Predictive factors inhibiting recovery of the respiratory function after anatomical pulmonary resection.

PURPOSE: Some patients have worse actual observed postoperative (apo) respiratory function values than predicted postoperative (ppo) values. The present study therefore clarified the predictive factors that hinder the recovery of the postoperative respiratory function. METHODS: This study enrolled 255 patients who underwent anatomical pulmonary resection for lung cancer. A pulmonary function test (PFT) was carried out before surgery and at one, three, and six months after surgery. In each surgical procedures, the forced expiratory volume in 1 s (FEV1) ratio was calculated as the apo value divided by the ppo value. In addition, we investigated the predictive factors that inhibited postoperative respiratory function improvement in patients with an FEV1 ratio < 1.0 at 6 months after surgery. RESULTS: The FEV1 ratio gradually improved over time in all surgical procedures. However, 49 of 196 patients who underwent a PFT at 6 months after surgery had an FEV1 ratio < 1.0. In a multivariate analysis, right side, upper lobe, segmentectomy and pleurodesis for prolonged air leakage were independent significant predictors of a decreased FEV1 ratio (p = 0.003, 0.006, 0.001, and 0.009, respectively). CONCLUSION: Pleurodesis was the only controllable factor that might help preserve the postoperative respiratory function. Thus, the intraoperative management of air leakage is important.

Patency of grafts after total resection and reconstruction of the superior vena cava for thoracic malignancy.

PURPOSES: Resection and reconstruction of the superior vena cava (SVC) is used for the complete resection of advanced lung cancer and mediastinal tumors. However, the optimal postoperative management for this procedure remains to be elucidated. METHODS: 1897 patients with lung cancer and/or mediastinal tumors underwent surgical resection at our institute. Among them, 12 patients underwent combined resection and replacement with a vascular graft of the SVC. Preoperative SVC syndrome was noted in 4, and preoperative chemo and/or radiotherapy were used in 2. The SVC pathway was reconstructed bilaterally in 9 patients (75 %), while 2 patients underwent a right-side single bypass, and 1 had a Y-shaped bypass. Antithrombotic agents were not used postoperatively. The factors related to occlusion of the graft were investigated. The median follow-up time for the surviving patients was 474 days. RESULTS: There were no instances of surgical mortality. Among the 22 grafts, three (14 %) were occluded. One (8 %) case of occlusion was noted on the right side and 2 (20 %) in the left graft. Bilateral reconstruction was performed in all except 2. Two single side reconstructions did not result in occlusion, while 3 occlusions were noted in the patients who had undergone bilateral reconstruction. CONCLUSION: Resection and reconstruction of the SVC system was feasible. Postoperative anti-thrombotic agents are not always needed to prevent acute graft occlusion.

Body Mass Index as a Prognostic Factor in Resected Lung Cancer: Obesity or Underweight, Which Is the Risk Factor?

BACKGROUND: In general, obesity is thought to be associated with increased surgical mortality and morbidity. On the other hand, low body mass index (BMI) has recently been reported as a poor prognostic factor for surgical candidates. This study investigated the effect of BMI on lung surgery. METHODS: A retrospective study was conducted on 1,518 consecutive patients who had malignant pulmonary tumors resected between February 2008 and March 2013. BMI was used to classify patients according to the World Health Organization definition: BMI < 18.5: underweight (UW); BMI 18.5 to <25: normal weight (NW); BMI 25 to <30: overweight (OW); and BMI ≥ 30: obese (OB). We defined surgical resection-related mortality as any patient who died within 90 days after resection or while in the hospital. We analyzed morbidity and surgical resection-related mortality, and logistic regression analysis was used to identify predictors for surgical resection-related mortality. RESULTS: Among the four groups, the incidence of cerebrovascular complications was 1.5% in UW, 0.4% in NW, 0% in OW, and 0% in OB, and that of pulmonary complications was 13.1% in UW, 8.4% in NW, 7.3% in OW, and 7.6% in OB. Surgical resection-related mortality was 2.9% in UW, 0.6% in NW, 1.7% in OW, and 0% in OB. Multivariate analysis revealed underweight, diffusing capacity of the lung for carbon monoxide, and male sex as the significant predictors. CONCLUSIONS: In this study, low BMI was an independent risk factor for mortality, and the incidence of cerebrovascular and pulmonary complications tended to be higher in patients with low BMI than in obese patients. Underweight patients should be closely monitored following pulmonary resection.

Endobronchial Watanabe Spigot Placement for Hepatic Abscess and Bronchobiliary Fistula Following Radiofrequency Ablation for Hepatocellular Carcinoma.

A bronchobiliary fistula (BBF) is an uncommon but severe complication after radiofrequency ablation (RFA). However, the definitive salvage methods are controversial. We herein report a patient with hepatocellular carcinoma with hepatic abscess and BBF following RFA. We also review previous reports of BBF after RFA. The patient was a man in his 70s who underwent RFA for recurrent hepatocellular carcinoma in the subphrenic area. Despite percutaneous transhepatic abscess drainage, bilioptysis persisted. Finally, the BBF was occluded with an endobronchial Watanabe spigot under fiber-optic bronchoscopy. Placing an endobronchial Watanabe spigot should be considered as a salvage therapy for refractory BBF following RFA.

Supradiaphragmatic intrathoracic migration of ventriculoperitoneal shunt with "double bending sign".

Ventriculoperitoneal shunt (VPS) is a common treatment for hydrocephalus. An 80-year-old woman presented with subarachnoid hemorrhage caused by rupture of an aneurysm of the right middle cerebral artery. Emergency clipping was performed. Hydrocephalus occurred shortly after and VPS placement was performed. She improved and was transferred to a rehabilitation hospital. She presented with dyspnea 5 months later. Chest computed tomography (CT) showed extensive pleural effusion and intrathoracic migration of the distal VPS catheter. Chest CT confirmed that the distal catheter had penetrated into the pleural cavity under the second rib, and the catheter tip was located at the bottom of the right thoracic cavity. Review of chest CT right after the shunt surgery found the distal catheter passing only under the second and third ribs and otherwise located in the subcutaneous layer to the abdominal cavity. Chest radiography showed that the distal shunt tube was distorted in a characteristic "double bending sign." This rare case of supradiaphragmatic intrathoracic migration of VPS indicates a possible mechanism of this migration, based on the anatomical physiology, and that "double bending sign" indicates the need for further investigation.