7 vs. 76.1%). Patients with BMI <17.0 kg/m2 had a worse prognosis than those with 17.0 ≤ BMI < 18.5 kg/m2 (5-year survival: 70.3 vs. 90.0%). CONCLUSIONS: Standard BMI categorization per the WHO criteria is inadequate for determining the post-LT survival, especially in underweight patients. For the nutritional evaluation of underweight pre-LT patients, BMI <17.0 kg/m2 should be used instead of BMI <18.5 kg/m2.

Development of a novel marking system for laparoscopic gastrectomy using endoclips with radio frequency identification tags: feasibility study in a canine model.

BACKGROUND: Intraoperative identification of early gastric cancer is difficult to conduct during laparoscopic procedures. In this study, we investigated the feasibility and accuracy of a newly developed marking system using endoclips with radio frequency identification (RFID) tags in a canine model. METHODS: RFID is a wireless near field communication technology. Among the open frequency bands available for medical use, 13.56 MHz is suitable for a surgical marking system because of the similar and linear signal decay both in air and in biological tissues. The proposed system consists of four parts: (a) endoclips with RFID tags, (b) endo-clip applier equipment, (c) laparoscopic locating probe, and (d) signal processing units with audio interface. In the experimental setting using canine models, RFID-tagged endoclips were applied to the mucosa of each dog's stomach. During the subsequent operation, the clips with RFID tags placed in five dogs were located by the detection of the RFID signal from the tag (RFID group), and the conventional clips in the other six dogs were located by finger palpation (FP group). The detected sites were marked by ablation on the serosal surface. Distance between the clips and the metal pin needles indicating ablated sites were measured with X-ray radiographs of the resected specimen. RESULTS: All clips were successfully detected by the marking system in the RFID group (10/10) and by finger palpation in the FP group (17/17). The medians of detection times were 31.5 and 25.0 s, respectively; the distances were 5.63 and 7.62 mm, respectively. The differences were not statistically significant. No adverse event related to the procedures was observed. CONCLUSIONS: Endoclips with RFID tags were located by our novel marking system in an experimental laparoscopic setting using canine stomachs with substantial accuracy comparable to conventional endoclips located by finger palpation through an open approach.

[A patient with descending necrotizing mediastinitis successfully treated by cervical, transthoracic, and mediastinoscopic drainage].

A 62-year-old man was admitted to a local hospital for cervical abscess. He was given an antibiotic, but his symptoms worsened. Computed tomographic cervical and chest scan 6 days after hospitalization revealed that left cervical abscess extended to the mediastinum. He was transferred to our hospital following a diagnosis of descending necrotizing mediastinitis. Cervical and left transthoracic drainage through a left cervical incision and a left antero-axillary thoracotomy were performed on hospital day 1. On hospital day 2, chest radiograph revealed enlargement of the superior mediastinal shadow. Mediastinoscopic drainage was performed for the abscess in the paratracheal space on hospital day 3. Two mediastinal drainage tubes were placed in the upper and middle mediastinal space using mediastioscopy. Postoperatively, he required additional right transthoracic drainage by chest tube for pleural effusion on hospital day 5. Then his clinical and radiological findings gradually improved, and he was discharged from hospital day 37.

[Nutritional treatment for bronchopleural fistula-promising effect of arginine as a pharmaconutrient].

Pharmaconutrition, which is a supportive nutritional care of surgical patients, has been proven to shorten hospital stay, decrease the incidence of infection, and reduce hospital costs in selected groups of patients. Arginine, one of the most essential pharmaconutrients, has also been proven to enhance would healing process. In severely malnourished patients like bronchopleural fistula with resultant empyema, aggressive nutritional approach should be mandatory. And management of the fistula is also important in stabilizing the ongoing infection. Our hypothesis was that basic nutritional support enhanced with arginine would be effective in not only improving the general condition including nutritional status but also in healing the fistula. We report a case of major bronchopleural fistula in which arginine-supplemented diet as well as aggressive nutritional support could accelerate the postoperative recovery after open thoracic window, ultimately leading to the healing of the fistula.

[Perioperative nutritional support with immune-enhancing diet for surgical closure of open thoracic window].

Immunonutrition, which is a therapeutic approach to modulate acute surgical or medical conditions, has been proven to decrease surgical site complications in patients undergoing major elective surgery for upper gastrointestinal and esophageal malignancy. For immunonutrition to be carried out effectively, specific nutrients called pharmaconutrients are quite important. In our case, to enhance the perioperative nutritional status of the patient, special formulas supplemented with specific pharmaconutrients, which are arginine and omega-3 fatty acids, were orally administered. The open thoracic window for chronic empyema caused by postoperative bronchopleural fistula was successfully closed. Perioperative immunonutrition is likely to have beneficial effect in decreasing postoperative infectious complications in high-risk malnourished thoracic surgical patients.

A novel technique for Endobronchial Watanabe Spigot placement for bronchopleural fistula: a traction method.

Empyema with bronchopleural fistula is a challenging condition that often requires open-window thoracostomy. Bronchial occlusion with Endobronchial Watanabe Spigot is an effective and less invasive procedure to close the fistula; however, delivering a spigot into the target bronchus requires high technical skills. Herein, we report a case of bronchopleural fistula occluded with a spigot using a new 'traction method' in which the spigot is tied as an anchor to a guidewire and pulled into the target bronchus. Our method allows selective and steady placement of the spigot for patients who undergo open-window thoracostomy for the treatment of bronchopleural fistula.

Congenital partial pericardial defect confirmed based on spontaneous pneumothorax: A case report and literature review.

INTRODUCTION: Congenital pericardial defects are rare but can cause fatal complications. Most cases are asymptomatic and incidentally detected during a thoracic surgery or autopsy. We report a case of a partial pericardial defect confirmed based on spontaneous pneumothorax. PRESENTATION OF CASE: A 16-year-old boy with left spontaneous pneumothorax showed pneumopericardium on chest X-ray. Chest computed tomography revealed a partial pericardial defect. Video-assisted thoracoscopic surgery was performed, and a small pericardial defect was confirmed at the level of the upper pulmonary hilum. We did not reconstruct the defect because of the improbability of cardiac herniation. DISCUSSION: Pneumopericardium combined with pneumothorax suggests the existence of a pericardial foramen. Partial pericardial defects could cause cardiac herniation or strangulation, and pneumothorax may worsen the protruding of the heart. Video-assisted thoracic surgery is an effective method to prevent the recurrence of pneumothorax and determine whether reconstruction of the defect is required. CONCLUSION: Video-assisted thoracic surgery should be performed in the case of a pericardial defect combined with pneumothorax.

Solitary Pulmonary Hematoma Radiographically Indistinguishable from Mediastinal Tumor.

Solitary pulmonary hematoma is a rare consequence of blunt chest trauma. Moreover, there has been no reported case of solitary pulmonary hematoma radiographically diagnosed as a posterior mediastinal tumor. We present the case of a 63-year-old man who was referred for an oval-shaped opacity at the left paraspinal area on a chest X-ray. Chest computed tomography showed a well-circumscribed posterior mediastinal tumor on the left paraspinal lesion with extrapleural sign and callus formation on the left ribs posteriorly (7th to 11th ribs). The tumor was thoracoscopically confirmed to be a subpleural pulmonary tumor of the left lower lobe, and wedge resection was performed. Histological examination confirmed the diagnosis of pulmonary hematoma. On reviewing the callus formation of the ribs, which was suggestive of rib fractures, the pulmonary hematoma was determined to be traumatic in origin. The postoperative course was uneventful. We reviewed a rare case of pathologically proven traumatic solitary pulmonary hematoma. The rarity of this case is enhanced because the hematoma initially appeared to be a posterior mediastinal tumor.

Solitary pulmonary capillary hemangioma presenting with a ground glass opacity: A case report & literature review.

INTRODUCTION: Solitary pulmonary capillary hemangioma (SPCH) is a rare benign lung tumor that clinically resembles early lung cancer and precancerous pulmonary lesions that present with similar imaging manifestations. PRESENTATION OF CASE: The patient was a 54-year-old Japanese man who was referred to Nagara Medical Center with a ground glass opacity (GGO) lesion within the right upper lung that was incidentally detected on computed tomography. After 8 months of follow-up, video-assisted thoracoscopic segmental resection of the right upper lobe was performed with diagnostic and therapeutic intent. Pathologic examination of the resected specimen demonstrated thickening of the alveolar septum caused by the proliferation of capillary vessels. This lesion was positive for CD31 and CD34 and negative for thyroid transcription factor-1 and cytokeratin on immunohistochemical staining. The tumor was diagnosed as SPCH pathologically. DISCUSSION: When radiological examination demonstrates a GGO in the lung, SPCH must be considered as one of the differential diagnoses. For a definitive diagnosis, pathological examination of a surgically resected specimen must be conducted. CONCLUSION: This study describes a case of SPCH and a review of the literature.

Impact of diabetes mellitus on postoperative outcomes in individuals with non-small-cell lung cancer: A retrospective cohort study.

OBJECTIVES: Studies showing that individuals with non-small cell lung cancer (NSCLC) and diabetes mellitus (DM) have reported poor outcomes after pulmonary resection with varying results. Therefore, we investigated the clinical impact of preoperative DM on postoperative morbidity and survival in individuals with resectable NSCLC. PATIENTS AND METHODS: Data of individuals who underwent pulmonary resection for NSCLC from 2000 to 2015 were extracted from the database of Kyoto University Hospital. The primary endpoint was the incidence of postoperative complications, and secondary endpoints were postoperative length of hospital stay and overall survival. The survival rate was analyzed using the Kaplan-Meier method. RESULTS: A total of 2,219 patients were eligible for the study. The median age of participants was 67 years. Among them, 39.5% were women, and 259 (11.7%) presented with DM. The effect of DM on the incidence of postoperative complications and postoperative length of hospital stay was not significant. Although the 5-year survival rates were similar in both patients with and without DM (80.2% versus 79.4%; p = 0.158), those with DM who had a hemoglobin A1c level ≥ 8.0% had the worst survival. CONCLUSIONS: In individuals with resectable NSCLC, preoperative DM does not influence the acute phase postoperative recovery. However, poorly controlled preoperative DM could lead to low postoperative survival rates.

Resected case of giant cystic thymoma with spontaneous intracystic hemorrhage.

BACKGROUND: Spontaneous intracystic hemorrhage of cystic thymoma is very rare. We encountered a patient with giant cystic thymoma with spontaneous intracystic hemorrhage and successfully resected the thymoma. CASE PRESENTATION: A 38-year-old man was referred to our hospital with chest pain. Computed tomography revealed a uniform anterior mediastinum cystic mass. Two days after hospitalization, his chest pain worsened. Subsequent computed tomography showed that the tumor had become inhomogeneous. The patient's symptoms gradually improved over a fortnight, and surgery was performed. The tumor was a cystic mass with a thick fibrous capsule filled with hemorrhagic necrotic tissue and was diagnosed as a cystic thymoma. CONCLUSIONS: Mediastinal cystic lesion with expansion or contrasting effects in the wall may be a cystic thymoma, and it has the possibility of hemorrhaging in the cyst. In such a case, surgical resection is recommended.

Development of a novel tissue-engineered nitinol frame artificial trachea with native-like physical characteristics.

BACKGROUND: Tracheal reconstruction is complicated by the short length to which a trachea can be resected. We previously developed a biocompatible polypropylene frame artificial trachea, but it lacked the strength and flexibility of the native trachea. In contrast, nitinol may provide these physical characteristics. We developed a novel nitinol frame artificial trachea and examined its biocompatibility and safety in canine models. METHODS: We constructed several nitinol frame prototypes and selected the frame that most closely reproduced the strength of the native canine trachea. This frame was used to create a collagen-coated artificial trachea that was implanted into 5 adult beagle dogs. The artificial trachea was first implanted into the pedicled omentum and placed in the abdomen. Three weeks later, the omentum-wrapped artificial trachea was moved into the thoracic cavity. The thoracic trachea was then partially resected and reconstructed using the artificial trachea. Follow-up bronchoscopic evaluation was performed, and the artificial trachea was histologically examined after the dogs were sacrificed. RESULTS: Stenosis at the anastomosis sites was not observed in any dog. Survival for 18 months or longer was confirmed in all dogs but 1, which died after 9 months due to reasons unrelated to the artificial trachea. Histological examination confirmed respiratory epithelial regeneration on the artificial trachea's luminal surface. Severe foreign body reaction was not detected around the nitinol frame. CONCLUSIONS: The novel nitinol artificial trachea reproduced the physical characteristics of the native trachea. We have confirmed cell engraftment, good biocompatibility, and survival of 18 months or longer for this artificial trachea in canine models.

Development of novel force-limiting grasping forceps with a simple mechanism.

OBJECTIVES: In endoscopic surgery, fragile tissues may be damaged by the application of excessive force. Thus, we developed novel endoscopic forceps with a simple force-limiting mechanism. METHODS: The novel forceps were constructed with a leaf spring, and the spring thickness determines grasping pressure. We established an evaluation system (maximum score is 11 points) for lung tissue damage leading to complications. We tested the conventional forceps (186.8 kPa) and 3 novel spring forceps with the following thicknesses: 1.3 mm (53.0 kPa), 2.2 mm (187.7 kPa) and 2.8 mm (369.2 kPa). After grasping, peripheral canine lung tissues were microscopically examined for acute- and late-phase damages. RESULTS: In the acute phase (20 sites), the novel forceps caused capillary congestion and haemorrhage in the subpleural tissue, whereas the conventional forceps caused deep tissue and pleural damages. In the late phase (30 sites), both forceps caused fibroblast formation and interstitial thickening, which progressed to the deeper tissues as grasping pressure increased. In the acute phase, the median scores were 2.0 and 6.0 for the novel and conventional forceps, respectively (P = 0.003). In the late phase, the median scores were 2.0, 2.5 and 5.0 for 1.3-, 2.2- and 2.8-mm thick forceps, respectively, and 5.0 for the conventional forceps (P < 0.001). In both phases, the novel forceps with grasping pressure set below 187.7 kPa (2.2 mm) caused significantly less lung tissue damage than the conventional forceps. CONCLUSIONS: The novel endoscopic forceps are able to regulate the tissue-grasping pressure and induce less damage in lung tissues than conventional forceps.

Development of a socket-type rib coaptation device made of poly-L-lactide fibers: feasibility study in a canine model.

BACKGROUND: Costal coaptation pins made of poly-L-lactide (PLA) are clinically available for fixing surgically divided ribs. However, the clinical results of such rib fixation have not been completely satisfactory. We aimed to develop a new rib coaptation socket system and explore its clinical applicability. METHODS: We surgically divided three consecutive ribs of each beagle dog, and rib coaptation sockets were implanted to stabilize each rib. Fifteen 3-dimensional (3D)-printed and 30 PLA fiber knitted sockets were implanted in five and ten dogs, respectively, to stabilize the artificially divided ribs. Mechanical analysis of the sockets and radiographical examination of costal fixation were performed to evaluate the effectiveness of the newly developed socket system for rib stabilization. RESULTS: All 15 ribs with 3D-printed sockets had displaced 1 month after the operation. Three ribs in one dog with implanted PLA fiber knitted sockets were displaced radiographically after 1 month, and the grade of displacement remained unchanged after 6 months. The remaining 27 ribs fixed with PLA fiber knitted sockets did not show any displacement. CONCLUSIONS: The PLA fiber knitted rib coaptation socket system was sufficiently durable for the stabilization of divided ribs with biocompatibility. This promising finding can be applied for clinical stabilization of divided ribs.

Tracheal papilloma with exceptionally longer interval of recurrence.

A case of recurrent respiratory papilloma of the trachea was reviewed in accordance with other literature. A 66-year-old man with the chief complaint of haemoptysis was referred to our department for meticulous checkup. According to his past medical history of laser ablation for laryngeal and tracheal papilloma, recurrence of the papilloma was first suspected and confirmed by bronchoscopic biopsy. The recurrent papilloma, of about 5 mm in diameter, was located at the same endotracheal lesion, left side of the middle trachea, where the former first and second tracheal papillomas had been detected and treated with Nd-YAG laser. Under general anaesthesia with endotracheal intubation, the patient underwent bronchoscopic resection of the recurrent papilloma with KTP laser. The bronchoscopic resection was uneventful, as was the postoperative course. In this report, the clinical manifestations of and therapeutic approach for tracheal papilloma are reviewed.