[Video-assisted Thoracoscopic Surgery for Chest Trauma].

Video-assisted thoracoscopic surgery (VATS) is now commonly used in emergency surgery to confirm the site of injury and observe the thoracic cavity, especially in cases of chest trauma with stable vital signs. VATS was used in all 33 chest trauma surgeries performed at our department from October 2009 to July 2023. The common injury mechanisms were traffic trauma and falls, but there were also cases of trauma from a bullhorn, heavy machinery and farm equipment, and penetrating injury. The common surgical procedures were treatment of rib fractures and pulmonary suture or partial lung resection, followed by treatment of diaphragmatic injuries. Unusual surgical procedures included extrapleural hematoma drainage, pericardial drainage, hemostasis of intrathoracic bleeding from thoracic vertebral fracture, and lobectomy for airway bleeding. Here, we report our surgical policies and techniques for chest trauma. First, the thoracic cavity should be observed thoracoscopically to determine the site of injury. The key to repair is placement of a small thoracotomy directly above the rib fracture site, where dislocation is largest, followed by suture repair of the lung and diaphragm by combining direct and thoracoscopic views.

[Three-dimensional and 4K Three-dimensional Uniportal Video-assisted Thoracoscopic Surgery for Mediastinal and Chest Wall Disease During Respiratory Surgery].

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy has recently been used with increasing frequency by thoracoscopic surgeons, even in Japan. However, few reports have previously described uniportal VATS for mediastinal and chest wall disease. From April 2008 to December 2022, 159 patients were treated for mediastinal and chest wall disease. We divided the patients into three groups based on the type of surgery:robot-assisted thoracoscopic surgery( RATS), n=21;multi-portal surgery (using a two-dimensional [2D] system), n=55;and uniportal surgery, n=83. Of the 83 cases in the uniportal surgery group, 49 underwent surgery with a three-dimensional( 3D) or 4K-3D system. The operation duration, blood loss, and postoperative stay duration were compared among the groups. A p-value of <0.05 was considered statistically significant. The operation duration, intraoperative blood loss, and postoperative stay duration were significantly lower in the uniportal group (3D, 4K-3D) than in the multi-portal group (2D), with respective p-values of 0.001, 0.034, and 0.005. The RATS group showed a reduced blood loss trend, but not to a significant degree. In conclusion, our findings suggest that a 3D system can optimize surgical performance compared to a 2D system. In particular, using a 4K-3D system with high-definition imaging and stereoscopic vision enables surgeons to perform less-invasive thoracoscopic surgery than would otherwise be feasible.

[Palmar Hyperhidrosis Associated with the Azygos Lobe].

A 66-year-old man visited our department because of palmar hyperhidrosis. Computed tomography had revealed division of the right upper lobe by a fissure and the azygos vein, and the presence of an azygos lobe had been diagnosed. Endoscopic thoracic sympathectomy (resection of T3 ganglion) was performed. Adhesion between the azygos lobe and parietal pleura was dissected to pulling out the azygos lobe and the sympathectomy was safely performed.

[Three-dimensional (3D)-Video-assisted Thoracic Surgery (VATS) and Robot-assisted Thoracic Surgery(RATS)].

We firstly introduced a 3-dimensional system [3D-video-assisted thoracic surgery (VATS)] to the world in 2012, and have since performed 3D-VATS-lobectomy. From March 2012 to October 2019, 224 patients for lung cancer were treated by 3D-VATS. Since then, we have added resection of mediastinal tumors and 3D-uniportal-VATS. One of the advantages of the 3D-VATS is the spatial depth. The disadvantages are a bad mood and dizziness. Since the introduction of robot-assisted thoracic surgery (RATS) in April 2018, its use has become widespread, even in Japan. RATS has the potential for enormous growth in the future. To avoid any risk of surgery, safety measures are important to the team from around the day. In the near future, there will be a distinction between robotic surgery and 2D, 3D-VATS.

CT findings of a displaced left upper division bronchus in adults: its importance for performing safe left pulmonary surgery.

PURPOSE: The aim of this study was to describe the CT findings of a displaced left upper division bronchus (DLUDB) in adults. MATERIALS AND METHODS: Ten patients with DLUDB were identified. The following CT features were assessed: origin of the DLUDB; distance between the origin of the DLUDB and the origin of the left upper lobe (LUL) bronchus; height of the origin of the DLUDB against the left pulmonary artery (LPA); difference of the main bronchial length; ventilated segment; course of the left pulmonary artery against the DLUDB; and presence of an accessory fissure or other anomalies. RESULTS: DLUDB arose from the posterolateral or lateral aspect of the left main bronchus immediately proximal to the origin of the LUL bronchus. It tended to course along the posterior wall of the LPA and to ventilate the apicoposterior segment with or without the anterior segment. The LPA passed between the displaced bronchus and the lingular bronchus. The origin of the DLUDB was located lower than the inferior wall of the proximal LPA in 6 patients. The accessory fissure between the associated segment and remaining part of the LUL and right tracheal bronchus coexisted in 7 and 3 patients respectively. CONCLUSION: DLUDB has characteristic findings on CT. Radiologists should be aware of this entity and inform the surgeon as it can prevent serious complications in a patient who may undergo lobectomy of the left lung.

[Single-incision thoracoscopic surgery( SITS) for mediastinal disease].

The use of single-incision laparoscopic surgery is spreading widely, even in Japan, however, in the field of thoracic surgery, there exist no previous reports on the use of the Wound retractor system in single-incision thoracoscopic surgery (SITS) for mediastinal disease. We herein describe the 1st cases of video-assisted SITS of the mediastinum. Fifteen patients (5 males, 10 females) with mediastinal disease underwent SITS. The average age of the patients was 66.8( 44 ~ 90) years. The mean operative time was 186.2 minutes. Chest drainage tubes were not placed in 12 cases. Chest tubes were removed after 2.5 days in three cases. The mean postoperative hospital stay was 3.3 (2 ~ 8) days. In this report, the use of an access instrument for SITS is presented. We performed extended thymectomy using Vein harvest during surgery in patients with myasthenia gravis. The device could be handled successfully, thereby avoiding interferences between the operator and assistants. In conclusion, we believe that SITS is a feasible and safe procedure that is beneficial in selected cases.

Carcinosarcoma of the duodenum: Report of a case.

This report describes a case of carcinosarcoma of the duodenum. Carcinosarcoma of the duodenum is a very rare tumor. A 72-year-old man was referred to the hospital because of appetite loss. Endoscopy demonstrated an irregularly depressed lesion (type 3) in the descending portion of the duodenum opposite to the ampulla of Vater. Computed tomography showed a thickened duodenal wall and swelling of the abdominal para-aortic lymph nodes. A biopsy specimen revealed a well-differentiated adenocarcinoma. A diagnosis of duodenal carcinoma was made (cT3, cN1, cM1, cStage IV according to the TNM classification). A subtotal stomach-preserving pancreatoduodenectomy and a lymph node resection were performed. On microscopic examination, adenocarcinoma cells and spindle type sarcoma cells were observed separately in the descending portion of the duodenum opposite to the ampulla of Vater. The adenocarcinoma cells were stained with antibodies against epithelial markers keratin and carcinoembryonic antigen for immunohistochemical analyses. In contrast, the sarcoma cells were stained with antibodies to vimentin and smooth muscle actin. The pathological diagnosis of a true duodenal carcinosarcoma was thus made.

Simultaneous occurrence of partial anomalous pulmonary venous return and major bronchial anomaly: computed tomography findings in 5 adult patients.

OBJECTIVE: The objective of this study was to describe the computed tomography (CT) findings of 5 adult patients with a combination of partial anomalous pulmonary venous return (PAPVR) and major bronchial anomaly. METHODS: A computerized search of the radiological database records of 4886 consecutive patients who underwent chest CT from April 2005 to May 2007 described 2 patients with a combination of PAPVR and tracheal bronchus (TB). Three additional patients with a combination of PAPVR and TB or accessory cardiac bronchus (ACB) were obtained by reviewing the CT images of the patients initially diagnosed as having PAPVR, TB, or ACB at our institution during the same period. The CT findings of these 5 patients were analyzed. RESULTS: Four patients had a combination of right PAPVR and right TB, and 1 patient had a combination of left PAPVR and ACB. These combinations were found in 42% (5/12) of patients with PAPVR, 16% (4/25) of patients with TB, and 14% (1/7) of patients with ACB. In 4 patients with a combination of right PAPVR and right TB, the anomalous vein was draining the right upper lobe and draining into either the posterior aspect of the superior vena cava (SVC) or the terminal portion of the azygos arch. The origin of the TB was the trachea in 1 patient and the carina in 2 patients. Two distinct TBs presented in 1 patient; the first TB was from the lower trachea, and the second was from the right main bronchus. The right upper lobe affected by PAPVR included the territory ventilated by the TB in all 4 patients. CONCLUSION: A combination of right PAPVR draining to the superior vena cava or azygos arch and right TB is most common. The possibility that the PAPVR and a major bronchial anomaly might coexist in 1 patient should be considered whenever either of them is encountered on CT.

[A case of long-term survival of postoperative brain metastasis of small cell lung cancer effectively treated with chemotherapy, whole brain radiotherapy and stereotactic radiosurgery].

A 63-year-old woman underwent right upper lobectomy for small cell carcinoma. She received a total of 2 courses of carboplatin and etoposide infusion as adjuvant therapy. One year after the operation, because of elevated serum Pro GRP levels and a metastatic brain tumor revealed by CT, 4 courses of IP therapy (irinotecan 60 mg/m(2), day 1, 8, 15 and cisplatin 60 mg/m(2), day 1, every 4 weeks) and whole brain radiotherapy (2 Gy f, 5 f/week, total 40 Gy) were given. A complete response was obtained, but a tumor relapse occurred ten months after the last chemotherapy. We then performed a stereotactic radiosurgery (marginal dose: 22 Gy, maximum dose 44 Gy), and one month later MRI showed the tumor had shrunk markedly. FDG-PET showed no intensive uptake, suggesting that there was no remaining viable tumor. No severe side effects were observed during these treatments. Currently, the patient has been alive with good performance status and no signs of relapse.

Feasibility trial of adjuvant chemotherapy with paclitaxel and carboplatin after surgical resection in Japanese patients with non-small cell lung cancer: report of the Lung Oncology Group in Kyushu (LOGIK) protocol 0501.

OBJECTIVES: The present study was designed to determine whether adjuvant chemotherapy with paclitaxel (TXL) and carboplatin (CBDCA) after surgical resection is feasible in Japanese patients with non-small cell lung cancer (NSCLC) in a multiinstitutional trial. METHODS: From August 2005 to March 2006, 34 patients received the following regimen: TXL (175 mg/m2) and CBDCA (AUC = 5) on day 1, every 3 weeks. The primary endpoint of this trial was the completion rate of four cycles. RESULTS: The completion rate of four cycles was 79.4% [90% confidence interval (CI), 67.5%-91.3%]. Perfect completion rate of four cycles on schedule and full doses without delay was 50% (90% CI, 34.9%-65.1%). The reasons for incomplete cycles were hypersensitivity to TXL infusion during the first cycle in 3 patients, patients refusal in 2, and anemia and cerebral infarction in 1 patient each. As a consequence of delay and/or dose reductions, the relative dose intensity of TXL and CBDCA was 86.2% and 85.8%, respectively. CONCLUSION: Doublet chemotherapy with TXL and CBDCA in the planned doses and schedule was found to be a feasible treatment for Japanese patients following surgical resection for NSCLC:

[A case of postoperative multiple pulmonary metastases of non-small-cell lung cancer successfully treated with S-1].

We report a case of postoperative multiple pulmonary metastases of NSCLC successfully treated with S-1. A 72-year-old man underwent rt. lower lobectomy + ND 2 a by VATS. The histopathological examination showed squamous cell carcinoma, pT4 (satellite nodules in same lobe) N0M0. Multiple pulmonary metastases appeared 3 months after operation. We started combination chemotherapy with S-1 and CBDCA. S-1 (100 mg/body) was administered on days 1-21. CBDCA (AUC=5.0) was administered on day 8. Multiple pulmonary metastases almost disappeared after 2 courses of combination chemotherapy. After 6 courses of combination chemotherapy with S-1 and CBDCA, we then converted to S-1 only. Every cycle was repeated every 5 weeks. One year later, there was no sign of disease progression. S-1 is considered to be effective and safely administered in patients with NSCLC.

Comparison of surgical outcome using the prediction scoring system of E-PASS for thoracic surgery.

OBJECTIVE: The purpose of this study was to determine if our predictive scoring system, E-PASS, can estimate the surgical outcome. METHODS: We conducted a multicenter cohort study for 3 years in four national hospitals. A consecutive series of 731 patients who underwent elective thoracic operations were analyzed. The preoperative risk score (PRS) and the comprehensive risk score (CRS) of the E-PASS were determined preoperatively and immediately after the operation, respectively. The cost of the surgical admission and the severity of the postoperative complications were recorded at the time of discharge. RESULTS: The CRS significantly correlated with the severity of the postoperative complications (rs = 0.728, P < 0.0001) and the charge (rs = 0.530, P< 0.0001). When the estimated/real morbidity ratio (MR) among the hospitals was compared, it varied from 0.16 to 0.59. A significant increase in the cost was observed according to the CRS. CONCLUSION: The E-PASS scoring system may be useful for standardizing the patient population and surgical severity to compare the surgical outcome.

[Minimally invasive surgery for primary hyperhidrosis].

Nine hundred twenty-three thoracoscopic sympathectomies for primary hyperhidrosis were performd in 462 patients (180 men, 282 women). Mean age was 29.2 (11-61) years. Synchronous bilateral sympathectomies were performed in 461 patient: right side alone in 1 patient. We started thoracic sympathectomy for primary hyperhidrosis under a thoracoscope using a 10 mm rigid endoscope in 1992. At present, we perform the surgery using a 3 mm rigid scope. The majority of our patient were satisfied with the result of operation. There is general agreement that postoperative side effect, such as compensatory and gustatory sweating, can cause discomfort and affect overall success. Thoracoscopic sympathectomy for primary hyperhidrosis is minimally invasive surgery and provides less pain and better cosmesis and short hospital stay, as compared with the conventional techniques. However, new technique is necessary to decrease compensatory sweating after the operation in the future and we should undergo a meticulous and critical selection to the patients in outpatient clinic.

Novel approach for a pulmonary bronchogenic cyst: a report of a case.

We present a case of a bronchogenic pulmonary cyst in a 48-year-old patient. We performed [corrected] mucoclasis using argon laser photocoagulation following resection of mucosa, closure of some drainage bronchus, and covering of the inner surface by the intrapulmonary bronchogenic cyst with an [corrected] absorbable vicryl mesh. At [corrected] 4-year [corrected] follow-up, the patient had no signs of recurrence.

A randomized trial of adjuvant chemotherapy with uracil-tegafur for adenocarcinoma of the lung.

BACKGROUND: In a previous phase 3 trial of adjuvant chemotherapy after resection of non-small-cell lung cancer, a combination of uracil and tegafur (often referred to as UFT) taken orally was shown to prolong survival. A subgroup analysis disclosed that most patients who benefited had pathological stage I adenocarcinoma. METHODS: We randomly assigned patients with completely resected pathological stage I adenocarcinoma of the lung to receive either oral uracil-tegafur (250 mg of tegafur per square meter of body-surface area per day) for two years or no treatment. Randomization was performed with stratification according to the pathological tumor category (T1 vs. T2), sex, and age. The primary end point was overall survival. RESULTS: From January 1994 through March 1997, 999 patients were enrolled. Twenty patients were found to be ineligible and were excluded from the analysis after randomization; 491 patients were assigned to receive uracil-tegafur and 488 were assigned to observation. The median duration of follow-up for surviving patients was 73 months. The difference in overall survival between the two groups was statistically significant in favor of the uracil-tegafur group (P=0.04 by a stratified log-rank test). Grade 3 toxic effects occurred in 10 of the 482 patients (2 percent) who actually received uracil-tegafur. CONCLUSIONS: Adjuvant chemotherapy with uracil-tegafur improves survival among patients with completely resected pathological stage I adenocarcinoma of the lung.

Lung adenocarcinoma with coexisting pulmonary cryptococcoma.

A 73-year-old female was referred to our hospital in June 2000 for the evaluation of an abnormal shadow in the left upper lobe of her lung and two other shadows in the left lower lobe. A computed tomography examination revealed an ill-defined tumor with ground glass opacity in the left upper division segment, suggesting a primary lung adenocarcinoma, and two well-defined nodules in the left lower lobe, suggesting metastatic carcinomas. A transbronchial lung biopsy of the tumor in the upper division segment confirmed the presence of an adenocarcinoma but failed to provide a histological diagnosis for the nodules in the lower lobe. A partial resection of the left lower lobe using video-assisted thoracoscopy revealed granulomatous tissue with no signs of malignancy. A curative resection of the adenocarcinoma in the left upper division segment was therefore performed. Histologically, the resected specimens obtained from the left lower lobe were diagnosed as cryptococcomas. The patient was diagnosed as having a stage IA lung adenocarcinoma and two cryptococcomas. The patient is presently well and has not experienced any recurrences or relapse for 3 years since the resection.