[Perspective of Uniportal Video-assisted Thoracic Surgery for Early Lung Cancer in Japan].

Uniportal video-assisted thoracic surgery (U-VATS) has become prevalent among thoracic surgeon in a part of countries including Japan. U-VATS and robotic-assisted thoracoscopic surgery( RATS) are 2 types of minimally invasive surgical techniques. Uniportal procedures are feasible although they can be technically challenging. RATS is superior to U-VATS in terms of the ability to perform procedures that require fine motor skills and to maintain wide visual fields during the procedure;however, it is not as feasible and more costly compared with U-VATS. U-VATS is also considered safer as it is easier than RATS to be converted to thoracotomy when needed. Thus, suitable procedures should be selected to meet the needs of specific cases. In the present study, we review the treatment outcomes of U-VATS for anatomical lung resection that were performed at our institution for patients with early-stage lung cancer.

A case of pulmonary visceral subpleural hematoma treated by hematoma evacuation during care of post-cardiopulmonary resuscitation.

BACKGROUND: The occurrence of pulmonary visceral subpleural hematoma during care of post-cardiopulmonary resuscitation including chest compressions and anticoagulant and antiplatelet therapies is extremely rare. Also, there are few reports of treatment of visceral subpleural hematoma, most of which are treated by lung resection. Here we describe a rare case that pulmonary visceral subpleural hematoma arose during post-cardiopulmonary resuscitation care and was treated by hematoma evacuation. CASE PRESENTATION: A 58-year-old male with no smoking history and, past medical histories of rheumatoid arthritis, chronic atrial fibrillation, hypertension, diabetes, and dyslipidemia developed ventricular fibrillation due to myocardial infarction and fainted. He received bystander cardiopulmonary resuscitation and defibrillation by the ambulance crew and had return of spontaneous circulation. After transfer to our hospital, the patient underwent percutaneous catheter intervention and stenting with a diagnosis of myocardial infarction, followed by anticoagulant and antiplatelet therapies. On the 8th hospital day, chest radiography suggested right lower lobe pneumonia, and subsequent chest computed tomography revealed pulmonary hematoma in the visceral subpleural area from S6 to S10. Since no improvement was observed in hypoxemia, treatment was considered necessary. First, an attempt at computed tomography-guided drainage of hematoma was made, but insertion of the Pig-tail catheter was difficult due to hardness of the hematoma. Next, evacuation of hematoma was performed on the 13th hospital day. The hematoma was located in the visceral subpleural area and was removed by incising the pleura. TachoSil Tissue Sealing sheet and Polyglycoal acid sheet were applied to the sites of air leakage and oozing after hematoma evacuation. No re-bleeding or air leakage was observed after the treatment, and the patient was discharged on the 26th hospital day after an uneventful course. CONCLUSIONS: Pulmonary visceral subpleural hematoma may occur during post-cardiopulmonary resuscitation care, including chest compressions and anticoagulant and antiplatelet therapies. In our case, CT-guided puncture and drainage was difficult and surgical treatment by incision of the visceral pleura and hematoma evacuation alone was done successfully.

Uniportal video-assisted thoracic surgery basal segmentectomy: a single-center retrospective cohort study.

Background: Uniportal video-assisted thoracic surgery (VATS) basal segmentectomy is technically challenging and requires a deep understanding of the segmental anatomy of the lung. This report describes the uniportal VATS segmentectomy of basal segments using a single-direction approach. Methods: A total of 49 patients who underwent uniportal VATS basal segmentectomy between April 2019 and April 2021 were included in this retrospective study. All the surgeries were conducted using a single-direction approach. The resections of segments 7-8 were mainly performed using the interlobar fissure approach, while the resections of segments 9-10 were performed using the inferior pulmonary ligament approach. Results: A total of 33 patients underwent a single basal segmentectomy and 16 patients underwent combined basal segmentectomy/sub-segmentectomy. The median operative time was 120 min (range, 60-180 min), and the median blood loss was 20 mL (range, 10-100 mL). The median chest tube duration was 2 days (range, 1-5 days), and the median hospital stay after surgery was 4 days (range, 2-15 days). The morbidity rate after surgery was 6.1% (3/49). There were no perioperative deaths. The pathological examinations revealed 3 cases of adenocarcinoma in situ (AIS), 33 cases of minimally invasive adenocarcinoma, and 13 cases of lepidic-predominant invasive adenocarcinoma. No recrudescence or mortality was reported during the median follow-up time of 7 months (range, 2-25 months). Conclusions: Uniportal VATS basal segmentectomy is a feasible and reliable technique based on our experience. This single-direction method allows the uniportal VATS basal segmentectomy to be performed in an easy manner with the targeted segmental bronchi and vessels exposed from superficial to deep in order of their appearance while avoiding the repeated turnover of the lung.

Venous hemangioma of the anterior mediastinum.

We report a rare case of venous hemangioma (VH) of the anterior mediastinum in a 56-year-old man admitted to our hospital because of hematemesis. Systemic examinations were performed and chest computer tomography (CT) revealed a 1.5-cm sized small nodule with contrast enhancement in the thymus. Both CT and magnetic resonance imaging (MRI) suggested a solid tumor such as a thymoma or neurogenic tumor rather than a vascular neoplasm. A partial thymectomy including this nodule by video-assisted thoracic surgery (VATS) was performed. Histological examination showed VH. There was no recurrence with no further treatment.

Partial lung resection by uniportal video-assisted thoracoscopic surgery: technique and pitfalls.

The use of uniportal video-assisted thoracoscopic surgery (VATS) has increased worldwide. The number of facilities introducing this simple and cost-effective surgical procedure in Japan has also increased. Partial lung resection is performed to diagnose or treat various cases and surgeons are required to flexibly deal with it. This report describes the technique and pitfalls of partial lung resection by uniportal VATS.

How to optimize the treatment strategy for patients of pulmonary sequestration with an elevated risk of fatal hemorrhage during operation: case discussion.

Video-assisted thoracoscopic surgery (VATS) lobectomy, especially uniportal VATS, is increasingly used for pulmonary sequestration (PS). However, there are few descriptions of safe handling of the aberrant artery with atherosclerosis, especially the diameter of arteries exceeds than 2.0 cm, under uniportal VATS approach. Here we report a 56-year-old man who was diagnosed with pulmonary sequestration following trauma. The patient had a long history of cough with purulent sputum. One month before the trauma, he had copious expectoration with foul smell again. A contrast CT scan revealed a 7.5 cm mass in his right lower lobe. The mass was supplied by a thick aberrant atherosclerotic artery (over than 2 cm in diameter), which stemmed from the thoracic aorta with multiple calcifications on both. After adequate preoperative evaluation, we performed a right lower lobectomy under uniportal VATS approach. No surgical-associated complications occurred, and the patient was discharged on the 5th days after the operation. We organized an iMDT (international multidisciplinary team) to discuss the reasonability and optimal treatment pattern for this patient. We found that fully assess the quality of the aberrant arteries of PS following blocking and cutting off in an appropriate way are crucial to avoid the happening of fatal bleeding during the operation.

Uniportal video-assisted thoracic surgery reduced the occurrence of post-thoracotomy pain syndrome after lobectomy for lung cancer.

BACKGROUND: Post-thoracotomy pain syndrome (PTPS) is difficult for thoracic surgeons to manage. PTPS should never arise after minimally invasive surgery (MIS). Uniportal video-assisted thoracoscopic surgery (U-VATS), a form of MIS for thoracic disease, has become more common around the world and might reduce the risk of PTPS after thoracic surgery. We compared the frequencies of PTPS after U-VATS-based and multi-port VATS (M-VATS)-based lobectomy for lung cancer. METHODS: We compared the data for 142 and 70 cases in which U-VATS- and M-VATS-based lobectomies were performed, respectively. General surgical outcomes, the numeric rating scale (NRS) score, analgesic usage, and neuropathic pain according to the pain DETECT questionnaire (PDQ) were assessed. The presence of >1 of the following items at two postoperative months (POM) was used to diagnose PTPS: (I) an NRS score of >3, (II) analgesic use, and (III) exhibiting >1 of a list of 7 symptoms according to the PDQ. RESULTS: There were no significant intergroup differences in the operation time, intraoperative blood loss, the number of dissected lymph nodes, or the duration of the drainage period or hospital stay. In the U-VATS and M-VATS groups, the mean NRS score during two postoperative months was 0.5±0.1 and 1.5±0.3, respectively (P<0.01), and analgesics were used for a mean of 7.3±1.5 and 13.3±1.8 days, respectively, during the postoperative 2 months (P<0.01). As for the frequency of PTPS-related symptoms on postoperative month (POM) 2, allodynia (U-VATS: 2.1% vs. M-VATS: 10%, P=0.028), hypoesthesia (2.1% vs. 10%, P=0.028), and numbness (1.4% vs. 8.6%, P=0.029) often arose in both groups. PTPS occurred in 2.8% and 11.4% of the patients in the U-VATS and M-VATS groups, respectively (P=0.025). CONCLUSIONS: Compared with M-VATS, U-VATS exhibited a significantly lower incidence of PTPS.

For which thoracic operation is U-VATS superior?

In this special issue, I review the types of thoracic surgery that uniportal video-assisted thoracic surgery (U-VATS) is most suited to.

Dissimilarity in gene expression profiles of lung adenocarcinoma in Japanese men and women.

BACKGROUND: Although clinical differences in lung cancer between men and women have been noted, few studies have examined the sex dissimilarity using gene expression analysis. OBJECTIVE: The purpose of this study was to determine the different molecular carcinogenic mechanisms involved in lung cancers in Japanese men and women. METHODS: Patients who received surgery for stage I lung adenocarcinoma were included. RNA was extracted from cancerous and normal tissue, and gene expression was then examined with oligonucleotide microarray analysis. A quantitative polymerase chain reaction assay was performed. RESULTS: In a microarray analysis of tissue from 13 men and 6 women, 12 genes were under-expressed and 24 genes were overexpressed in lung adenocarcinoma in women compared with men. Genes related to cell cycle were present in underexpressed genes, and genes related to apoptosis, ubiquitination, and metabolism were observed in overexpressed genes. Of interest among the selected genes were WAP four-disulfide core domain 2 (WFDC2) and major histocompatibility complex, class II, DM alpha (HLA-DMA); these genes were classified into 2 groups by hierarchical clustering analysis. Expression of WFDC2 in nonsmokers was significantly higher than that in smokers (P=0.023). However, there was no significant difference in HLA-DMA expression between smokers and nonsmokers. CONCLUSION: Thirty-six genes that characterize lung adenocarcinoma by sex were selected. This information may contribute to the development of novel diagnostic techniques and treatment modalities that consider sex differences in lung adenocarcinoma.

Long-term survival of Askin tumor for 10 years with 2 relapses.

An abnormal shadow was noted on a chest X-ray of a 32-year-old female in a medical check-up in March 1995, 3 months after she had given birth. Thoracic CT detected a tumor in contact with the left thoracic wall, and tumorectomy was performed in May 1995. The tumor was diagnosed as a primitive neuroectodermal tumor (PNET). After surgery, the thoracic wall to which the tumor adhered was treated with irradiation at 50 Gy. Chemotherapy was considered, but the patient did not wish to undergo this treatment. Lung metastasis occurred 5 years after the first surgery, and the left lower lobe of the lung was partially resected. Four years later, lobectomy of the left lower lobe of the lung was performed, due to further lung metastasis. The patient remains healthy as of April 2005.

Analysis of risk factors for postpneumonectomy bronchopleural fistulas in patients with lung cancer.

BACKGROUND: Bronchopleural fistula is a potentially fatal complication of pulmonary resections, especially pneumonectomy. METHODS: Univariate and multivariate analyses of the development of bronchopleural fistula were performed in 12 patients with bronchopleural fistula and 102 patients without bronchopleural fistula who had undergone pneumonectomy from January 1983 through December 2005. RESULTS: Bronchopleural fistula developed after pneumonectomy in 12 patients (8.5%). Seven (58.7%) of the 12 patients died of bronchopleural fistula. Univariate analysis showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease significantly contributed to the development of postpneumonectomy bronchopleural fistula (p=0.0002, p=0.0043, and p=0.0387, respectively). Multivariate analysis also showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease were significant risk factors for postpneumonectomy bronchopleural fistula. CONCLUSIONS: Bronchopleural fistula is strongly associated with preoperative infection, right pneumonectomy, and pathological N2, 3 disease. Bronchial stump coverage with pedicled tissue flaps and preservation of the bronchial arteries during mediastinal lymph node dissection are recommended to maintain the blood supply to the bronchial stump in patients at risk.

Single-incision thoracoscopic surgery and conventional video-assisted thoracoscopic surgery: a retrospective comparative study of perioperative clinical outcomes†.

OBJECTIVES: To assess the feasibility, safety and postoperative wound pain of single-incision thoracoscopic surgery (SITS) for Stage I lung cancer in patients who had previously undergone surgery compared with conventional video-assisted thoracoscopic surgery (c-VATS). METHODS: Lobectomy by SITS (60) and c-VATS (20) was performed for Stage I lung cancer between 2011 and 2014. In SITS, an ∼ 5-cm small incision was placed at the fourth or fifth intercostal space from the anterior to posterior axillary line. C-VATS was performed via three or four ports using trocars only. The evaluation items were general operative outcomes, pain stress using the Numeric Rating scale (NRS) on postoperative days 3, 7 and 30, and some pathological symptoms related to the neuropathic wound pain through the operative course. The number of days of use of analgesic agents was also evaluated for 1 month after surgery. RESULTS: SITS showed similar perioperative outcomes (postoperative hospital stay, blood loss, surgical time, drainage duration, creatine phosphokinase (CPKmax), creactive protein (CRPmax) and frequency of postoperative complications) to those of c-VATS. Additionally, the average NRS in SITS decreased on postoperative days 7 and 30 (Day 7: 2.4 ± 0.4 vs 4.2 ± 0.3, P = 0.041, Day 30: 1.7 ± 0.4 vs 3.3 ± 0.3, P = 0.038) and the number of days analgesic agents were administered was also reduced (SITS: 8.1 ± 0.9 vs c-VATS 13.1 ± 1.2 days, P = 0.045). The frequency of allodynia, hyperalgesia, hypaesthesia and numbness was significantly reduced in the SITS group. CONCLUSIONS: Although conclusive evidence has not yet been obtained, SITS is more minimally invasive in regard to postoperative wound pain compared with c-VATS. This procedure should be considered as a treatment option for early-stage lung cancer.

Single-port video-assisted thoracic surgery for early lung cancer: initial experience in Japan.

BACKGROUND: Single-port video-assisted thoracic surgery (SPVATS) emerged several years ago as a new, minimally invasive surgery for diseases in the field of respiratory surgery, and is increasingly becoming a subject of interest for some thoracic surgeons in Europe and Asia. However, the adoption rate of this procedure in the United States and Japan remains low. We herein reviewed our experience of SPVATS for early lung cancer in our center, and evaluated the safety and minimal invasiveness of this technique. METHODS: We retrospectively analyzed patients who had undergone SPVATS for pathological stage I lung cancer in Nippon Medical School Chiba Hokusoh Hospital between September 2012 and October 2015. In SPVATS, an approximately 4-cm incision was made at the 4(th) or 5(th) intercostal space between the anterior and posterior axillary lines. A rib spreader was not used at the incision site, and surgical manipulation was performed very carefully in order to avoid contact between surgical instruments and the intercostal nerves. The same surgeon performed surgery on all patients, and analyzed laboratory data before and after surgery. RESULTS: Eighty-four patients underwent anatomical lung resection for postoperative pathological stage I lung cancer. The mean wound length was 4.2 cm. Eighty-four patients underwent lobectomy and segmentectomy, respectively. The mean preoperative forced expiratory volume in 1 second (FEV1%) was 1.85%±0.36%. Our patients consisted of 49 men (58.3%) and 35 women (41.7%), with 64, 18, 1, and 1 having adenocarcinoma, squamous cell carcinoma, adenosquamous carcinoma, and small-cell lung cancer, respectively. The mean operative time was 175±21 min, operative blood loss 92±18 mL, and duration of drain placement 1.9±0.6 days. The duration of the postoperative hospital stay was 7.1±1.7 days, numeric rating scale (NRS) 1 week after surgery 2.8±0.6, and occurrence rate of allodynia 1 month after surgery 10.7%. No patient developed serious complications, and no deaths occurred within 30 days of surgery. Two patients (2.4%) were converted to open thoracotomy. CONCLUSIONS: SPVATS is a safe and feasible technique, and is promising for next-generation thoracoscopic surgery. It may also reduce postoperative wound pain and contribute to improvements in the activities of daily living of patients.

Surgical treatment for lung cancer patients with poor pulmonary function.

UNLABELLED: This retrospective study was aimed to review the risk factors of postoperative hospital death in lung cancer patients with poor pulmonary reserves. We performed surgery on 30 lung cancer patients (average age: 71 years) with less than 1.0L of preoperative forced expiratory volume in one second (FEV1.0 < 1.0L) between 1982 and 2003. The preoperative FEV1.0 of these 30 patients was 0.81+/-0.1L on average. Six of 20 patients who underwent surgery between 1982 and 1997 died during their postoperative hospital stay (hospital death group). Between 1998 and 2003, 10 patients underwent surgery with uneventful postoperative courses. The clinical background was evaluated between the hospital death group (n = 6) and the survivor group (n = 24). The single-variable analysis of the preoperative conditions of the postoperative hospital death revealed the presence of two or more preoperative concomitant diseases (p < 0.001) and a performance status of grade 2 or higher (p = 0.005). Peripheral obstructive pneumonia with abscess and chronic pleurisy with adhesion influenced surgery and related to their postoperative hospital death. Whereas, patients with chronic obstructive pulmonary diseases (COPD) tended to show that pulmonary resection resulted in an improvement of pulmonary functions. CONCLUSION: To achieve better results of surgical treatment for patients with preoperative FEV1.0 < 1.0L, patient selection should be required based on precise evaluation of physical conditions and management of infectious diseases. Moreover, we thought that a preoperative performance status of grade 1 or lower, at most one preoperative concomitant disease, and a COPD are desirable for deciding the surgical indication.

Thoracoscopic surgery in children.

PURPOSE: A minimally invasive thoracoscopic surgery offers several options in diagnosis and surgical treatment in the field of pediatric surgery. We would like to review our surgical experience and to assess the clinical outcomes and problems encountered during thoracoscopic surgery in children and adolescents focusing on children less than 6 years old. PATIENTS AND METHODS: In 1992 and 2003, 977 patients underwent thoracoscopic surgery for chest diseases. Among them, from 1994 to 2003, 71 children and adolescents underwent thoracoscopic surgery. The thoracoscopic surgical procedures were classified into thoracoscopic surgery (TS) and video-assisted thoracic surgery (VATS). TS was performed through three or four trocar ports. VATS was performed through a small chest incision (minithoracotomy) with one or two trocar ports. RESULTS: There was no morbidity or mortality associated with the thoracoscopic surgical procedures. None of the patients required a conversion to standard thoracotomy. The thoracoscopic surgical procedures were feasible in 71 children and adolescents with chest diseases including spontaneous pneumothorax, pulmonary nodules, diffuse pulmonary disease, pulmonary sequestration, and mediastinal tumors, and in those with palmar hyperhidrosis. TS was performed on two of five children with benign diseases including diffuse pulmonary disease and mediastinal bronchogenic cyst. VATS was performed on three children with pulmonary sequestration, lymphoid interstitial pneumonia and mediastinal Ewing's sarcoma. In one child with lymphoid interstitial pneumonia, the thoracoscopic surgery was converted to VATS because adhesion did not allow TS. The TS allowed rapid histological diagnosis and surgical treatment for benign pulmonary diseases and mediastinal cyst. Patients who were suffering from disease-related symptoms obtained complete relief with an uneventful postoperative course and quickly returned to their normal life. A boy who underwent lobectomy showed a normal growth rate for 4 years postoperatively. In the case of malignant chest diseases, the combination of chemotherapy and VATS was an effective treatment strategy. CONCLUSIONS: We considered that the thoracoscopic approach is a rapid and simple method in the therapeutic diagnosis and surgical treatment of children and adolescents, even in children less than 6 years old. Cosmetic benefits were also obtained for girls. However, the most important consideration is the decision on a treatment strategy made by both pediatrician and thoracic surgeon.

Primary pulmonary mucosa-associated lymphoid tissue lymphoma combined with idiopathic thrombocytopenic purpura and amyloidoma in the lung.

Three abnormal shadows were detected in the right lung on chest X-ray films and computed tomography in a 75-year-old woman during follow-up for idiopathic thrombocytopenic purpura. Because a definitive diagnosis was not obtained through general examinations, exploratory thoracotomy was performed for diagnosis and treatment. The main lesion in the right middle lobe was diagnosed as mucosa-associated lymphoid tissue (MALT) lymphoma according to histopathological findings, cytogenic studies and reverse transcriptase-polymerase chain reaction analysis, and nodular lesions in S(3) and S(7) were diagnosed with Congo-red staining as local deposition of amyloid. The patient had no recurrence of the MALT lymphoma of the lung or other organs for 4 years after surgery. To our knowledge, this is the first reported case of primary pulmonary MALT lymphoma combined with idiopathic thrombocytopenic purpura/lung amyloidoma.

Basaloid carcinoma of the lung.

Basaloid carcinoma (BC) of the lung is a rare and an aggressive subtype of non small cell lung cancer. We report a patient with preoperative cytologic features of either lung BC or squamous cell carcinoma. Finally, the tumor was diagnosed as a pure BC of the lung by the immunohistological findings. The patient's recovery was uneventful and remained asymptomatic without recurrence 18 months after surgery. However, considering to the biological behavior of BC, regular follow-up for this patient will be required.