A case of refractory hepatic hydrothorax due to pleuroperitoneal communication successfully controlled by diaphragmatic plication and subsequent peritoneovenous shunting.

In general, control of hepatic hydrothorax is difficult, and patients have a poor prognosis. A case in which hepatic hydrothorax was well controlled for a long time after diaphragm plication and subsequent Denver shunt placement is reported. A 70-year-old man with decompensated liver cirrhosis presented with progressive exertional dyspnea. 5 years before admission, hepatic ascites associated with portal hypertension appeared, and a left pleural effusion subsequently developed. The pleural effusion was not controlled by salt restriction and diuretics. Based on the clinical findings, the existence of pleuroperitoneal communication was strongly suspected, and surgical diaphragmatic plication was performed. After the treatment, the pleural effusion did not accumulate, but ascites increased significantly, and conservative therapy was ineffective. For the treatment of massive ascites, a peritoneovenous shunt (Denver shunt®) was placed. Although more than 2 years have passed, the thoracoabdominal effusions have not accumulated, and the patient has been asymptomatic. The present case suggests that multidisciplinary treatment may improve the prognosis of patients with refractory thoracoabdominal effusions.

Two different methods of bronchial dissection and coverage in robotic bilobectomy for advanced lung cancer.

INTRODUCTION: Due to its many technical advantages, the scope of robot-assisted thoracic surgery (RATS) is expanding to include extended pulmonary resection. Among such procedures, right bilobectomy is one with a high risk of inducing development of a bronchial stump fistula. MATERIALS AND SURGICAL TECHNIQUE: The pericardial fat pad case involved a 71-year-old man with a 31-mm adenocarcinoma in the right lung that had progressed to the intermediate bronchus. During lower bilobectomy, to confirm the tumor margin, an L-shaped stapler was used with stapling only at the oral side, and the bronchus was cut using a scalpel blade grasped with robot forceps. After confirming a negative stump, the pericardial fat was collected at the pedicle and sewn onto the stump. The intercostal muscle (ICM) flap case involved a 61-year-old man with a 16-mm nodule shadow in the lower lobe of his lung and swollen #11i and 7 lymph nodes. Intraoperatively, the #7 lymph node was diagnosed as non-small-cell lung cancer by frozen sections, and lower bilobectomy was performed. The bronchus was divided using a stapler with a green cartridge, and the ICM flap was harvested by changing the direction of the camera to a look-up view and positioning the camera at the 5th intercostal site. His numeric rating score (NRS) at 30 and 90 days post-surgery was 2 and 0, respectively. DISCUSSION: Our RATS technique was useful for harvesting the ICM flap. More cases should be accumulated to extend the surgical indication for RATS.

New evaluation of the tumor immune microenvironment of non-small cell lung cancer and its association with prognosis.

BACKGROUND: A better understanding of the tumor immune microenvironment (TIME) will facilitate the development of prognostic biomarkers and more effective therapeutic strategies in patients with lung cancer. However, little has been reported on the comprehensive evaluation of complex interactions among cancer cells, immune cells, and local immunosuppressive elements in the TIME. METHODS: Whole-exome sequencing and RNA sequencing were carried out on 113 lung cancers. We performed single sample gene set enrichment analysis on TIME-related gene sets to develop a new scoring system (TIME score), consisting of T-score (tumor proliferation), I-score (antitumor immunity) and S-score (immunosuppression). Lung cancers were classified according to a combination of high or low T-score, I-score, and S-scores (eight groups; G1-8). Clinical and genomic features, and immune landscape were investigated among eight groups. The external data sets of 990 lung cancers from The Cancer Genome Atlas and 76 melanomas treated with immune checkpoint inhibitors (ICI) were utilized to evaluate TIME scoring and explore prognostic and predictive accuracy. RESULTS: The representative histological type including adenocarcinoma and squamous cell carcinoma, and driver mutations such as epidermal growth factor receptor and TP53 mutations were different according to the T-score. The numbers of somatic mutations and predicted neoantigens were higher in Thi (G5-8) than Tlo (G1-4) tumors. Immune selection pressure against neoantigen expression occurred only in Thi and was dampened in Thi/Ilo (G5-6), possibly due to a reduced number of T cells with a high proportion of tumor specific but exhausted cells. Thi/Ilo/Shi (G5) displayed the lowest immune responses by additional immune suppressive mechanisms. The T-score, I-score and S-scores were independent prognostic factors, with survival curves well separated into eight groups with G5 displaying the worst overall survival, while the opposite group Tlo/Ihi/Slo (G4) had the best prognosis. Several oncogenic signaling pathways influenced on T-score and I-scores but not S-score, and PI3K pathway alteration correlated with poor prognosis in accordance with higher T-score and lower I-score. Moreover, the TIME score predicted the efficacy of ICI in patients with melanoma. CONCLUSION: The TIME score capturing complex interactions among tumor proliferation, antitumor immunity and immunosuppression could be useful for prognostic predictions or selection of treatment strategies in patients with lung cancer.

Spontaneous pneumothorax in a 17-year-old male patient with multiple exostoses: A case report and review of the literature.

BACKGROUND: Multiple exostoses generally develop in the first decade of life. They most frequently arise from the distal femur, proximal tibia, fibula, and proximal humerus. Costal exostoses are rare, contributing to 1%-2% of all exostoses in hereditary multiple exostoses (HME). They are usually asymptomatic, but a few cases have resulted in severe thoracic injuries. Pneumothorax caused by costal exostoses is rare, with only 13 previously reported cases. We report a new case of pneumothorax caused by costal exostoses. CASE SUMMARY: A 17-year-old male with HME underwent surgery for removal of exostoses around his right knee. Four months following the operation, he felt chest pain when he was playing the trumpet; however, he did not stop playing for a week. He was referred to our hospital with a chief complaint of chest pain. The computed tomography (CT) scan revealed right pneumothorax and multiple exostoses in his right ribs. The CT scan also revealed visceral pleura thickness and damaged lung tissues facing the exostosis of the seventh rib. We diagnosed that exostosis of the seventh rib induced pneumothorax. Costal exostosis resection was performed by video-assisted thoracoscopic surgery (VATS) 2 wk after the onset. The patient's postoperative course was uneventful, and there was no recurrence of pneumothorax for 2 years. CONCLUSION: Costal exostoses causing thoracic injuries should be resected regardless of age. VATS must be considered in cases with apparently benign and relatively small exostoses or HME.

Endobronchial brachytherapy as definitive treatment for endobronchial metastasis after surgery of non-small cell lung cancer.

BACKGROUND: Endobronchial metastasis is a very rare type of recurrence after lung cancer surgery. Surgical intervention may be difficult to perform due to the postoperative reduction in the activities of daily living (ADL) and the invasiveness associated with redo surgery. In such cases, endobronchial brachytherapy (EBBT) plays an important role not only as a palliative treatment, but also as a definitive treatment with curative intent. CASE PRESENTATION: Three men (64, 69, and 74 years old) underwent combination therapy of external beam radiation therapy (EBRT) and EBBT for endobronchial metastasis after lobectomy of stage I-II non-small cell lung cancer (NSCLC): 2 cases of squamous cell carcinoma and 1 of adenocarcinoma. We used a special source-centralizing applicator for EBBT to avoid eccentric distribution of the radiation dose. Follow-up was considered to start from the end of brachytherapy. None of our patients experienced severe adverse events, and none needed extensive outpatient treatment. Local control was achieved in all cases by a bronchoscopic evaluation. All patients were alive after 31, 38, and 92 months of follow-up, respectively. In the adenocarcinoma patient, two metastases to the lung were discovered 3 years after EBBT, and the patient underwent partial wedge resection. CONCLUSIONS: EBBT may be a promising treatment with curative intent for endobronchial metastasis after surgery of NSCLC.

Thoracoscopic mediastinal tumor resection by subxiphoid approach-dual port thymectomy plus one (DPT+1).

Thoracoscopic subxiphoid approaches, such as the single-port thymectomy (SPT) and dual-port thymectomy (DPT) approaches have been demonstrated to have several advantages compared with the traditional median sternotomy approach or the bilateral or hemilateral video-assisted thoracoscopic (VATS) approach. However, SPT and DPT are technically demanding for novice surgeons since they require precise concomitant manipulation of surgical instruments and the thoracoscope within the same port, without interference. To overcome these limitations, we have developed a new method, termed DPT plus one (DPT+1), to facilitate separation of the surgical access ports and camera port by adding another intercostal port to the DPT approach. Our method is easy and safe not only for simple mediastinal resection but also for extended thymectomy.

Introduction of thoracoscopic surgery for congenital pulmonary airway malformation in infants: review of 13 consecutive surgical cases.

BACKGROUND: Although complete video-assisted thoracic surgery (C-VATS) has been demonstrated to have several advantages compared with conventional thoracotomy, there are few reports on the clinical feasibility of C-VATS for CPAM in infants. METHODS: We retrospectively evaluated 13 consecutive patients (neonates 4; infants 9) surgically treated for congenital pulmonary airway malformation (CPAM) from 1 January 2008 to 31 March 2017. RESULTS: In the group of neonates, all 4 cases were prenatally diagnosed and they underwent semi-emergent surgery after birth due to respiratory failure. In the group of 9 infants, 5 cases were prenatally diagnosed and 4 cases were diagnosed at age >2.5 years due to symptoms associated with pulmonary cystic infection. Pulmonary resection consisted of the following: 8 lobectomies, 1 segmentectomy, 2 wedge resection, 1 fractionated lung resection and 1 lobectomy with segmentectomy. Overall, there were 9 thoracotomy and 4 thoracoscopic surgeries. Mean operation time was 162 min (range, 67-290 min) and blood loss was 21 mL (range, 0-74 mL) on average. There were no complications such as thoracic deformity or respiratory failure, however in 2 of those who underwent segmentectomy the cystic remnant remained. No statistically significant differences were observed between the thoracotomy Group and C-VATS group in terms of age and height at intervention, operation time, blood loss, postoperative day of drain removal, and length of hospital stay after surgery. However, only the average body weight was heavier in C-VATS group (P=0.03). CONCLUSIONS: Since early surgical resection of asymptomatic CPAM is often recommended for the prevention of infections and the development of lung malignancy, we recommend performing surgery after the age of 1 year if the patient's condition is stable. Furthermore, C-VATS lobectomy may be feasible if they are older than 18 months or weigh more than 10 kg.

[Aortic Valve Regurgitation with Dove-coo Murmur: Report of Two Cases].

We performed aortic valve replacement in 2 patients with aortic regurgitation (AR) in whom a "dovecoo" murmur was heard. Here we discuss the valve shape and the origin of the heart murmur. In the 1st patient, echocardiography revealed prolapse of the right coronary valve cusp toward the left ventricular outflow tract during the diastolic phase and fibrillation of the valve leaflet due to the AR jet. In the 2nd patient, surgical findings revealed thickening of the middle part of the leaflet of the right coronary cusp, which caused prolapse of the right coronary valve cusp toward the left ventricle. We hereby report 2 rare cases of "dove-coo" murmur in which the cause of the murmur was morphologically confirmed by echocardiography in one case and by surgical findings in the other case.

Thymectomy via a subxiphoid approach: single-port and robot-assisted.

BACKGROUND: We have previously reported on single-port thymectomy (SPT), which involves performing thymectomy via a single subxiphoid incision, and trans-subxiphoid robotic thymectomy (TRT), which is performed using the da Vinci surgical system. The aim of this study was to investigate the early surgical outcomes of thymectomy using the SPT and TRT subxiphoid approaches and to discuss their appropriate uses. METHODS: The subjects included 80 patients who underwent thymectomy via a subxiphoid approach. These patients were selected from among 99 surgical cases of myasthenia gravis or anterior mediastinal tumors at Fujita Health University Hospital between March 2011 and November 2015. The patients were divided into a SPT group (n=72) and a TRT group (n=8). RESULTS: The operative time was shorter in the SPT group compared with that in the TRT group (135±48 and 20±40 min, respectively; P=0.0004). There were no significant differences between the groups in terms of blood loss volume (5.9±16.8 and 5.4±4.6 mL, respectively; P=0.48), postoperative hospital stay duration (4.0±2.0 and 4.3±3.6 days, respectively; P=0.21), or the period of postoperative oral analgesic use (10.7±5.4 and 10.1±3.4 days, respectively; P=0.89). There were no intraoperative complications, such as intraoperative bleeding, in either group. In the SPT group, there was one case (1.4%) of postoperative left phrenic nerve paralysis and one case (1.4%) of transient paroxysmal atrial fibrillation. No one died during or after the surgery. CONCLUSIONS: TRT may be as equally minimally invasive as SPT. In cases where the thymoma has infiltrated the surrounding organs, the extent of the infiltration should be used to determine whether to select TRT, or median sternotomy.