Tracheal leiomyoma resected with endobronchial electrocautery snare.

Tracheobronchial leiomyoma is a rare benign tumor, which comprises about 2% of benign tumors of the lower respiratory tract. Bronchoscopic intervention is a minimally invasive treatment, but incomplete resection or recurrence has been reported. We report a case of a 76-year-old woman with a tracheal tumor of 14 mm in diameter incidentally detected on chest computed tomography. Bronchoscopic examination revealed a smooth polypoid tumor which pedunculated from the left side of the cartilaginous tracheal wall. An endobronchial electrocautery snare with flexible bronchoscope was successfully used under general anesthesia and with intubation. The resected specimen was pathologically consistent with leiomyoma. Bronchoscopic intervention can yield successful treatment of pedunculated tracheobronchial leiomyomas, although surgical resection should also be considered in cases of broad-based or iceberg-type leiomyomas because of the risk of incomplete resection or recurrence.

Placement of self-expandable metallic stents for tracheal stenosis secondary to thyroid cancer.

The indications and suitable approaches for treating upper airway obstruction secondary to thyroid cancer are controversial. Patients with thyroid cancer generally have a good prognosis, but airway stenosis and vocal cord paralysis are not uncommon. Subglottic airway stenting may be challenging, due to stent migration, granulation tissue formation and supraglottic stenosis. In this study, we evaluated the application of covered self-expandable metallic stents to relieve upper airway obstruction. This was a retrospective study of 5 patients with airway stenosis due to thyroid cancer treated in 2009 and 2010. Immediate airway enlargement was achieved in 3 patients with stenosis at the middle mediastinum. Gradual enlargement over 2 months was observed in the remaining 2 patients with stenosis at the cervical level. The performance status was improved in all 5 patients, including a case with anaplastic carcinoma. The follow-up averaged 13 months (range, 8-27 months). Granulation tissue developed at both ends of the stent in 3 patients, sputum was retained in 2 cases and bacterial colonization was detected in all 5 cases. No stent migration was reported. Additional tracheostomy was required in 2 patients, due to proximal tumor growth or progressive bilateral vocal cord paralysis after 10 and 6 months, respectively. In conclusion, stenting for central airway stenosis secondary to thyroid cancer may be beneficial, even in patients with anaplastic carcinoma. Long-term regular bronchoscopic follow-up is required to monitor complications, as patients with thyroid cancer are at high risk of granulation tissue formation, sputum retention and bacterial colonization.

An anomalous unilateral single pulmonary vein associated with a bone morphogenetic protein receptor II gene mutation.

Anomalous unilateral single pulmonary vein (AUSPV), a rare congenital anomaly, is associated with an aberrant course but normal drainage, and resembles arteriovenous malformation (AVM). We treated a 26-year-old man with AUSPV in the right lung and an anomalous segmental pulmonary vein in the left lung. CT revealed a tortuous vascular shadow with an enhancement pattern identical to that of the pulmonary vein, suggesting AUSPV. This was confirmed by pulmonary angiography. Although pulmonary AVMs were not detected on angiography, microvascular AVMs could not be excluded because delayed bubbles appeared on contrast echocardiography. A genetic examination revealed a missense mutation of BMPR2.

Therapeutic bronchoscopy followed by lobectomy for pulmonary sarcoma.

Malignant central airway obstruction is a life-threatening presentation requiring emergency palliative procedure. In selected patients, bronchoscopic intervention could be used as a bridge to curative resection. Here we report a 54-year-old male with pulmonary sarcoma of the right upper lobe, presenting with acute respiratory failure because of endobronchial extension. Emergency coring with the rigid bronchoscope and Dumon stent insertion stabilized the patient, and subsequent lobectomy resulted in occurrence-free survival over a 71-month follow-up.

Recovery of lung perfusion after sleeve resection for tuberculous bronchial stenosis.

Parenchyma-sparing main bronchial sleeve resection is a safe and effective procedure to restore impaired lung function. We present a case illustrating recovery of lung perfusion in a 24-year-old woman with dyspnea on exertion because of bronchial tuberculosis. Bronchoscopic examination revealed pin-hole stenosis of the left main bronchial orifice. 99mTc-macroaggregated albumin perfusion scanning revealed essentially absent left lung perfusion. Because of bronchomalacia in the distal portion, six rings of the left main bronchus were resected by carinoplasty. Symptoms abated and perfusion recovered to a large extent 2 months later. She became pregnant and delivered successfully 12 months postoperatively.

[A case with an aberrant systemic arterial supply to the basal lung diagnosed by three-dimensional computed tomography and successfully treated with surgical resection of an aberrant artery].

A 21-year-old man was admitted to our hospital complaining of recurrent hemoptysis. Computed tomography revealed ground-glass opacities in the right lower lung field, and three-dimensional computed tomography (3D-CT) demonstrated an aberrant artery which originated from the descending aorta and supplied the right S10b. Bronchoscopy showed no evidence of intraluminal bleeding or bronchial branching abnormalities. The patient was given a diagnosis of aberrant systemic arterial supply to the right normal basal segment of the lung (Pryce type I). Since the affected area, supplied from an aberrant systemic artery, was very small with no abnormalities in the lung parenchyma, the patient underwent a single resection of the aberrant artery via video-assisted thoracoscopy (VATS) without segmentectomy. The patient remained free of hemoptysis during 5 months follow-up after the operation.

Pulmonary hamartoma diagnosed by convex probe endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

A 71-year-old man with a right hilar mass shadow was referred to our department. Chest computed tomography showed a small fatty area inside. Convex probe endobronchial ultrasound (CP-EBUS) images revealed a heterogeneous low-echoic mass, resembling a stone wall and showing a smooth sliding movement along the tracheal wall during respiration. Transbronchial needle aspiration (EBUS-TBNA) was performed and cartilage cells were identified, compatible with the presence of a hamartoma. The patient requested follow-up without surgical intervention. CP-EBUS images are easier to interpret than other methods for monitoring respiratory dynamics. We conclude that CP-EBUS is a useful addition to techniques both for non-invasive imaging as well as guiding pathological examination.

Late onset postoperative pulmonary fistula following a pulmonary segmentectomy using electrocautery or a harmonic scalpel.

PURPOSE: The purpose of this study is to retrospectively examine the postoperative pulmonary fistula as a complication after the use of either electrocautery or a harmonic scalpel without stapling devices. PATIENTS AND METHODS: The subjects of this study consisted of 28 patients who received a segmentectomy for a pulmonary malignant tumor, 25 cases of lung cancer and 3 of metastatic lung tumor. The electrocautery was used in 17 patients (EC group) and the harmonic scalpel in 11 (HS group). The levels of postoperative air leakage and postoperative complications were examined among the two groups retrospectively. The histological findings of the cut surface of the segmentectomy by electrocautery and harmonic scalpel were also examined. RESULTS: Hemostasis and air leakage both were well controlled during the operation, and the postoperative drainage period was short. No major postoperative complications occurred, and all patients began walking in the early postoperative days. However, 1 to 3 postoperative months after discharge, 8 patients showed late onset of a pulmonary fistula, 3 of the 17 (18%) in the EC group and 5 of the 11 (45%) in the HS group. The histological findings of the cut surface of the segmentectomy showed that most of the layer of coagulation necrosis by the harmonic scalpel measured 2 mm thick, and it was denser than that cut from electrocautery. The lumen of the bronchus markedly decreased in size, but it remained, as it also did under the effects of electrocautery. CONCLUSIONS: In the months following the operation, the incidence of the late onset of a pulmonary fistula was higher when the harmonic scalpel was used. It was believed that the small bronchial stump could not tolerate the airway pressure because the thick coagulation necrosis delayed healing of the postoperative wound. It was necessary to ligate the stump of a small bronchus, even though the stump had been temporally closed by coagulation necrosis with the electrocautery or harmonic scalpel during the operation.

Use of emergency rigid bronchoscopy to reduce tumour mass prior to surgical resection.

Two patients with lung adenocarcinoma developed acute respiratory failure as a result of unilateral lung collapse. They were successfully treated by tumour de-bulking using a rigid brochoscope and subsequent radical sleeve lobectomy. Case 1 was a 46-year-old man whose carcinoma was pathological stage IIIb (P-T4N2M0), and he remains tumour-free 39 months after the surgery. Case 2 was a 79-year-old man whose carcinoma was pathological stage IIb (P-T3N0M0). Following treatment, he was able to resume his daily activities, however, his tumour recurred and he died 5 months after the surgery. Debulking of tumours with a rigid bronchoscope was useful for improving patients' quality of life and for the subsequent multidisciplinary treatment of lung carcinoma.

Infected giant bulla treated by percutaneous drainage followed later by resection: report of a case.

A 55-year-old man was hospitalized for treatment of a giant, fluid-filled bulla in the upper lobe of the right lung. The infection was resistant to antibiotics, and the resulting drug-induced liver dysfunction prohibited us from performing emergency lobectomy. Percutaneous drainage of the bulla was done initially, using a 28-Fr chest tube, after which the symptoms of infection improved rapidly. Despite a small air leakage, which became evident on day 4 of drainage, shrinkage of the bulla was achieved, and elective bullectomy was performed after continuous drainage for 21 days. Thus, percutaneous drainage was effective in controlling the infection and minimizing the invasiveness of surgery.

[Usefulness of FDG-PET for the diagnosis of postoperative recurrence of lung cancer].

No standardized postoperative follow-up strategy has been established for lung cancer patients, although CT and tumor markers are often employed. We conducted a retrospective study evaluating fluoro-2-deoxyglucose positron emission tomography (FDG-PET) for the diagnosis of postoperative recurrence of lung cancer. We evaluated 28 patients with suspected postoperative recurrence of lung cancer, who underwent FDG-PET between July 2004 and November 2005. Of these, 15 showed positive PET finings. Recurrence of lung cancer cases confirmed in 14 of these and the remaining case showed a postoperative scar. Thirteen patients with no findings on PET scan have demonstrated no evidence of recurrence during follow-up periods between 10 to 23 months. The negative predictive value was therefore 100%. FDG-PET in addition to chest CT and tumor markers for the diagnosis of the postoperative recurrence of lung cancer is considered to be beneficial in terms of avoiding excessive radiation exposure and limiting medical costs, but further evaluation in more patients is necessary.

Defibrillation effects of intravenous nifekalant in patients with out-of-hospital ventricular fibrillation.

Nifekalant (NF), a pure K(+) channel blocker developed in Japan, has been reported to be effective in the treatment of life-threatening ventricular arrhythmias. We studied its efficacy in 18 men and 4 women with out-of-hospital ventricular fibrillation (VF) admitted to our emergency department between August 2001 and March 2004. The number of DC shocks delivered for out-of-hospital VF, serum Na(+) and K(+), arterial blood pH, and base excess were compared in 8 patients treated with NF, 0.3 mg/kg i.v. followed by a continuous intravenous (group N) versus 14 patients treated with lidocaine, 2 mg/kg, i.v. (group C). The two groups were similar with respect to their baseline characteristics. Sinus rhythm returned in 5 of 8 patients in group N versus 2 of 14 patients in group C (P < 0.05). These seven patients were admitted to the intensive care unit, though all died within 1 month. The results of this study suggest that NF may be effective in defibrillation of out-of-hospital VF, though controlled studies are needed to confirm our observations.