Purpose: Although metastases to the lung from other organs are usually removed with limited lung resections (e.g., wedge resections or segmentectomies), pulmonary lobectomies are often required to remove whole pulmonary tumors. This study investigated the clinical applicability of pulmonary lobectomies to treat metastatic lung tumors.Methods: We retrospectively reviewed clinical records of 143 consecutive patients with metastatic tumors in the lung who underwent surgery in our department, including data sets for 100 patients treated for their first metastatic lung tumors.Results: Of the 100 patients, 23 received pulmonary lobectomies, 69 received wedge resections and eight received segmentectomies. Patients in the lobectomy group were more likely to be younger, have larger and/or multiple tumors, and to have tumors of musculoskeletal origin (sarcomas) than those who underwent segmentectomies or wedge resections (the limited resection group). The two groups did not significantly differ in survival (3-year survival rate; lobectomy vs limited resection: 75.2% vs 80.4%, P = 0.15), or post-operative morbidity, although the only post-operative morbidity was associated with post-operative prognosis in the lobectomy group.Conclusions: Pulmonary lobectomy is a safe and applicable surgical procedure for metastatic lung tumors when long survival is expected after the tumor resection.

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Purpose: This retrospective study examined whether the severity of chronic obstructive lung disease (COPD) affects surgical outcomes.Methods: The subjects were 243 consecutive patients who underwent lobectomy for clinical stage IA lung cancer from 1999 to 2008 in our hospital. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) grading system was used to classify the severity of COPD in smokers.Results: Among the 149 smokers, 62 were diagnosed with COPD (25 as GOLD 1, 33 as GOLD 2, and 4 as GOLD 3). In univariate analysis, postoperative pulmonary complications were associated with male sex and more severe COPD. The frequencies were 17.1% in non-COPD, 24.0% in GOLD 1-COPD, and 46.0% in GOLD 2/3-COPD smokers (p = 0.0006). In univariate analysis, older age, smoking history, higher smoking pack-years and more severe COPD were associated with poor relapse-free survival. Relapse-free survival at five years was 80.7%, 66.9%, and 61.3% in non-COPD, GOLD 1-COPD, and GOLD 2/3-COPD smokers, respectively (p = 0.0005). Multivariate analyses showed that only GOLD 2/3-COPD was associated with postoperative pulmonary complications and relapse-free survival. Inhaled bronchodilators were prescribed preoperatively to 24.3% of the GOLD 2/3-COPD group.Conclusion: Smokers with GOLD 2/3-COPD are at high risk for pulmonary complications and have an unfavorable long-term prognosis.

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Purpose: Solid tumors show increased interstitial fluid pressure (IFP), which correlates to a number of pathophysiological features of tumors. There have been no reports on the usefulness of measuring IFP in lung cancer. The aim of this study was to examine the relationship between IFP and the clinicopathological characteristics of lung cancer.Methods: IFP was measured prospectively in 215 patients with 219 lesions showing solid or part-solid appearance. Four patients with double lung cancer were excluded from the analysis, resulting in 211 patients with lung cancer being analyzed for the correlation between IFP and computed tomography (CT) appearance, size, Tumor-node-metastasis (TNM) classification, maximal standardized uptake value (SUVmax), histological type, tumor grade, pleural and vessel invasion, Ki-67 index, and recurrence-free survival (RFS).Results: The mean IFP was 8.5 mmHg; IFP was significantly correlated with the tumor size, SUVmax, TNM, vessel and pleural invasion, and Ki-67 index. Low IFP was associated with a better RFS compared to high IFP. Multivariate analysis did not select IFP as independent prognostic factor. In subgroup analysis of patients with adenocarcinoma, IFP was selected as independent one.Conclusions: IFP correlates clinicopathological factors of lung cancer. IFP might be used as a prognostic factor for lung cancer.

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Purpose: Growing number of elderly lung cancer patients reflecting a lengthening life span has become a serious problem. Purpose of this study was to elucidate the short and long-term outcome of the surgery for octogenarians, and to evaluate the role of lung cancer surgery for this high age group.Methods: The patients with lung cancer aged 80 years or more who underwent the surgery at our institute from January 1998 through December 2012 were retrospectively analyzed by chart review, and the operative mortality, morbidity and the long-term survival were assessed.Results: Out of a total of 1107 patients with primary lung cancer who received surgery during the study period, 94 were octogenarians (8.5%). Sixty-nine patients (73.4%) had preoperative co-morbidity including hypertension in 50 (53.2%), coincidence of other malignancy in 35 (37.2%), anti-coagulant therapy in 29 (30.9%). Twenty-six patients (27.7%) had major or minor postoperative morbidity, and one (1.1%) died due to bronchopleural fistula. Overall-5-year survival rate was 57.5%. Univariative and multivariative analysis using Cox proportional hazard model revealed that male gender and non-adenocarcinoma histology were significant risk factors for poor prognosis.Conclusion: Gender and histology should be taken into account in preoperative evaluation of indication for lung cancer in octogenarians.

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Purpose: Non-small cell lung cancers (NSCLCs) with pathologically documented ipsilateral mediastinal lymph node (LN) metastases (pN2) are a broad spectrum of diseases. We retrospectively analyzed prognostic factors for cases of pN2 NSCLC treated by surgical resection.Methods: Clinicopathological data were reviewed for consecutive 121 patients who underwent anatomical pulmonary resection with mediastinal LN sampling or dissection for pN2 NSCLC over a 15-year period.Results: The 5-year survival rate for all patients was 29.9%. Clinical N status, curability, surgical procedure and adjuvant chemotherapy were favorable prognostic factors in univariate analysis, with 5-year survival rates of 35.0% for cN0/1 vs. 17.7% for cN2/3 cases; 33.1% for R0 vs. 14.7% for R1/2 resection; 31.5% for lobectomy vs. 25.0% for bilobectomy and 15.6% for pneumonectomy; and 72.7% with adjuvant chemotherapy vs. 23.8% without adjuvant chemotherapy. Survival did not differ significantly based on gender, age, smoking status, clinical T status, tumor location, histology, skip metastasis, subcarinal LN metastasis, or number of involved N2 levels. In multivariate analysis, adjuvant chemotherapy, R0 resection, and lobectomy emerged as independent favorable prognostic factors.Conclusion: Complete resection using lobectomy and adjuvant chemotherapy are favorable prognostic factors in cases of pN2 NSCLC.

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Objective: The present work aimed to retrospectively assess the outcomes associated with decortication by video-assisted thoracic surgery (VATS) in patients with tuberculous empyema.Methods: Patients (n = 274) who underwent decortication by VATS for surgical management of pleural empyema between January 2000 to 2010 were included. Pre-, intra-, and postoperative characteristics were observed for all patients, which were followed up for 12 months to evaluate surgical outcomes such as postoperative complications and disease recurrence.Results: No patients required conversion to thoracotomy, and no death or postoperative bleeding was reported. The mean operation time was 104.5 ± 20.4 min, with 271.5 ± 41.3 ml intraoperative blood loss and median length of hospital stay of 7.2 ± 3 .4 days. Of the 274 patients, 262 were followed up for 12 months; 26 (9.9%) patients showed complications, including incomplete lung re-expansion (11 patients) and persistent air leak (6 patients). While early disease recurrence was observed in 3 (1.1%) patients after surgery, late recurrence was reported for 6 (2.3%) individuals. Interestingly, the complication rate was much higher in patients with chronic empyema (15/34, 44.1%) than in subjects with acute empyema (11/228, 4.8%).Conclusions: Decortication by VATS decreases postsurgical complications, and results in decreased disease recurrence. This study demonstrated improved outcomes by decortication by VATS, even in patients with stage III tuberculous empyema.

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Objective: The aim of our study was to investigate clinical importance of neutrophil/ lymphocyte ratio in patients with Chronic thromboembolic pulmonary hypertension.Methods: 125 consecutive patients with a diagnosis of Chronic thromboembolic pulmonary hypertension were operated pulmonary thromboendarterectomy in our center between February 2011 and August 2013. 106 patients included into the study due to limitations. The patients were classified into two groups as patients discharged alive (Group 1) and those dying in the hospital (Group 2). Baseline neutrophil/lymphocyte ratio level was measured by dividing neutrophil count to lymphocyte count.Results: 84 patients (79%) were in Group 1, 22 patients (21%) were in Group 2. Patients with higher neutrophil/lymphocyte ratio in admission have a significantly higher mortality rate and postoperative pulmonary vascular resistance was found statistically significant variable to predict the mortality. Receiver operator characteristic (ROC) analysis revealed that using a cut-off point of 2.54, admission neutrophil/lymphocyte ratio predicts mortality. Also, correlation analysis showed a significant correlation between preoperative pulmonary vascular resistance and neutrophil/lymphocyte ratio.Conclusion: The neutrophil/lymphocyte ratio level may be a useful and noninvasive biomarker for operative risk stratification for mortality after pulmonary thromboendarterectomy.

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Objectives: We previously showed that the standardized uptake value (SUV) index, which was defined as the ratio of the maximum SUV of the tumor to mean SUV of the liver, was a surrogate marker of lung cancer aggressiveness. In this study of patients with pulmonary nodules (PNs), we explored whether the SUV index could be used to differentiate small malignant from small benign PNsMethods: A total of 284 patients with solitary PNs ≤2 cm in size underwent positron emission tomography/computed tomography and surgery. The associations between pathological findings and clinical factors were evaluated.Results: The median SUV indices of lung cancer, metastatic PNs and benign nodules were 1.2, 1.5, and 0.6, respectively (P <0.01). A SUV index cut-off value of 1.2 was used to differentiate benign from malignant nodules. When patients were grouped according to SUV index cut-off values of <1.2 or ≥1.2, the following cases were false-negative: lung adenocarcinoma (P <0.01), kidney as primary site (P <0.01), and metastatic PNs with long disease-free survival (P = 0.02).Conclusions: As a noninvasive diagnostic marker, the SUV index was found to be useful for differentiating benign from malignant small PNs.

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Objective: We evaluated the predictive power of the EuroSCORE, EuroSCORE II and Society of Thoracic Surgeons (STS) score for isolated redo aortic valve replacement.Materials and Methods: 78 consecutive patients underwent the aforementioned procedure mainly with a stentless valve prosthesis at our institution. Observed mortality was compared to the predicted mortality, Receiver Operating Characteristics (ROC) curves were calculated and the area under the curve (AUC) analyzed.Result: Observed mortality was 11.5%. EuroSCORE and EuroScore II predicted a mortality of 28.2 ± 21.6% (p <0.001) and 10.2 ± 11.8% (p = 0.75), respectively. AUC of the EuroSCORE was 0.74 (95% CI: 0.62–0.83), p = 0.009 and of the EuroSCORE II 0.86 (95% CI: 0.76–0.93), p <0.0001. Optimal Youden index of the EuroSCORE II was 0.59 refering to a predicted mortality of 9.9% (sensitivity: 77.8% and specificity: 81.2%). Predicted mortality of STS score was 17.8 ± 10.6% (p = 0.08) and AUC was 0.64 (95% CI: 0.53–0.75), p = 0.06.Conclusion: EuroSCORE II calculation was not only superior to EuroSCORE and STS score but led to a very realistic mortality prediction for this special procedure at our institution. A EuroSCORE II greater 10 should encourage to consider an alternative treatment.

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In this study, we investigated the early and long-term results of conventional aortic valve replacement (AVR) in very old patients.Methods: Seventy-five patients with aortic stenosis underwent conventional AVR for patients aged 80 years.We examined early death and major adverse cardiovascular and cerebrovascular event (MACCE).Results: The operative mortality was 0% for isolated AVR and 19.2% for concomitant surgery. The postoperative survival rate and MACCE free-rate were no significant differences between the isolated AVR and the concomitant surgery. Univariate analysis confirmed that cardiac dysfunction, severe chronic kidney disease (CKD), hemodialysis, + coronary artery bypass grafting, and norepinephrine use were risk factor of early death. Univariate analysis confirmed that severe CKD, BNP >1000 pg/ml, aortic cross clamping time (ACCT) >180 min, and non-use carperitide and multivariate analysis confirmed that ACCT >180 min, and non-use carperitide were risk factor of MACCE.Conclusions: This study showed that the results of conventional AVR in very old patients were not satisfactory. However, the results obtained with isolated AVR were favorable with no operative deaths. The present study demonstrated that preoperative cardiac function, preoperative renal function, and operative factors have an important impact on early mortality and MACCE.

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Background: Based on the revised AHA/ACC guidelines, it might be necessary to take into consideration the average life expectancy of Japanese people and revise the Japanese guidelines accordingly. Accordingly, we performed the present study to compare the long-term outcome in patients aged 65 years or older who underwent prosthetic valve replacement at our hospital using mechanical valves or biological valves.Methods: We have performed valve replacement in 416 patients aged 65 years or older (mechanical: 157; biological: 244).Results: There was no significant difference between the mechanical and biological valve for the actuarial survival rate. As for the valve-related complication free rate, in the mechanical valve group, the rates were significantly higher for all patients, aortic valve replacement (AVR) patients, and mitral valve replacement (MVR) patients.Conclusions: Following revision of the AHA/ACC guidelines for selection of prosthetic valves, it is necessary to investigate whether patients aged 60–70 represent the gray zone for selecting valves as in US and European guidelines, or whether a higher age is more appropriate in view of the longer average life expectancy in Japan. Accordingly, further evaluation of the long-term outcome for mechanical and biological valves in Japanese patients is needed to obtain evidence for preparation of original Japanese guidelines on prosthetic valve selection.

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Purpose: Early and long-term outcomes of coronary artery bypass grafting (CABG) in patients with left main disease (LMD) with acute coronary syndrome (ACS) have never been assessed.Methods: Between September 2004 and April 2012, 459 patients with LMD underwent first-time isolated CABG. Of those, 191 patients had ACS and 268 did not. Early and late postoperative outcomes were compared between two groups.Results: Patients in the LMD+ACS group were older and more likely to be female. Left ventricular ejection fraction was lower in the LMD+ACS group. In both groups, bilateral internal thoracic artery grafts were used in over 90% of patients and off-pump technique in over 95%. Operative death rate was not significantly different between the groups (LMD+ACS: 2.1% vs. LMD–ACS: 0.4%). Log-rank test revealed that the actuarial survival rate (79.2 ± 3.7% vs. 81.5 ± 3.5%) and freedom from major adverse cardiac and cerebrovascular events (MACCE) (69.2 ± 4.2% vs. 67.0 ± 4.1%) were similar between groups at 7 years. Multivariate analyses demonstrated that ACS was not identified as an independent predictor of operative death, late mortality, and late MACCE.Conclusion: ACS did not have a negative impact on early and late outcomes of CABG in patients with LMD.

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Purpose: We aimed to evaluate the effects of preoperative pulmonary hypertension (PH) on early and long term results in patients undergoing coronary bypass surgery and the effects of coronary bypass surgery on PH.Methods: Among 2325 patients who underwent elective isolated coronary artery bypass surgery between March 2003 and March 2012, 287 patients with high preoperative pulmonary arterial pressure (PAP) ≥30 mmHg were examined. Patients’ data were obtained by retrospective examination of our clinic’s database. 69 patients who had complete parameters included in the study.Results: There was no increase in the New York Heart Association (NYHA) functional classification 84% of cases. Preoperative and postoperative values of the mean ejection fraction and mean PAP of patients was respectively 45.28 ± 9.67 (25–65), 46.03 ±12.4 (20–65) (p = 0.447), 36.67 ± 6.81 (30–60) mmHg, 37.81 ± 10.07 (20–70) mmHg (p = 0.378). The late mortality of cases was 5.79%. In our study, during 33.9 ± 17 (9–100) months follow up period, life expectancy was calculated as 94.7 months.Conclusion: Preoperative evaluation of these patients for appropriate medical treatment at peroperative and postoperative period, coronary bypass can be performed with low morbidity and mortality rates. In the late period after surgical revascularization PH showed no significant change and had no adverse effect on quality of life.

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Cerebral infarction after coronary artery bypass grafting (CABG) is a serious complication and a problem that remains unsolved. We will report the onset of cerebral infarction in CABG patients in our institution, and its cause, preventive method. The subjects of this research were 761 patients who underwent on-pump isolated CABG. Preoperative, intraoperative and postoperative factors, onset of cerebral infarction and atrial fibrillation were investigated. Postoperative cerebral infarction and postoperative atrial fibrillation were recognized in 1.4% and 24% of the patients, respectively. The risk factors for cerebral infarction were carotid artery stenosis, cardiopulmonary bypass time >180 min, postoperative atrial fibrillation, and β-blocker non-use. The risk factors for postoperative atrial fibrillation were 75 or higher years of age, chronic kidney diseases, emergency surgery, cardiopulmonary bypass time >180 min, intraoperative carperitide non-use, intraoperative landiolol hydrochloride non-use, preoperative angiotensin II receptor blockers (ARB) non-use, preoperative calcium antagonist use, preoperative statin use, postoperative β-blocker non-use, and postoperative aldosterone blocker non-use. The results of this study showed that cerebral infarction occurs frequently in patients who have developed atrial fibrillation, and it was considered that perioperative cerebral infarction can be prevented by perioperative β-blocker, carperitide, anticoagulation therapy and adequate extracorporeal circulation. Since preoperative, intraoperative and postoperative drug use is closely involved in the risk factor for postoperative atrial fibrillation, it was considered possible that adequate perioperative drug therapy can prevent atrial fibrillation and onset of cerebral infarction. (This article is a secondary publication of J Jpn Coron Assoc 2014; 20: 91–7.)

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Objectives: The purpose of this study was to assess the feasibility of the mattress suturing technique in repairing large perimembranous ventricular septal defects (VSDs) in infants.Methods: This was a retrospective review of 120 patients undergoing surgical closure of perimembranous VSD between 2010 and 2012. The mattress suturing technique was performed to close the infero-posterior rim of the perimembranous VSD in 60 patients (Group I) while the conventional shallow suturing method was used in the others (Group II). Propensity-score matching was performed to adjust for potential baseline confounders, which resulted in 120 patients matched to 95 patients. Perioperative outcomes were compared.Results: Postoperative mortality in both groups was zero. Two patients in Group II developed atrioventricular block (1 complete heart block and 1 temporal II-degree atrioventricular block) compared with none in Group I (p >0.05). Complete right bundle branch block was found in four patients in Group I and 12 patients in Group II (p = 0.035). Mean follow-up time was 26.6 ± 8.9 months. Three patients in Group II developed a small residual VSD while only one patient in Group I did during the follow-up period (p >0.05). Conclusions: The mattress suturing technique produced results comparable with the conventional shallow suturing method and seems to be of value in reducing the incidence of complete right bundle branch block. It appears to provide an optional method for surgical closure of large perimembranous VSDs in infants.

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A 59-year-old woman presented with a 1- year history of dysphagia. She suffered from a large mediastinal mass obstructing trachea and bilateral main bronchus, which led to dyspnea and disturbed consciousness. Immediate intubation and surgery was required. A solid tumor that included esophagus and right vagal nerve, and adhered to the membranous part of the bronchus was found. However, the tumor could be resected en bloc and the patient has been free from recurrence. Pathologically, the tumor exhibited proliferative spindle cells and was diffusely positive for S-100 protein. It was therefore diagnosed as a benign esophageal schwannoma. To our knowledge, this is the first report of tracheal obstruction from a benign esophageal schwannoma, which we successfully treated with emergency subtotal esophagectomy.

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Ectopic cervical thymoma (ECT) is a rare tumor. We present a case of 56-year-old woman with an ECT in the anterior neck that was correctly diagnosed preoperatively. The patient had no symptoms of myasthenia gravis or other immune disorders, and the tumor was not invading any adjacent structures. We performed tumor resection and thymectomy through a transcervical approach using video-assisted thoracoscopic surgery with a multi-access single port. To our knowledge, this is a novel combined technique for the resection of an ECT.

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