Extensive Lung Resection for Nontuberculous Mycobacterial Lung Disease With Multilobar Lesions.

BACKGROUND: Nontuberculous mycobacterial lung disease often spreads to multiple lobes, and extensive lung resection (ELR) is sometimes required to control the disease. The safety and feasibility of ELR for nontuberculous mycobacterial lung disease remain unclear, however. METHODS: This retrospective study included patients with nontuberculous mycobacterial lung disease who underwent adjuvant lung resection. Characteristics were compared between patients who underwent ELR and those who underwent simple anatomic lung resection (SALR). The outcome data were analyzed by a Cox regression analysis. RESULTS: A total of 146 patients underwent ELR (n = 54) or SALR (n = 92). ELR was associated with a longer operative time (306 vs 237 minutes; P < .001) and higher incidence of prolonged air leak (17% vs 3.3%; P = .016) than SALR. Rates of mortality, sputum culture conversion (positive to negative), and microbiological recurrence did not differ markedly between the groups. In the multivariate analysis, ELR was not a significant risk factor for an unfavorable outcome after nontuberculous mycobacterial lung disease surgery (hazard ratio, 2.23; 95% confidence interval, 0.82-6.03; P= .11). CONCLUSIONS: ELR for nontuberculous mycobacterial lung disease has some drawbacks compared with SALR but seems as safe and feasible as SALR. ELR may provide improved disease control in some cases of nontuberculous mycobacterial lung disease with multilobar lesions.

Outcomes and risk factors after adjuvant surgical treatments for Mycobacterium avium complex lung disease.

BACKGROUND: Limited information is currently available on the postoperative outcomes of Mycobacterium avium complex lung disease (MAC-LD). OBJECTIVE: To show the outcomes of pulmonary resection and identify risk factors after adjuvant surgical treatments for MAC-LD. METHODS: One hundred and eight patients underwent adjuvant lung resection for MAC-LD at two hospitals between January 2008 and July 2016. We retrospectively evaluated outcomes and risk factors. RESULTS: Postoperative complications occurred in 14 patients (13%). After lung resection, 98 out of 108 patients (91%) achieved sputum culture conversion, eight (8.2%) of whom developed microbiological recurrence during the follow-up period. As a result, the success rate of adjuvant surgical treatments for MAC-LD with drug resistance was 83%. A multivariable analysis showed that a longer period from the initial medical treatment to surgery (hazard ratio, 1.01; 95% confidence interval, 1.00-1.02; p = 0.008) was independently associated with an increased risk of unfavorable outcomes after adjuvant surgery. CONCLUSIONS: Adjuvant surgical treatments for MAC-LD have acceptable outcomes. Better control of the disease may be achieved in some patients with drug resistance and indications for surgery through surgical treatments, and pulmonary resection needs to be performed earlier rather than continuing chemotherapy in these patients because it reduces unfavorable outcomes.

[CHANGES IN MAC ANTIBODY LEVELS BEFORE AND AFTER SURGERY AND AT THE TIME OF RELAPSE/RECURRENCE IN MAC LUNG DISEASE--Can MAC Antibodies Be an Indicator of Postoperative Relapse/Recurrence?].

BACKGROUND: Patients receiving surgical treatment for Mycobacterium avium complex (MAC), lung disease should be followed up with careful attention paid to relapse/recurrence, but there is some debate regarding the findings based on which relapse/recurrence should be diagnosed. PURPOSE AND METHODS: We hypothesized that we might be able to use anti-GPL core IgA antibodies (MAC antibodies), which have been attracting attention as a factor that may support diagnosis of MAC lung disease, to diagnose postoperative relapse/recurrence. Therefore, we compared the levels of these antibodies before and at the time of relapse/recurrence, and also compared antibody titers before and after surgery. RESULT: MAC antibody titers were elevated by an average of about 50% at the time of relapse/recurrence compared to those before relapse/recurrence for 6 patients. In contrast, MAC antibody titers were about 30% lower after surgery compared to those before surgery for 37 patients. CONCLUSION: It may be possible to use MAC antibodies as an indicator of postoperative relapse/recurrence for MAC lung disease.

[SURGICAL TREATMENT FOR TWENTIES PATIENTS WITH PULMONARY NONTUBERCULOUS MYCOBACTERIOSIS RESISTING CHEMOTHERAPY].

SUBJECTS AND METHODS: We report five cases of surgical treatment for pulmonary nontuberculous mycobac- teriosis (NTM) resisting chemotherapy in twenties. Of the five, one was male and four were female. They had cavitary or nodular lesion in their lung. After chemotherapy, partial resection or lobectomy was performed. RESULT: Though postoperative chemotherapy had contin- ued for only 6 months or 1 year, there was no relapse/recurrence at more than 86 months in average after surgery. Consideration. In younger patients, NTM lesions in the lung are sometimes more localized than senior patients, therefore they can be removed as a smaller portion by the operation, and we can sometimes keep more pulmonary function of the patient. CONCLUSION: Surgical treatment for twenties patients with pulmonary nontuberculous mycobacteriosis resisting chemo- therapy should be carried out aggressively at an early stage to resect a smaller portion of the lung and also decrease relapse/ recurrence after surgery.

[A STUDY OF SURGICAL TREATMENT FOR PATIENTS WITH MYCOBACTERIUM ABSCESSUS PULMONARY DISEASE AND A COMPARATIVE EXAMINATION OF MYCOBACTERIUM AVIUM COMPLEX DISEASE].

OBJECTIVE: This is a retrospective study on six surgical cases of Mycobacterium abscessus pulmonary disease, including a comparison with M. avium complex (MAC) disease. SUBJECTS AND METHODS: We performed surgery for six cases of M. abscessus pulmonary disease between July 2012 and June 2014. In all the cases, video-assisted thoracic surgery alone was performed. Age, sex, bacillus identification method, disease type, preoperative anti-glycopeptidolipid core immunoglobulin A antibody value, preoperative chemotherapy, preoperative chemotherapy period, adaptation of the operation, surgical method, result of the bacillus culture of an organization that was extracted at operation, postoperative hospitalization period, surgical complications, and postoperative relapse were examined for the six cases of M. abscessus pulmonary disease. In addition, the cases were compared with 36 cases of MAC disease for which operation was performed during the same period. RESULT: None of the patients had major surgical complications or in-hospital death. Although three patients survived for more than 1 postoperative year and completed chemotherapy, relapses are not accepted in all cases at present. In the comparison with MAC disease, the mean preoperative chemotherapy period for M. abscessus pulmonary disease was 5.5 months, which was 18.9 months shorter than that for MAC disease, with a statistically significant difference. CONCLUSION AND CONSIDERATION: Surgery for M. abscessus pulmonary disease may be considered a safe and effective therapeutic procedure. Moreover, some physicians believe that surgical treatment is required at an earlier stage of M. abscessus pulmonary disease compared with MAC disease.

Complications after video-assisted thoracic surgery in patients with pulmonary nontuberculous mycobacterial lung disease who underwent preoperative pulmonary rehabilitation.

[Purpose] Video-assisted thoracic surgery and preoperative pulmonary rehabilitation are effective in preventing postoperative complications in patients with cardiopulmonary disease. The present study aims to elucidate the presence of postoperative pneumonia and atelectasis in patients with nontuberculous mycobacterial lung disease who underwent lung resection with video-assisted thoracic surgery and preoperative pulmonary rehabilitation. [Subjects and Methods] Nineteen patients with nontuberculous mycobacterial lung disease who had undergone lung resection with video-assisted thoracic surgery and preoperative pulmonary rehabilitation were enrolled in this study. The presence of postoperative pneumonia and atelectasis was evaluated, and preoperative and postoperative pulmonary functions were compared. [Results] Postoperative pneumonia and postoperative atelectasis were not observed. Decreases of pulmonary function were 5.9% (standard deviation, 8.5) in forced vital capacity (percent predicted) and 9.6% (standard deviation, 11.1) in forced expiratory volume in 1 s (percent predicted). [Conclusion] The present study indicates that the combination of lung resection with video-assisted thoracic surgery and preoperative pulmonary rehabilitation in patients with nontuberculous mycobacterial lung disease may be effective in preventing postoperative complications.

[A study of relapse/recurrence cases after surgical treatment for patients with pulmonary nontuberculous mycobacteriosis].

PURPOSE: This is a retrospective study on relapse/recurrence of surgical cases of pulmonary nontuberculous mycobacteriosis (NTM). Surgical treatment was performed at one hospital and by one surgeon. METHOD: Fifty patients had undergone surgical treatment from August 2004 to July 2011 in hospital. From this group, 37 patients were selected after one year, and of these, 9 patients had a relapse/recurrence (group A) and the others (28 patients without relapse/recurrence, group B). Data was recorded about their age, gender, pre-operative image score, cavernous lesions, residual lesions after operation, drugs of pre-operative chemotherapy, the duration of pre-operative chemotherapy, the duration of any follow-up after operation, type of mycobacteria, the results of bacterial cultivation of surgical specimens, type of mycobacterium and operative procedure. RESULT: Three factors, the result of bacterial cultivation of surgical specimens, duration of chemotherapy before operation and existence of residual lesions, showed a significant difference statistically. No case with major surgical complication and hospital death was recognized. CONCLUSION: The visible foci should be removed as thoroughly as possible. Pre-operative chemotherapy should not be continued unnecessarily, and surgical treatment should be chosen at an early stage. The results of bacterial cultures of surgical specimens could be very useful for predicting the possibility of relapse/recurrence after operation. Surgical treatments of our patients were carried out safely. However, as the patients have a risk of relapse/recurrence, they require careful monitoring and post-operative chemotherapy over along period.

[Secondary pulmonary hypertension due to pulmonary tumor thrombotic microangiopathy diagnosed by open lung biopsy].

A 67-year-old woman was admitted with progressive exertional dyspnea. Arterial blood gas analysis showed severe hypoxia. A chest radiograph and a computed tomography showed bilateral interstitial infiltrations and patchy ground-grass opacities. Initially, she was given antibiotics with no effect. Since transthoracic echocardiography revealed right ventricular overload, cardiac catheterization was performed, which showed pulmonary hypertension. Pulmonary angiography revealed irregular filling defects along with pulmonary peripheral sites. Open lung biopsy was performed to establish a definitive diagnosis and to treat the diffuse lung disease. Microscopically, multiple tumor thrombi of mucinous adenocarcinoma were found in small sized pulmonary artery. Primary sites of malignancy has not been found in spite of postoperative examinations.

Robot-assisted thoracoscopic lung resection aimed at solo surgery for primary lung cancer.

The surgical robotic system has been advanced as a tool that enables surgeons to perform precision operations of high quality. Many reports have been presented in cardiovascular surgery using the robotic system, but its use is uncommon in general thoracic surgery. We describe our two experiences with single-surgeon video-assisted thoracoscopic surgery lobectomy for primary lung cancer using a remote-controlled robot, named Naviot, to manipulate an endoscope. We believe that Naviot might be one of the robotic devices whose use could lead to solo surgery, even for complicated thoracoscopic procedures such as anatomical pulmonary resections with lymph node dissection.

Mediastinoscopy and mediastinotomy after cardiac surgery: are safety and efficacy affected by prior sternotomy?

BACKGROUND: The diagnostic and staging value of cervical mediastinoscopy is well established. Left anterior mediastinotomy is of further value in assessing left upper lobe tumors. However the efficacy and safety of both these procedures after median sternotomy for cardiac surgery is unknown. METHODS: We undertook a retrospective review of our experience of mediastinal exploration by cervical mediastinoscopy with or without left anterior mediastinotomy in patients with prior sternotomy between 1980 and 2001. RESULTS: During this period 28 patients (25 male and 3 female; mean age, 63 +/- 10 years), all with prior sternotomy for cardiac surgery (14 had left internal mammary artery graft), underwent mediastinal exploration. The mean interval between sternotomy and mediastinal exploration was 7.2 +/- 5.1 years. Additionally, 3 patients also had superior vena cava obstruction. Cervical mediastinoscopy was performed in all 28 patients and additionally left anterior mediastinotomy was undertaken in 7 of 28 patients (4 with left internal mammary artery graft). Indications for exploration were staging of lung cancer in 22 patients (cervical mediastinoscopy, n = 22; left anterior mediastinotomy, n = 7) and diagnostic biopsy of mediastinal mass in 6 patients (cervical mediastinoscopy, n = 6). Thorough mediastinal assessment was possible in all 28 patients. In the 22 patients with lung cancer the median number of lymph node stations sampled during mediastinoscopy was 3 (range, 1 to 5). A specific diagnosis was obtained in 16 patients (metastatic lung cancer, n = 10; lymphoma, n = 3; sarcoidosis, sinus histiocytosis, and metastatic melanoma, n = 1 each). The other 12 patients with negative findings underwent pulmonary resection and only 1 of 12 (8%) patients had unexpected N2 disease, a similar proportion to our overall experience with lung cancer. There were no operative complications. CONCLUSIONS: Prior sternotomy for cardiac surgery does not compromise the efficacy and the safety of mediastinoscopy and mediastinotomy.

Peripheral lung adenocarcinomas: 10 mm or less in diameter.

BACKGROUND: Few reports have been published regarding peripheral lung adenocarcinomas that are 10 mm or less in diameter. This is considered to be the smallest tumor size detectable by present diagnostic modalities. METHODS: Clinicopathologic studies were performed in 57 patients with peripheral lung adenocarcinomas of 10 mm or less in diameter. Outcomes were compared with two other groups that consisted of 32 patients with adenocarcinomas between 11 and 15 mm in diameter and 35 patients with adenocarcinomas between 16 and 20 mm in diameter. Tumors were curatively resected between 1992 and 2002. RESULTS: The mean age was 61.7 years. The following three features were more frequent: female sex (78.9%), nonsmokers (77.2%), and cases with carcinoma detected by computed tomography despite negative chest radiography (96.5%). Negative lymphatic invasion (94.7%) was significantly higher. Three cases showed lymphatic invasion that was classified as types E or F, according to Noguchi's classification. There were no cases of lymph node metastasis, pleural involvement, or intrapulmonary metastasis. Well-differentiated type was in 93.0%. Types A and B, which are noninvasive alveolar replacement-type adenocarcinomas, were significantly dominant (86.0%). The 5-year postoperative survival rate was 97.3%, which was significantly better than in the other two groups (75.5%, 78.1%). CONCLUSIONS: Histopathologic features of most peripheral lung adenocarcinomas of 10 mm or less in diameter were types A and B. Types A and B were considered fundamentally indicated for thoracoscopic wedge resections. However, the other types required the standard operation.

Cervical mediastinoscopy after total laryngectomy and radiotherapy: its feasibility.

OBJECTIVE: The feasibility of cervical mediastinoscopy after total laryngectomy and radiotherapy has not been documented. METHODS: We describe our experience with cervical mediastinoscopy in two patients with total laryngectomy and radiotherapy for squamous cell carcinoma and had a Blom-Singer speaking tracheostomy valve in situ. Both patients presented with mediastinal lymphadenopathy and radiographic features suggesting a new pulmonary malignancy. RESULTS: Rigid bronchoscopy and cervical mediastinoscopy were undertaken and paratracheal and subcarinal lymph nodes were biopsied. Both patients made uneventful post operative recovery. Mediastinal lymph node biopsy was definitive in deciding their further care. CONCLUSION: Cervical mediastinoscopy is feasible in patients with total laryngectomy, tracheostomy and radiotherapy.