[Improved Surgical Technique for Closing the Tracheocutaneous Fistula].

The tracheocutaneous fistula is a late complication after tracheotomy decannulation, which decreases the quality of life. Though several procedures to close tracheocutaneous fistula were reported, postoperative wound dehiscence was frequently noted. We developed new surgical technique to prevent this complication and report a case in which the technique was successfully applied. This surgical technique is useful simple method to be effective, and safe.

[Outcomes of Surgical Cases of Solitary Rib Metastases in Renal Cell Carcinoma].

BACKGROUND: Aggressive surgical treatment for renal cell carcinoma (RCC) bone metastasis has shown good results. METHODS: Since January 1995, four patients underwent surgery at our institution for rib metastasis of operated RCCs. Of these patients, three were male and one was female. The patients had a mean age of 67.5 years. Except one patient who presented with rib metastasis at the time of diagnosis of RCC, the average period of metastasis to the ribs after RCC surgery was 24.3 months. All patients underwent resection of metastasized tumors involving the ribs, with or without chest wall involvement. The clinical features of the surgical treatment for RCC bone metastasis were retrospectively analyzed. RESULTS: The mean time to tumor recurrence was 22.3 months postmetastasectomy. All patients developed other bone metastases and underwent multidisciplinary therapy. After metastasectomy, the four patients survived for 19~93 months. CONCLUSION: Surgical treatment for patients with rib metastases of RCC may contribute in prolonging survival.

[Surgical Cases of Solitary Lesion after Surgery for Primary Lung Cancer].

Lung nodules during postoperative follow-up of lung cancer are generally suspected to be its recurrence, but some cases are diagnosed as non-malignant disease. From January 2001 to November 2018, we experienced 5( 4.5%) new non-malignant lesions in 112 lung cancer patients who underwent a lung resection. The average period from first to second lung surgery was 36.2 months (range:3-64), and computed tomography findings before the second surgery were solid nodules in four cases and groundglass opacity in one case. The average maximum standardized uptake value of the lesions on fluorodeoxyglucose positron emission tomography was 4.29 (range:0-10.85). The diagnosis after the second surgery was pulmonary cryptococcosis in 2 cases, nontuberculous mycobacteriosis in 1 case, inflammatory mass in 1 case, and pneumonia in 1 case. The differential diagnosis between these diseases and lung cancer recurrence is discussed in the present study.

Selection of and Retention in Surgical Specialty during Early Career in Japan.

The number of surgeons is decreasing in Japan. We investigated the trend and factors influencing surgeons' selection of and retention in surgical specialty. In 2016, we obtained data of biennial surveys conducted by the government, and analyzed the annual data of doctors up to the latest available survey at that time (survey, 1994-2014; medical license acquisition, 1993-2014). The rate of selecting surgery by male and female doctors during early career (first three surveys after acquiring medical license) decreased from 28.1% in 1994 to 21.3% in 2010 (first to nineth survey). Female surgeons increased from 7.8% in 1993 to 12.4% in 2003, but decreased from 12.5% in 2006 to 10.7% in 2010. Total number of surgeons declined throughout the period. In females, the rate of selecting surgery tended to increase at the beginning of the new training system in 2004, but declined slightly thereafter. The retention rate in those who selected surgery at least once by the third survey (1998) after acquiring medical license in 1993 showed a downward trend. The retention rate in females declined continuously to 48.4% in 2002, stabilized thereafter, and then increased from 47.6% in 2006 to 50.8% in 2014. The retention rate after 10 years (1993-2003) was almost stable (72.4%) in males, but increased to 57.5% in females, and the gender difference tended to decrease. Younger doctors tend to value their private life, and may not choose or continue to practice surgery unless working conditions in surgery improve and income is commensurate with their work.

Mediastinal paraganglioma successfully resected by robot-assisted thoracoscopic surgery with en bloc chest wall resection: a case report.

BACKGROUND: Robot-assisted thoracoscopic surgery (RATS) is useful for surgery in the apical region of the chest cavity, as it narrows towards the head. Here, we describe a nonfunctional, rib-invasive paraganglioma arising in the posterior mediastinum that was successfully removed using RATS combined with chest wall resection. CASE PRESENTATION: A 31-year-old woman presented with a posterior mediastinal mass on chest computed tomography (CT) scan during a medical check-up 2 years prior. Positron emission tomography/computed tomography scan with F-18 fluorodeoxyglucose revealed a mass associated with standardized uptake maximum value of 2.69. With a preoperative diagnosis of neurogenic tumor by CT-guided percutaneous fine-needle aspiration biopsy, we performed robot-assisted tumor resection combined with chest wall resection. The wristed instruments of the robotic surgical system have increased range of motion and enabled the tumor resection without organ injury in the thoracic cavity. Histopathology examination revealed a non-functional paraganglioma with rib invasion. CONCLUSIONS: RATS is a useful technique, enabling safer and easier resection of a mediastinal tumor adjacent to surrounding organs.

[Usefulness of Long Shaft Stapler in Robot-assisted Thoracic Surgery Lung Resection].

Since national health insurance began to cover robot-assisted thoracoscopic surgery (RATS) for malignant lung tumors, malignant mediastinal tumors, and benign mediastinal tumors in Japan starting in 2018, the number of RATS performed domestically has increased rapidly. In the case of undiagnosed lung tumor, it is necessary to perform a thoracoscopic lung biopsy in the port arrangement for RATS lung resection in the case of undiagnosed lung tumor. The 2 ports are placed in the same 8th intercostal space and a 3 cm utility thoracotomy is added to the 4th or 5th intercostal space for the thoracoscopic lung biopsy. Because the assistant uses the stapler from the port, the distance to the target area increases. When it is converted to RATS for malignant lung diseases, the utility thoracotomy is often hidden by the robot arm and all ports placed in the 8th intercostal space are far from the target area. Furthermore, the assistant working space outside the patient's body is limited by the robot arms. The Signia stapling system has an adapter to extend the shaft. By attaching the adapter, the shaft can be extended by 10 cm. This permits easy handling of the stapler during both thoracoscopic biopsy and RATS lung resection.

Thoracoscopic surgical case of an ectopic mediastinal parathyroid adenoma detected by chance: a case report.

BACKGROUND: Ectopic mediastinal parathyroid tumor (EMPT) is a rare cause of primary hyperparathyroidism (PHPT); it is difficult to resect using the cervical approach. We describe a case of using video-assisted thoracic surgery (VATS) for EMPT resection. CASE PRESENTATION: A 67-year-old woman with a history of postoperative thyroid cancer had no symptoms. She was diagnosed with PHPT and underwent thyroid cancer surgery. She had serum calcium and intact parathyroid hormone (PTH) levels of 11.1 mg/dL and 206 pg/mL, respectively. Chest computed tomography showed a 10-mm nodule in the anterior mediastinum. Technetium-99 m methoxyisobutyl isonitrile scintigraphy showed an abnormal uptake lesion in the anterior mediastinum. She was diagnosed with PHPT caused by EMPT and underwent VATS. The pathological examination confirmed parathyroid adenoma. Her serum calcium and intact PTH levels were normal from 15 min after tumor resection. She has had no recurrence of EMPT. CONCLUSIONS: The VATS approach was effective for the resection of EMPT.

A severely short-statured girl with 47,XX, + 14/46,XX,upd(14)mat, mosaicism.

The predominant symptoms of trisomy 14 mosaicism are prenatal and postnatal growth failure, ear abnormalities, congenital heart disease, developmental delay, and genitourinary abnormalities. Maternal uniparental disomy of chromosome 14 (upd(14)mat) presents discernible clinical features such as prenatal and postnatal growth failure, hypotonia, precocious puberty, and obesity. Given the small number of previously reported patients with a combination of trisomy 14 mosaicism and upd(14)mat, the detailed clinical features of these patients remain to be elucidated. Here we report a severely short-statured girl with feeding difficulties and failure to thrive, ear abnormalities, deafness, small hands, and developmental delay. Karyotyping, FISH analysis, methylation analysis, and microsatellite marker analysis using her leukocytes and buccal cells showed that she had a combination of trisomy 14 mosaicism and upd(14)mat. Furthermore, a comparison of the clinical features of this patient with those of previously reported patients with genetic anomalies including the combination of trisomy 14 mosaicism and upd(14)mat or upd(14)mat suggested that the severe short stature observed in patients with a combination of trisomy 14 mosaicism and upd(14)mat stemmed from the synergic effect of these two events. In severely short-statured patients with trisomy 14 mosaicism, we should be aware of the possible coexistence of upd(14)mat.

[Surgery for Lower Intestinal Perforation Due to Peritoneal Dissemination].

INTRODUCTION: we examined the cases in which surgery was performed for the lower intestinal perforation due to peritoneal dissemination in our hospital. SUBJECTS: Four cases of lower intestinal perforation of patients with peritoneal dissemination who underwent emergency operation in our hospital were enrolled. RESULTS: Two males and 2 females patients with median age of 65.5 year old(63-71)were included. The perforated sites were 3 cases of small intestine and 1 case of ascending colon, and the APACHE II score at the visit was 14.5(10-16)points. The surgical procedure was performed in 3 cases of resection of the perforated site and 3 cases of stoma creation. In 2 out of 4 cases, it became difficult to control bacterial peritonitis and died on the 16th postoperative day. One case could discharge hospital and continued BSC, survived 4 months after surgery. CONCLUSION: Although long-term prognosis could not be expected, there were cases in which it was possible to restart the oral intake after surgery or discharge. Surgical treatment might be selected for the lower intestinal perforation due to peritoneal dissemination.

[Multiple Resections for Metastases from Colorectal Cancer].

PURPOSE: We analyzed to clarify an outcome of multiple resections of metastases from colorectal cancer. PATIENTS AND METHOD: Total 7 cases who underwent several resections for metastases from colorectal cancer in Saiseikai Kurihashi Hospital after 2010 were enrolled for analysis. RESULT: Age of patients at the time of the primary site resection was 67(45-78)year-old, including 4males and 3 females. Patients located at cecum/ascending/sigmoid/rectosigmoid/upper rectum were 1/1/2/2/1 respectively. Metachronous metastases were found in 5 patients. There were 1 patient for Stage I , 2 patients for Stage III a and III b each and all Stage III patients received adjuvant chemotherapy. The resected organs were 9 in lung, 8 in liver, 1 case in lymph node, local site and peritoneum and the median resected sites were 3(2-4)lesions. In 17 months median observation periods after latest resection, 5 cases have not been prolapsed including 3 cases with chemotherapy. Two cases were relapsed with unresectble status. One case died for 24 months and one case is under the chemotherapy for 12 months. Five year survival rate was 75% and 2 year prolapse free rate was 66.7%, since the relatively good prognosis was obtained by multiple resections. CONCLUSION: The cases that multiple resections with R0 were able to perform for the metastases were analyzed. Although cases which become finally to be unresectable exist, it is suggested that the relatively good prognosis might be obtained by multiple resections for metastases.

[Application of Ultrasonography in Detecting Multiple Schwannomas from a Single Intercostal Nerve;Report of a Case].

A 31-year-old man was referred to our hospital for chest abnormal shadow on a routine health checkup. Two nodular lesions were found at the 2nd intercostal space by computed tomography. Chest wall ultrasonography showed 2 masses suspecting tumors. Tumors were resected through 3-cm skin incision with the assistance of thoracoscope. Pathological diagnosis was both schwannomas. Ultrasonography was useful in resecting chest wall tumor.

[A Case of Hepatectomy for Liver Metastases during Long-Term Chemotherapy after Three Hepatectomies for Liver Metastases from Rectal Cancer].

We report the case of a 78-year-old man with liver metastases from rectal cancer treated with hepatectomy after 14 months of chemotherapy. This was the fourth hepatic recurrence after hepatectomy. Distant metastasis of colorectal cancer can be considered for resection, if it can be an R0 resection; however, there is no consensus regarding the timing and extent of resection. Although a study has shown the efficacy of perioperative chemotherapy for resectable liver metastasis from colorectal cancer, the regimen and duration of chemotherapy has not been established yet. It is important that an adequate treatment should be selected for each case, such as chemotherapy as systemic therapy and surgery as local therapy.

Intraoperative robotic surgical system-related problems in robot-assisted thoracoscopic surgery.

BACKGROUND: Malfunctions of robotic instruments during robotic surgery are well known to occur; however, detailed reports on the inherent problems associated with robotic instruments and robotic surgical systems are scarce. The objective of this study was to retrospectively investigate the intraoperative problems associated with robotic surgical systems and robotic instruments. MATERIALS AND METHODS: This was a single-center retrospective study. Between April 2012 and December 2022, 544 patients with consecutive lung malignancies and/or mediastinal tumors underwent robot-assisted thoracoscopic surgery. Among these, 15 cases had intraoperative problems associated with the robotic surgical system. Human error was defined as a problem caused by the incorrect operation of the robotic surgical system and human factors as problems in which the robotic surgical system stopped owing to damage to the instruments of the robotic surgical system or the self-diagnosis of the robotic surgical system. We retrospectively investigated the causes of intraoperative problems in these cases. RESULTS: There were 4 cases (0.7%) with problems related to the robotic surgical system, 2 of which were human errors, and 11 (2.0%) with problems related to robotic surgical instruments, 6 of these were related to instruments and 5 were related to robotic staplers. Five of these were related to human factors. CONCLUSION: Teams performing robot-assisted thoracoscopic surgery should be familiar with the features of robotic surgical systems and various robotic devices, be aware of reported problems during robot-assisted thoracoscopic surgery, and be prepared for emergencies.

Comparison of different approaches in complete thoracoscopic segmentectomy of lung lower lobe.

Background: Safe and oncologically acceptable segmentectomy outcomes were reported for early-stage lung cancer. The high-resolution computed tomography allowed us to find detailed structures inside the lungs, such as the pulmonary ligaments (PLs). Hence, we have presented the relatively anatomically challenging thoracoscopic segmentectomy, for the resection of the lateral basal segment, the posterior basal segment, and both segments through the PL as a PL approach. This study aimed to retrospectively examine the lung lower lobe segmentectomy, excluding the superior and basal segments (from S7 to S10), using the PL approach as an option to treat the lower lobe tumors of the lung. We then compared the efficacy of the PL approach in terms of safety with the interlobar fissure (IF) approach. The characteristics of the patients, intra- and postoperative complications, and surgical outcomes were analyzed. Methods: Of the 510 patients who underwent segmentectomy for malignant lung tumors from February 2009 to December 2020, 85 were included in this study. Among them, 41 underwent a complete lung lower lobe thoracoscopic segmentectomy, excluding S6 and basal segments (from S7 to S10), using the PL approach, and the remaining 44 used the IF approach. Results: The median age in 41 patients in the PL group was 64.0 years (range, 22-82), and that in 44 patients in the IF group was 66.5 years (range, 44-88), with significant differences in gender between these groups. Video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery were performed on 37 and 4 patients in the PL group and 43 and 1 patient in the IF group, respectively. Postoperative complication frequency was not significantly different between these groups. The most common complications were the air leaks that persisted for over 7 days in 1 and 5 patients in the PL and IF groups, respectively. Conclusions: Complete thoracoscopic segmentectomy of the lower lobe, excluding S6 and basal segments, using the PL approach is a reasonable option for lung lower lobe tumors compared with the IF approach.

Complete thoracoscopic S9 and/or S10 segmentectomy through a pulmonary ligament approach: a retrospective study.

BACKGROUND: The high resolution of computed tomography has found the pulmonary ligaments that consists of a double serous layer of visceral pleura, forms the intersegmental septum, and enters the lung parenchyma. This study aimed to investigate the clinical feasibility of thoracoscopic segmentectomy (TS) of the lateral basal segment (S9), posterior basal segment (S10), and both through the pulmonary ligament (PL). METHODS: Between February 2009 and November 2021, 542 patients underwent segmentectomy for malignant lung tumors at Tokyo Women's Medical University Hospital (Tokyo, Japan). This study included 51 patients. Among them, 40 underwent a complete TS of the S9, S10, or both by the PL approach (PL group), and the remaining 11 by the interlobar fissure approach (IF group). RESULTS: Patients' characteristics did not significantly differ between the two groups. In the PL group, 34 underwent video-assisted thoracoscopic surgery (VATS), and 6 underwent robot-assisted thoracoscopic surgery. In the IF group, all 11 underwent VATS. Operation duration, estimated blood loss, and postoperative complication frequency were not significantly different between these groups, but the maximum tumor diameter showed a significant difference. CONCLUSIONS: Complete TS of the S9, S10, and both through the PL is a reasonable option for tumors located in such segments. This approach is a feasible option for performing TS.

Factors influencing the psychological independence of retired community-dwelling older adults in Japan.

Background: In an aging society, it is necessary to promote successful aging by helping older adults maintain engagement in social activities, especially after retirement. Focusing on psychological independence is critical for helping community-dwelling older adults maintain their ability to do things independently and build appropriate relationships with neighbors. However, shifting one's mindset from the workplace to the local community can be difficult, especially for Japanese people who prioritize work over local community activities. Few studies have investigated the factors associated with the psychological independence of community-dwelling older adults, so this study examined the factors influencing the psychological independence of older adults in T town, a typical commuter town in Japan. Methods: A self-administered, anonymous questionnaire was distributed to 246 neighborhood association members aged 65 and older. T-test, Pearson's correlation coefficient, Cronbach's alpha, and multiple regression analysis were used to develop a model for predicting psychological independence and its two subconstructs, purposefulness and personal accountability. Results: The results demonstrated that psychological independence, purposefulness, and personal accountability were significantly predicted by having abilities that are useful to other people (ß = 0.399, p = 0.001; ß = 0.277, p = 0.019; and ß = 0.394, p = 0.001, respectively). Conclusion: The findings suggest that older adults can maintain psychological independence using their existing characteristics, such as hobbies and life skills that are useful to others in the community.

Right ventricular perforation, pneumothorax, and a pneumatocele by a pacemaker lead: a case report.

BACKGROUND: Perforation of the right ventricle by a pacemaker lead is a rare and potentially life-threatening complication. We present a patient who developed right ventricular perforation, pneumothorax, and a cyst and underwent partial lung resection. CASE PRESENTATION: A 94-year-old woman was diagnosed with sick sinus syndrome and underwent a dual-chamber permanent pacemaker implantation. The next day, pacing failed and chest radiography showed that the right ventricular lead was outside the cardiac silhouette. Computed tomography revealed that the lead had perforated the right ventricular apex, causing a left-sided pneumothorax and a cystic lesion at the site of pulmonary injury by the pacemaker lead. The patient underwent lung resection and a right ventricular lead extraction. Pathological analysis revealed the cystic lesion to be an acute pneumatocele. CONCLUSIONS: Pneumothorax and pneumatocele associated with right ventricular pacemaker lead perforation is extremely rare. In our case, a radical surgical intervention provided an excellent outcome.

Effects of robot- and video-assisted thoracoscopic lobectomy experiences on the learning curve of lobectomy.

BACKGROUND: This study aims to investigate the effects of robot- and videoassisted thoracoscopic lobectomy on the learning curve of lobectomy. METHODS: Between September 2013 and February 2020, the first 68 consecutive patients (28 males, 40 females; median age: 71 years; range, 33 to 86 years) who were operated for lung malignancies and scheduled for robot-assisted thoracoscopic lobectomy were retrospectively analyzed. The characteristics of the patients and operative data were analyzed, and the operation times of the first 51 cases of video-assisted thoracoscopic lobectomy were compared with those of robot-assisted thoracoscopic lobectomy performed by a single surgeon. RESULTS: Of the patients, 62 had primary lung cancer and six had metastatic lung tumors. The majority of primary lung cancer patients (87.1%) had an adenocarcinoma. The most common clinical stage was IA1 (30.9%). There was no emergent conversion to thoracotomy in any of the patients. The median operation time was 223.5 min, and console time was 151 min. The most common complication was an air leak. All patients were alive. Compared to video-assisted thoracoscopic lobectomy, the median operation time was significantly longer in the robot-assisted thoracoscopic lobectomy group (p=0.0002). Similar to the operation time learning curve of the video-assisted thoracoscopic surgery group, the operation time learning curve of the robotassisted thoracoscopic surgery group increased from the first to ninth case (Phase 1), plateaued from the 10th t o 14th c ase ( Phase 2 ), and decreased from the 15th case (Phase 3). There was a statistically significant decrease in the operation time between Phase 1 and Phase 3 (p=0.0063). CONCLUSION: The results of robot-assisted thoracoscopic lobectomy by a single surgeon show that this surgery has a longer operation time, but the perioperative outcomes are satisfactory. The learning curve of this surgery may be gradual for experienced video-assisted thoracoscopic surgeons.