Comparison of surgical results after pneumonectomy and sleeve lobectomy for non-small cell lung cancer: trends over time and 20-year institutional experience.

OBJECTIVE: Sleeve lobectomy is a lung-saving procedure for central tumors for which the alternative is pneumonectomy. The purpose of this study was to report the clinical characteristics, operative results, survival, and late outcomes over 20 years in patients who underwent sleeve lobectomy and pneumonectomy at our institution. METHODS: There were 62 patients who underwent sleeve lobectomy (SL group) and 110 who underwent pneumonectomy (PN group). Comparisons of the demographics, morbidity, and survivals between the groups were performed by unpaired t-test, chi(2)-test, and log-rank test. RESULTS: Patients who underwent a pneumonectomy showed a significantly advanced pathological stage, and a larger tumor size than those who received a sleeve lobectomy, whereas there were no significant differences in histology, ratio of combined resection and induction therapy, or total morbidity. There were three in-hospital deaths (4.8%) in the SL group and four (3.6%) in the PN group. Local relapse and distant recurrence incidence were similar between the two groups. The 5-year-survival rates of the SL and PN groups were 54% and 33%, respectively (p<0.0001). However, there were no differences in 5-year survivals in patients with pathological stage I/II (SL, 59% vs PN, 63%) and those who received induction therapy (SL, 22% vs PN, 52%) between the groups. CONCLUSIONS: Both pneumonectomy and sleeve lobectomy were performed with an acceptable risk of operative mortality and satisfactory 5-year survival rate. The indication of pneumonectomy is aimed to perform a curative resection for locally advanced lung cancer, particularly after induction therapy that is otherwise unresectable, and the selected patients will likely benefit from a complete resection.

Risk stratification for lung cancer surgery: impact of induction therapy and extended resection.

STUDY OBJECTIVES: Current surgical strategies for lung cancer are directed toward the following two distinct targets: the increased prevalence of early-stage lung cancer; and locally advanced lung cancer treated with induction therapy (IT). To establish the risk stratification for operative morbidity from this viewpoint, we evaluated the impact of IT and/or an extended surgical procedure on operative results. DESIGN: Retrospective study. SETTING: A 674-bed teaching hospital. PATIENTS AND METHODS: The morbidity and mortality of 758 consecutive patients who underwent surgery for the treatment of non-small cell lung cancer were analyzed. There were 666 patients who underwent surgery alone (S group; 560 standard lobectomies and 106 extended resections) and 92 patients who received IT (IT group; 35 standard lobectomies and 57 extended resections). Comparisons between the groups were performed using unpaired t tests or chi(2) tests. Univariate and multivariate logistic regression analyses were used to determine the risk factors for operative morbidity and mortality. RESULTS: IT and extended surgery were strong independent factors for predicting postoperative morbidity (p < 0.0001). Significant differences were observed for pathologic stage (p < 0.0001), preoperative hemoglobin and Dlco levels (p < 0.001), the ratio of extended resection (p < 0.0001), and operation time and intraoperative bleeding (p < 0.001) between the S and IT groups. The overall morbidity and mortality rates were 16.8% and 0.9%, respectively, in the S group, and 55.4% and 5.4%, respectively, in the IT group (p < 0.01). The overall morbidity and mortality rates were 63.2% and 7.0%, respectively, for extended resection after IT, and 12.8% and 0.3%, respectively, for those who underwent a standard resection without IT. CONCLUSIONS: The morbidity and mortality of lung resection are both significantly increased after IT, and the patients with the greatest risk are those who have undergone IT and extended resection. The impact of IT on risk stratification should be emphasized in perioperative care.

[The usefulness of the processed nasal airway for fiberscope guided nasotracheal intubation].

BACKGROUND: The fiberscopy has become an essential tool for tracheal intubation. As we realized that nasal airway acts like a conduit to guide a fiberscope toward the larynx, we have devised a unique nasal airway named "Osaka airway" which is suitable for fiberoptic naso-tracheal intubation. This airway has two pre-cut line from the head to the tip which can be peeled off easily after the insertion of fiberscope. To verify this advantages, we measured the length of nares-vocal cords and assessed the fiberoptic visibility of vocal cords under the aid of nasal airway. METHODS: At the end of operation, 54 patients were extubated and nasal airway was inserted to measure the length of nares-vocal cords and to observe vocal cords and epiglottis. Then, in another series, two beginners conducted fiberoptic intubation on several cases with the aid of Osaka airway. RESULTS: The length of nares-vocal cords of male was 20.2 +/- 1.0 S.D.cm, and that of female 17.3 +/- 1.1 S.D.cm. The length correlated with the body height. In 34 patient, we could see vocal cords just below the airway tip. Two beginners could complete the intubation within 2 min in almost all cases. CONCLUSION: Osaka airway was a help for fiberoptic naso-tracheal intubation for beginners.

A case of acute cerebellitis with a unique sequential change on magnetic resonance imaging.

BACKGROUND: Acute cerebellitis with unilateral onset is rare, and magnetic resonance imaging (MRI) is a useful method for demonstrating cerebellar involvement. PATIENT: We report a 12-year-old girl with acute cerebellitis with a unique sequential change on her MRI. RESULTS: The patient's brain MRI first revealed cortical lesions mainly in the right cerebellar hemisphere. These subsequently disappeared, and at the same time, new lesions appeared in the opposite cerebellar hemisphere. All the lesions were confined to gray matter in the cerebellum and were isotense on diffusion-weighted imaging and had high signal intensity on the apparent diffusion coefficient map, consistent with the characteristic of vasogenic edema. CONCLUSION: The sequential MRI demonstrates conversion of hemicerebellitis to bilateral cerebellitis during subacute phase, and vasogenic edema might be contributing to the pathogenesis of acute cerebellitis in this patient.

Selective lobar bronchial blockade using a double-lumen endotracheal tube and bronchial blocker.

We report our experience of a selective lobar bronchial blockade (SLBB) technique with a bronchial blocker (BB) which was employed successfully with a routine double-lumen endotracheal tube (DLT) in three patients. For the first case, we selectively blocked the infected left lower lobe in a surgical patient with a lung abscess in a DLT setting. For the second case, we applied this method to block the right middle and lower lobes in order to assess air leakage from the upper lobe during video-assisted thoracic surgery (VATS). For the third case, selective continuous positive airway pressure (CPAP) to the blocked lobes on the operative side resulted in oxygenation improvement with one-lung ventilation (OLV) in a DLT. This novel technique provides benefits during general thoracic surgery by preventing contamination, providing a better operative field, and improving oxygenation with lobar CPAP.

Fall in diffusing capacity associated with induction therapy for lung cancer: a predictor of postoperative complication?

BACKGROUND: Pulmonary resection after induction therapy is associated with high rates of pulmonary morbidity and mortality. However, the impact of induction therapy on the pulmonary toxicity and associated pulmonary complications has not been fully investigated in the setting of lung cancer surgery. METHODS: We assessed the 66 consecutive patients who underwent a pulmonary resection after induction therapy, 48 of whom received chemoradiotherapy and 18, chemotherapy alone. Results of pulmonary function before and after induction therapy were compared, and logistic regression analyses utilized to explore the risk factors of pulmonary morbidity. RESULTS: After induction therapy, forced expiratory volume in 1 second (FEV1) was increased significantly (from 2.28 +/- 0.61 L to 2.40 +/- 0.62 L; p < 0.05); however, percent vital capacity (%VC) and FEV1/FVC did not change significantly. The diffusing capacity of lung for carbon monoxide (D(LCO)) was decreased significantly by 21% (from 90.3% +/- 18.3% to 71.1% +/- 12.5%; p < 0.0005). Patients with respiratory complication showed lower predicted postoperative %FEV1 (49.5% +/- 11.1% versus 57.2% +/- 14.2%; p = 0.031) and predicted postoperative %Dlco (41.9% +/- 8.0% versus 55.4% +/- 10.1%; p < 0.0001) results than those without complications. Univariate and multivariate analyses revealed that predicted postoperative %D(LCO) alone was an independent factor to predict postoperative pulmonary morbidity. CONCLUSIONS: For patients who undergo a pulmonary resection after induction therapy, predicted postoperative %D(LCO) is more important to predict pulmonary morbidity rather than static pulmonary function (predicted postoperative %VC or %FEV1). The decrease in D(LCO) is thought to reflect a limited gas exchange reserve, caused by the potential toxicity of chemotherapy or chemoradiotherapy. We believe that the impact of diffusion limitation after induction therapy should to be emphasized to decrease the pulmonary morbidity.