Diaphragmatic repair of hepatic hydrothorax with VATS after abdominal insufflation with CO(2).

Hepatic hydrothorax is defined as the presence of a significant pleural effusion that develops in a patient with cirrhosis of the liver who does not have an underlying cardiac or pulmonary disease. There have been few published case reports dealing with hepatic hydrothorax treated surgically. Recently, we treated a patient with refractory hepatic hydrothorax by directly suturing the diaphragmatic defect during VATS. During surgery, the diaphragmatic defect was identified by using abdominal insufflation with CO(2) . The defect was sutured and the diaphragm was covered by polyglycolic acid felt and fibrin glue. After surgery, the patient's pleural effusion improved, his postoperative course was uneventful and he did not require a drainage tube at discharge.

[Localized fibrous mesothelioma with bloody pleural effusion; report of a case].

Diffuse malignant mesothelioma with bloody pleural effusion is not rare, but a localized fibrous mesothelioma with bloody pleural effusion is relatively rare. A 45-year-old woman presented with a localized fibrous mesothelioma causing a bloody pleural effusion. Her chief complaint was right-sided lateral chest pain. A chest roentgenogram demonstrated a right-sided pleural effusion, so a chest tube was inserted, and the bloody fluid drained. A preoperative diagnosis of localized fibrous mesothelioma was made based on chest computed tomography and examination of computed tomographic guided percutaneous needle biopsy specimen. At operation, the tumor seemed to have originated from the right lung parenchyma or had invade the right lower lobe because tumor had penetrated deeply in the lung. Tumor and part of the parietal pleura were resected by right lower lobectomy. Final pathology established that the tumor was adherent to the right lung and was only encapsulated by the lung.

[Current condition of early peripheral lung cancer and related problems].

Early peripheral lung cancer is defined as a tumor whose diameter is within 20 mm and that has not metastasized to lymph nodes. We developed thoracoscopic surgery (two windows method) in 1993. We have been conducting this thoracoscopic surgery in early peripheral lung cancers to identify possible indications as well as to clarify problems related to early peripheral lung cancer. The subjects of this study were 176 tumors, with diameters within 30 mm, including 97 lung cancers with diameters within 20 mm. Of the 97 tumors 20 mm or less in diameter, 18 were N 1 or more severe (N 1, 8 cases: N 2, 10 cases). One patient (N 2) died of bone metastasis and two patients died due to diseases other than lung cancer. Nearly 20% of the patients with tumors 20 mm or less were in the advanced stage, suggesting that mediastinal lymph node resection is necessary. Based on these results, it is advisable to define tumors with a diameter of no more than 10 mm as early peripheral lung cancer.

FDG uptake in the morphologically normal thymus: comparison of FDG positron emission tomography and CT.

The purpose of this study was to evaluate the correlation between fluorine-18 fluorodeoxyglucose (FDG) thymic uptake and a normal appearing thymus on CT. Non-attenuation corrected FDG positron emission tomography (PET) data from 94 young persons (mean age 25.4 years, range 18-29 years) with a normal thymus diagnosed on CT were retrospectively evaluated. No subject had clinical symptoms suggestive of thymus-related disease or mediastinal tumour (follow-up period 6-69 months). PET images were visually assessed and the count ratio between the thymus and the lung (T/L ratio) was calculated. Increased FDG uptake occurred in 32 (34%) subjects. In these 32 cases, the T/L ratio was 2.86+/-0.49 (range 2.02-3.99). In 86 subjects whose CT images were available to calculate the CT attenuation of the thymus (CAT), the CAT value was -17.5+/-45.7 HU (range -103.6 HU to 79.9 HU). The T/L ratio correlated with the CAT value (r=0.58). CAT values in subjects with positive PET findings were significantly higher than CAT values in subjects with negative PET findings (p<0.001, unpaired t-test). These results suggest that even in young adults, if the thymus has a relatively high CT attenuation value, the presence of physiological thymic uptake in FDG-PET is a normal variant. In this study, the diagnosis of normal thymus was based on CT appearance and clinical course. Further studies are needed to clarify the relationship between histopathology and FDG uptake in the thymus.

18F-FDG PET detection of colonic adenomas.

UNLABELLED: The adenomatous polyp of the colon is clinically important as a precursor of colonic cancer. The aim of this preliminary study was to evaluate the potential usefulness of (18)F-FDG PET for detecting adenomatous polyps of the colon. METHODS: We performed a retrospective study of 110 subjects who underwent both PET study and total colonoscopy. On nonattenuation-corrected PET images, focal distinct FDG accumulation along the large intestine was considered a positive finding, and the PET results were compared with colonoscopic findings. Histology and adenoma size were determined by polypectomy. RESULTS: Fifty-nine adenomatous polyps, 5-30 mm in size, were found in 30 subjects by total colonoscopy. PET findings were positive for 14 of the 59 adenomas (24%). The positivity rate for PET images rose with the increase in size of the adenomas; it was 90% in adenomas (9/10) that were > or =13 mm. The overall false-positive rate was 5.5% (6/110 subjects). CONCLUSION: Increased glucose metabolism is observed in colonic adenomas, and detectability with PET increases with the increase in adenoma size. Adenomas are premalignant lesions, and it is important to realize that colonic adenomas may be found incidentally during an FDG PET study.

Blunt chest trauma with deep pulmonary laceration.

BACKGROUND: Deep pulmonary laceration (DPL) is rare and its survival rate is low. The present study focused on the prognostic factors of DPL. METHODS: The present study concerned 17 DPL patients treated in Tokai University Hospital between 1988 and 1998. The prognostic factors of DPL were compared with systolic blood pressure (SBP), PaO2, and the volume of intrathoracic blood loss. Characteristic findings of initial chest roentgenograms of DPL were investigated. RESULTS: Eleven patients were saved and 6 patients died. An SBP of less than 80 mm Hg on arrival at the hospital and a blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival were poor prognostic factors. Hypoxemia on arrival was not a poor prognostic factor. Chest roentgenograms showed macular infiltrative shadow with moderate lung collapse and deviation of the mediastinal shadow toward the unaffected side. Selective bronchial occlusion with a Univent prevented suffocation by intrabronchial blood. CONCLUSIONS: Two poor prognostic factors of DPL are SBP less than 80 mm Hg on arrival and blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival.

Is it permissible to omit mediastinal dissection for peripheral non-small-cell lung cancers with tumor diameters less than 1.5 cm?

BACKGROUND: Recently the pros and cons of limited surgery for small-sized peripheral non-small-cell lung cancers (PNSCLCs), such as omission of mediastinal dissection, etc., have been vigorously debated. We analyzed whether hilar/mediastinal lymph node metastases were present in 30 small-sized PNSCLCs. MATERIAL AND METHODS: In the nine years from 1990 to 1998, 294 lung cancer patients underwent lobectomy or pneumonectomy combined with hilar/mediastinal dissection in the Tokai University Hospital. Thirty of these patients diagnosed as having cT1N0M0 PNSCLC with tumor diameters of 1.5 cm or less by computed tomography, are evaluated in this article. RESULTS: The 30 PNSCLC patients consisted of 14 males and 16 females with a mean age of 61 +/- 9 years. Twenty six patients (87%) had no hilar nor mediastinal lymph node metastases (pN0), one patient (3%) had a hilar lymph node metastasis (pN1), and three patients (10%) had mediastinal lymph node metastases (pN2). CONCLUSIONS: Mediastinal lymph node metastases were histologically observed in 3 (10%) of 30 PNSCLC patients with tumor diameters of 1.5 cm or less. Our results show that mediastinal dissection is still necessary even for small-sized lung cancers.

Usefulness of video-assisted thoracic surgery (Two Windows Method) in the treatment of lung cancer for elderly patients.

BACKGROUND: We have been performing it less invasively by making just two, small skin incisions (Two Windows Method) for lung cancer surgery. We assess the usefulness of VATS by the Two Windows Method in elderly patients. METHODS: The subjects were 32 of the 75-year-old or older patients with primary lung cancer in our department. We assessed cases in which thoracotomy was performed and the cases in which VATS by Two Windows Method was performed, and compared postoperative complications, hospital deaths, and postoperative length of stay. RESULTS: Operations by video-assisted thoracic surgery (VATS) by the Two Windows Method were completed in 20 of the 32 patients, and a conversion to thoracotomy was done in two patients (rate 9%). Ultimately, thoracotomy was performed in a total of 12 cases, including these two. In the thoracotomy patients, the most common postoperative complication was pneumonia/atelectasis (4 cases) secondary to poor sputum expectoration. There were 2 hospital deaths due to septicemia, and there was 1 due to pulmonary artery embolism. In the VATS patients, the rate of occurrence of postoperative complications was 30%, and clearly lower than the 67% among the thoracotomy patients (p<0.05). No hospital death occurred among the VATS patients. The postoperative hospital stay of the VATS patients (21 days) was shorter than that of the thoracotomy patients (31 days), (p<0.05). CONCLUSIONS: VATS by the Two Windows Method is safer than thoracotomy, and it should be considered first for lung cancer surgery in the aged.

Thoracoscopic diagnosis and treatment of mediastinal masses. Usefulness of the Two Windows Method.

BACKGROUND: We report on the usefulness of thoracoscopic surgery by the Two Windows Method in mediastinal diseases. While the positioning of the two-window skin incisions was originally decided for lung cancer, but we have been using precisely the same method to biopsy and remove mediastinal lesions. METHODS: Thoracoscopic surgery by the Two Windows Method was performed in 40 cases in which it had been impossible to make a diagnosis by noninvasive methods. Access to the pleural cavity was achieved by making skin incisions in two places anterior and posterior to the inferior angle of the scapula in the fourth intercostal space. RESULTS: Biopsy was performed in 17 of the 40 patients to make a histological diagnosis. It was possible to make a definitive histological diagnosis in all of the patients. Complete resection of a mediastinal tumor was performed in 23 patients, and the resection was concluded thoracoscopically by the Two Windows Method in 22 of these patients (95.7%), with the only exception of one patient in whom we converted to standard thoracotomy because of intraoperative bleeding. There were no postoperative complications and no perioperative deaths. CONCLUSIONS: We conclude that the Two Windows Method is also useful for the diagnosis and complete resection of mediastinal diseases and that this is a low-invasive and safe method.

Application of the fold plication method for unilateral lung volume reduction in pulmonary emphysema.

BACKGROUND: Unilateral lung volume reduction procedures are used to treat pulmonary emphysema. The most significant technical problem with this operation is an air leak from the pulmonary stump. Bovine pericardium has been used to prevent air leaks but is associated with interstitial pneumonia and a high cost. METHODS: The fold plication method was devised to prevent postoperative air leaks to avoid interstitial pneumonia, and to decrease cost. This technique was applied in 20 consecutive patients with emphysema who underwent a unilateral lung volume reduction operation via a thoracoscopic two windows approach. RESULTS: The operative time was approximately 1 hour. There was minimal postoperative bleeding, no persistent air leaks, and no evidence of pneumonia. Pulmonary function improved in all patients. CONCLUSIONS: The unilateral fold plication method is an economical and safe alternative to bovine pericardial patching after lung volume reduction operation to prevent stump air leaks.

A new device for thoracic access: the Thoraco Holder.

BACKGROUND: We present a novel invention (Thoraco Holder; Fuji Systems Corporation, Tokyo, Japan) for thoracoscopic surgery. Made of silicone, automatically stops bleeding from the chest wall, increases range of motion for manipulation, and decreases postoperative pain. METHODS: Under general anesthesia using the Univent tube (Fuji Systems Corporation, Tokyo, Japan), two Thoraco Holders were used in each of 300 thoracoscopic procedures for lung cancer, mediastinal tumor, pneumothorax, chest trauma, and emphysema, most using the Two Windows Method). RESULTS: No patient experienced more than 10 mL of bleeding from the chest wall. In addition, analgesics were not needed by any patient for over 1 week. No patient experienced trouble caused by the Thoraco Holder. CONCLUSIONS: The Thoraco Holder is made of silicone. Silicone rubber causes less pain postoperatively. The silicone cuff (balloon) causes less bleeding from the chest wall. This Thoraco Holder is useful access for video assisted thoracoscopic surgery.

Experience with the two-windows method for mediastinal lymph node dissection in lung cancer.

BACKGROUND: Continuing to refine minimally invasive thoracoscopic surgical procedures, we have established the two-windows method. METHODS: Skin incisions required by this method consist of a 2- to 3-cm skin incision posteriorly, and a 2- to 3-cm skin incision anteriorly in the fourth intercostal space, with the inferior angle of the scapula as the midpoint. We used this method to perform pulmonary lobectomies in combination with thoracoscopy and mediastinal lymph node dissection in 100 consecutive patients with lung cancer (preoperative diagnosis, stage I, T1 N0 M0). RESULTS: The mean operative time was 2 hours 46 minutes, the mean blood loss was 68.2 mL, and the mean number of mediastinal lymph nodes dissected was 24.3. In developing this minimally invasive thoracoscopic procedure, which facilitates mediastinal lymph node dissection, we realized that it is best performed through the fourth intercostal space. Because the tracheal bifurcation can be seen directly below this level, surgical manipulation in this area can be easily performed. This enables the same extent of mediastinal lymph node dissection as that performed during a standard thoracotomy. Another advantage of this method is that a standard posterolateral thoracotomy incision can be made whenever necessary by simply connecting the two incisions. CONCLUSIONS: We believe that the two-windows method is capable of serving as the standard method for the surgical treatment of stage I lung cancer.

Thoracoscopic surgery for lung cancer using the two small skin incisional method. Two windows method.

Pulmonary lobectomy and mediastinal lymph node dissection was performed in 25 patients with Stage I lung cancer under thoracoscopic guidance using the two-windows method. A posterior skin incision (3 cm) and lateral skin incision (2 cm) were made in the 4th intercostal space centering on the inferior angle of the scapula. The site closest to the operating surgeon was used for direct vision, while the distant site was used for insertion of the thoracoscope. The mean operative time was 2 hours and 15 minutes, and the mean blood loss was 82.6 ml. The mean number of dissected mediastinal lymph nodes was 32. The length of hospitalization ranged from 5 to 17 days. Recovery was uneventful, and analgesics were not required by postoperative day 6. The two-windows method overcomes the three-dimentional inaccuracy due to the one-directional observation of the operative field employed during conventional thoracoscopy. In addition, since we developed this method for mediastinal lymph node dissection, the tracheal bifurcation can be confirmed under direct vision, increasing the accuracy of the procedure. The advantages of the two-window thoracoscopic method of pulmonary lobectomy are cosmesis, preservation of respiratory function, and reduced postoperative pain. In addition, there is reduced intraoperative bleeding and shortened operative time, while achieving mediastinal dissection similar to that of standard thoracotomy. The two-windows method of thoracoscopic pulmonary lobectomy is equal or superior to standard thoracotomy in every respect. This method should become the standard surgical technique for Stage I lung cancer.

[Video assisted lung resection and mediastinal lymph nodes dissection for lung cancer: small incisions for 4th intercostal space].

We established a thoracotomy method in which visual observation and a thoracoscope are used in combination. This method requires only small dermal incision--a three-cm-long posterior and two-cm-long anterior incision--in the fourth intercostal space around the angulus inferior scapulae. Using this method, we performed lobectomy and mediastinal lymph node dissection on 20 lung cancer cases (preoperatively diagnosed as stage I, T1N0M0 cases). Because the conventional thoracoscopic surgery relies strictly on two-dimensional images obtained from a thoracoscope, stereoscopic information on the location of the operation could not be obtained. Our new method, however, in corporates both a direct view obtained from two small incisions and a view on a video monitor, so the surgeon has constant access to a stereoscopic information on the location of the operation. We found that this thoracotomy using a thoracoscope was not only very useful in terms of respiratory function, the alleviation of pain, and aesthetic appearance, but that it also reduced hemorrhaging during surgery, decreased the length of time required for the thoracotomy and suturing, and enabled mediastinal dissection equal to that of standard thoracotomy.

Combined apical hypertrophic cardiomyopathy and left atrial myxoma.

A patient had apical hypertrophic cardiomyopathy and left atrial myxoma. We believe that this is the first description of such a combination.