Thoracoscopic bullectomy for primary spontaneous pneumothorax has a relatively high postoperative recurrence rate. One of the reasons for postoperative recurrence is the regrowth of bullae around the staple line. Therefore, reinforcement of the visceral pleura around the staple line is a reasonable way to prevent postoperative recurrence. This study was conducted to determine the efficacy of preventing postoperative recurrent pneumothorax of widely covering the staple line and apex with an absorbable sheet after thoracoscopic bullectomy. Our study subjects were 397 patients under the age of 30 treated with the following three methods during the first surgery for primary spontaneous pneumothorax: Group T received open thoracotomy but no visceral pleural covering; Group V received thoracoscopic bullectomy but no visceral pleural covering; Group O received thoracoscopic bullectomy and wide coverage of the staple line with oxidized regenerated cellulose (ORC) sheet; Group P received thoracoscopic bullectomy and wide coverage of the staple line with a polyglycolic acid (PGA) sheet. The postoperative recurrence rates of Group T, V, O, and P were 3.5, 12.4, 25.0, 1.2%, respectively. The recurrence rate in Group V was significantly higher than that in Group T (p=0.05). The recurrence rate (1.2%) in Group P was significantly lower than that in Group V (p=0.01). The recurrence rate (15.4%) in teenagers was significantly higher than that (4.3%) in those in their twenties (p=0.001). In the analysis of teenagers, there was no recurrence in Group P. These results suggest that wide coverage of the staple line with a PGA sheet is effective for decreasing the rate of postoperative recurrence of spontaneous pneumothorax in younger patients.
Anomalies of the bronchi are rarely encountered in thoracic surgery. Among these anomalies, a tracheal bronchus is found relatively more frequently as an anomaly of the superior lobar bronchus, while cases of multiple superior lobar bronchi branching from the right main bronchus are quite rare. Here, we report a surgical case of lung cancer in the right upper lobe with such an anomaly of the superior lobar bronchus.
A 66-year-old woman was followed-up for an abnormal chest radiograph. A nodule in her right upper lobe was detected by computed tomography (CT). She was admitted to our hospital, where she underwent open surgical lung biopsy. She received an intraoperative rapid diagnosis of adenocarcinoma; an immediate right upper lobectomy and lymphadenectomy were performed. There were two superior lobar bronchi branching from this patient's right main bronchus; we resected them separately.
Anomalies of the bronchi are rare but do exist. Therefore, thorough investigation of individual anatomy before surgery is important.
A 72-year-old woman rapidly developed hemoptysis, hypoxia, and low blood pressure during pulmonary artery catheter (PAC) insertion as a preoperative examination for mitral regurgitation. The patient was emergently intubated, put on one-lung ventilation, and administered a vasopressor intravenously. Contrast-enhanced CT and pulmonary angiography revealed massive extravasation from the ruptured right lower lobar branch (A8) to both the airway and pleural space. We transported the patient to the operating room immediately while pumping fluids and blood, and opened the chest as soon as anesthesia had been administered. Intraoperative examination showed blood welling up from the thoracic cavity, and the right lower and middle lobes were solid and dark purple. The hilum was controlled with a vascular clamp, and percutaneous cardiopulmonary support (PCPS) was administered while resuscitation was being carried out, and then the bi-lobectomy was promptly completed. Consequently, the patient's hemodynamics stabilized and PCPS could be withdrawn immediately after surgery. She did not show any neurologic sequelae or recurrent hemorrhage, and could be discharged after cardiopulmonary rehabilitation. Pulmonary artery injury is a rare but often fatal complication of PAC. If massive hemorrhage cannot be controlled conservatively, we should not hesitate to perform surgical intervention, which may offer the best chance for survival. Moreover, multidisciplinary support, PCPS that might control bleeding by reducing the pulmonary blood flow, for example, would be essential to rescue the patient with pulmonary artery perforation of PAC.
Background: Immune checkpoint-blocking antibodies cause specific side effects known as immune-related adverse events (irAE).
Case presentation: A 61-year-old Japanese woman had undergone right lower lobectomy with lymph node dissection for lung adenocarcinoma, of which the pathological stage was Stage IIIA (T2aN2M0). The cancer cells at the margin of the subcarinal lymph node suggested microscopic residual disease. Four courses of chemotherapy with cisplatin, pemetrexed, and bevacizumab were administered after the surgery. However, metastases to the cervical and lower paratracheal lymph nodes were revealed at 11 months after the surgery. After nivolumab as the 4th line was administered for 4 cycles, the patient complained of dizziness and general fatigue. Brain magnetic resonance imaging revealed the presence of multiple spatio-temporal lesions in the deep white matter, which showed a high intensity on T2-weighted imaging and a contrast effect. Myelin basic protein in the cerebrospinal fluid was positive. Dexamethasone improved the psychomotor state temporarily. However, she entered a shock state due to colon bleeding caused by a cytomegalovirus ulcer of the rectum. Her condition deteriorated over a period of a few weeks, with worsening respiratory symptoms.
Conclusion: Programmed cell death-1 and its ligands have been reported as important immune system-regulatory molecules. Their disruption is associated with several autoimmune disorders, such as multiple sclerosis. Further studies are needed to elucidate biomarkers for the prediction of irAE of immune checkpoint-blocking antibodies, and an effective treatment will evolve.
The patient was a 63-year-old woman who developed upper respiratory tract symptoms 1 month prior to admission, but had ignored them. She was transported to our hospital by ambulance due to the aggravation of her symptoms. A chest radiograph revealed infiltrative shadows in the right upper lobe and both lower lobes of the lungs, with vacuolar fluid-filled lesions between the right and middle lobes and on the dorsal lower lobe. The patient was diagnosed with empyema due to severe pneumonia. As part of her artificial respiratory management, the patient underwent thoracic cavity drainage and antibiotic treatment. Air leaks continued after hospitalization and so, taking her systemic status (TP6.4 Alb2.4 PS3) into account, the bronchus was occluded with an Endobronchial Watanabe Spigot (EWS) via a bronchoscope under thoracoscopic observation. Surgical findings included multiple fistulas inside the lung parenchyma, leading to a diagnosis of empyema with fistulas. During the course of her treatment, the patient underwent 3 bronchial occlusion procedures involving 7 fistulas in the right B6 B10, which were occluded with EWS. After surgery, the leaks disappeared, empyema improved, and the patient was discharged on Day 72 of hospitalization. This method of EWS occlusion under thoracoscopy can space the lung parenchyma and be performed for patients with empyema with fistulas who show a poor systemic condition, and could thus prove very useful.
Esophagopleural fistula caused by iatrogenic injury during pulmonary resection is a severe complication. Although a variety of treatments exist, management of the fistula must be individualized because of the diversity of patient's conditions and specific characteristics of the fistula. We report a case of esophagopleural fistula related to an intraoperative esophageal injury during pulmonary lobectomy for a chronic lung abscess, which was successfully treated by open-window thoracotomy followed by Negative Pressure Wound Therapy (NPWT). A 72-year-old man was referred to our hospital with persistent cough and recurrent fever. He was diagnosed with chronic lung abscess in the right lower lobe and underwent right lower lobectomy. An esophageal injury occurred during adhesiolysis around the lung as the lower lobe rigidly adhered to the esophagus and the boundary between these two organs was unclear. The injured esophagus was directly repaired and reinforced with a pericardial fat pad flap. Five days after surgery, empyema developed due to the suture line leak. We immediately performed a re-thoracotomy. The residual lung lobes had not adhered to the chest wall;therefore, the injured part of the esophagus was resutured after debridement of the damaged tissue, and then the patient was mechanically ventilated for 5 days to localize the empyema cavity. An open-window thoracotomy was performed to drain the cavity soon after the esophageal fistula had been confirmed by a contrast study 11 days after the second surgery, and the cavity was irrigated two times daily with saline. To optimize the caloric intake, parenteral nutrition was used together with enteric feeding via a nasojejunal tube. We used NPWT to facilitate granulation and reduce the size of the cavity after the fistula had healed. The wound was closed directly without any flap transplantation 46 days after the open-window thoracotomy. The patient was discharged in a favorable condition.
We report the case of a 49-year-old man who received allogeneic bone marrow transplantation 5 years previously in the Department of Hematology of our hospital. There was no problem during his clinical course after transplantation, especially chronic GVHD, so he did not receive a regular check-up involving chest radiograph or CT for 4 years. Because of dyspnea on exertion starting 2 months before consultation, he underwent chest radiograph and pneumothorax was pointed out on the right side. We inserted a chest tube and operated on the pleurodesis; the right pneumothorax was subsequently resolved. However, left pneumothorax developed 3 months later, and so VATS (video-assisted thoracic surgery) was performed due to persistent air leakage after chest tube drainage. His lung showed subpleural parenchymal fibrosis with upper lobe predominance, suggesting his condition to be a late-onset noninfectious pulmonary complication after bone marrow transplantation.
Recently, some cases of subpleural parenchymal fibrosis with upper lobe predominance after bone marrow transplantation were reported, but the relationship with chronic GVHD remains unclear. We suggest that accumulating similar cases is important.
An 83-year-old man, who had received right extrapleural lucite ball plombage for pulmonary tuberculosis 64 years previously presented to our hospital complaining of fever. Chest radiograph and CT revealed empyema. Thoracentesis was performed, and the pus obtained revealed group G streptococcus. We diagnosed this patient with empyema caused by group G streptococcus, extirpated the lucite balls, and performed fenestration. Twenty-two months after the operation, omentoplasty was carried out. Prolonged air leakage from a bronchial fistula continued, but the air leakage disappeared on bronchial embolization using EWS (Endobronchial Watanabe Spigot). After this episode, the postoperative course was uneventful.
In the 1940-50s, surgical treatment for pulmonary tuberculosis played a very important role, especially in collapse therapies, such as thoracoplasty or plombage. Extrapleural lucite ball plombage was one of them, but it soon disappeared because of its various associated complications. Suvivors also experience late complications such as empyema. However, it is also true that this patient had been free of tuberculosis and asymptomatic for 64 years. Cases of extirpated lucite ball plombage have rarely been reported, and so we report this Japanese case.
A 56-year-old woman presented with left chest pain and chest wall swelling. A tumor of 6 cm in diameter involving the left 8th rib was detected by computed tomography. Left chest wall resection including the 7th, 8th, and 9th ribs coupled with reconstruction with polypropylene mesh was performed, and local control was achieved. Immunohistochemical examinations of the tumor revealed positive reactions to alpha-smooth muscle actin and desmin. Chest wall leiomyosarcoma was finally diagnosed. Initial metastatectomy was performed for solitary liver metastasis 1 year and 11 months later. A total of three liver metastatectomies, a total of three lung metastatectomies, and proton-beam radiotherapy for sacral metastasis were performed over a period of 13 years. The patient was alive without any recurrence at 14 years and 3 months after the first operation. Chest wall leiomyosarcoma is very rare, and no case of a long-term survivor who underwent repeated metastatectomies had been reported prior to the present case in Japan.
The patient was a 33-year-old woman who had undergone extensive resection for synovial sarcoma in the left thigh. Three years after the surgery, CT revealed two metastatic tumors in the right lower lobe of the lung (S6, S7). She received right middle and lower lobectomies because the tumor in S6 had invaded the intermediate pulmonary artery. Eight years after the pulmonary resection, CT revealed a pulmonary nodule shadow, indicating invasion of the right main pulmonary artery. We diagnosed this abnormal shadow as recurrent synovial sarcoma. Consequently, we adopted an intrapericardial approach via a median sternotomy, and could easily cut off the right main pulmonary artery and pulmonary vein in the pericardium. We followed the procedure to separate adhesive parts from the lung, but massive bleeding was caused by collateral blood flow from the chest wall. We added trans-sternal thoracotomy and then we performed completion pneumonectomy. When the lung adheres firmly and adhesiotomy may cause massive bleeding, we recommend cutting off the pulmonary vein after adhesiotomy, even if we can easily cut off the pulmonary artery and vein in the pericardium.
We report an 80-year-old woman who underwent pulmonary resection for metastasis of an intraductal papillary mucinous carcinoma (IPMC) of the pancreas. The patient had undergone pylorus-preserving pancreaticoduodenectomy prior to pulmonary resection. Based on the pathological specimen, the primary tumor was diagnosed as an invasive IPMC, pT3N0M0, Stage III. A follow-up chest computed tomography scan, 2 years after the operation, showed a solitary pulmonary nodule in the left lower lobe. Thoracoscopic left lower lobectomy and partial resection of the lingula segment were performed for the purposes of diagnosis and treatment. The tumor was diagnosed as a metastatic lung tumor from the IPMC because hematoxylin-eosin staining and the phenotype of the secreted mucopolysaccharide of the lung lesion were similar to those of the primary lesion. Because invasive IPMC generally represents aggressive clinical characteristics, lung metastasis is rarely resected. We performed radical resection of a lung tumor in a case in which it was difficult to distinguish primary lung cancer from metastatic cancer.
We studied four surgically treated cases of traumatic hernia of the diaphragm.
Case 1: The patient had suffered subarachnoid hemorrhage, liver injury, and a right diaphragm hernia as a result of a fall from a height. Part of the liver protruded into the thoracic cavity through the herniated diaphragm. This was repaired by direct suturing via a thoracotomy on the 10th day after injury.
Case 2: The patient had suffered a right diaphragm hernia combined with subdural hematoma and subarachnoid hemorrhage as a result of a traffic accident. The hernia was repaired by direct suturing via a thoracotomy on the 9th day after injury.
Case 3: The patient had suffered a right diaphragm hernia, multiple bone fractures, and pulmonary contusion as a result of a fall from a height. The hernia was sutured directly via a thoracotomy on the day after injury, as one day of observation revealed exacerbation of liver invagination into the thoracic cavity.
Case 4: The patient had suffered a left diaphragm hernia, subarachnoid hemorrhage, and renal injury in a traffic accident. The hernia was repaired by direct suturing via a thoracotomy on the day of injury.
Conclusion: Repair of traumatic diaphragm hernia by direct suturing was possible in all four cases. The time period that elapsed between injury and surgical repair was 10, 9, 1, and 0 days, respectively. Coronal or sagittal imaging using multislice CT allows the accurate diagnosis of traumatic diaphragm hernia. Traumatic hernia of the diaphragm should be repaired as soon as possible because of the likelihood of hernia exacerbation during the observation period.
A 49-year-old man with no history of tuberculosis or chest surgery showed an abnormal shadow on a chest radiograph at a medical checkup every year from 2011. In 2015, dyspnea increased gradually, and he visited another hospital. Chest CT revealed a huge mass of 26×16 cm in the left thoracic cavity and a compressed left lung. He was then referred to our hospital. A mosaic of various signal intensities was noted inside the mass as well as a low-signal band at its periphery as specific features of a chronic expanding hematoma on T2-weighted MR images. Under a clinical diagnosis of chronic expanding hematoma of the left thorax, we performed an operation via a median sternotomy following thoracotomy. The mass with a tough capsule adhered strongly to the chest wall, left lung, and diaphragm. Finally, we could rescue the left lung and remove the mass by dissecting the mass completely from the surrounding tissues. The operative time was 420 minutes, and blood loss was 103 mL. It is noteworthy that we selected an appropriate approach, on considering the course of the mass progression and respiratory function improvement by preservation of the left lung.
A 60-year-old man was found to have an abnormal shadow on a chest radiograph. Chest computed tomography revealed a pulmonary nodule of 18 mm in diameter in the upper lobe of the right lung. The nodule had a lobulated edge and also contained small areas of fat without calcification. Three-dimensional computed tomography (3D-CT) showed an abnormal distribution of the aberrant pulmonary vein (V1 and V2), descending dorsally to the intermediate bronchus and draining directly into the left atrium. Video-assisted thoracic surgery (VATS) segmentectomy of the right S1 was performed. The rapid pathological diagnosis was pulmonary hamartoma. Preoperative 3D-CT helps understand the anatomy of the pulmonary vessels, which could play an important role in safe and secure VATS anatomical resection.
A 40-year-old male had a 2-week history of fever and left chest pain prior to consultation. Pneumonia with pleuritis was suspected based on a chest radiograph. Chest CT and MRI showed a polycystic mass in the superior anterior mediastinum.
Therefore, intrathoracic perforation by a mature mediastinal teratoma was suspected.
Operation was performed with a median sternotomy. The intra-operative histopathological diagnosis showed no malignant findings.
The adhesion of the mass and the left lung was marked because of inflammation, and we removed the mass and resected part of the left upper lobe of the lung.
The final pathological diagnosis was a mature mediastinal teratoma.
The cause of this perforation was most likely to be histolysis with pancreatic enzymes in the tumor. We considered that the autolysis with pancreatic enzymes was the cause of this perforation, because there was pancreatic tissue based on pathologic findings and no other potential cause present, although amylase of the pleural effusion did not show a high level.
Perforation caused by a mature mediastinal teratoma can cause a variety of complications. Because a mature mediastinal teratoma can show malignant transformation, we should resect it completely.
The patient was a 64-year-old male. He visited his local doctor with mild fever and general malaise. His white blood cell count was 82,500/μL, and so he was referred to our hematology department. Acute leukemia was diagnosed upon examination of the bone marrow. Remission induction therapy was administered. Complete remission was achieved but fever, coughing, blood-tinged sputum, and chest pain appeared. CT and radiograph of the chest showed left-sided pneumonia, and pulmonary mycoses was suspected. Sputum culture and bronchoscopy did not facilitate pathogen identification. Antibiotics and antifungals were administered, and the symptoms and inflammation showed improvement. However, further CT of the chest showed a remaining mass with a 4.9-cm cavitation in the left lower lobe. Post-remission therapy was scheduled next but due to the high risk of recurring inflammation, left lower lobectomy was performed. Postoperative pathological examination revealed pulmonary mucormycosis. The postoperative course was uneventful, and the patient was discharged after post-remission therapy. Thereafter, there were two recurrences of acute leukemia, and chemotherapy resulted in complete remission. Now, 4 years and 8 months have passed since surgery, but there has been no relapse of lung mucormycosis.
We present a case of endobronchial actinomycosis in localized cystic bronchiectasis, diagnosed after lobecotmy for recurrent massive hemoptysis. A 77-year-old woman showed massive hemoptysis occurring twice 1 year previously, and underwent bronchial artery embolization at another hospital. However, massive hemoptysis occurred again, and she was admitted to our hospital for examination. Chest computed tomography (CT) revealed a cavity lesion in the right laterobasal segment (S9), and the wall of the cavity showed gradual thickening. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed high-level FDG accumulation in the cavity wall. A diagnosis of pulmonary aspergillosis or tuberculosis was ruled out, and we suspected primary lung cancer. To control hemoptysis, right lower lobectomy was performed. Pathological examination showed that the cavity wall was covered with ciliated epithelium, diagnosed as cystic bronchiectasis. In the dilated bronchus, sulfur granules were recognized and she was diagnosed with actinomycosis. The massive hemoptysis was considered to have been caused by not only bronchiectasis but also actinomycosis. Actinomycosis in localized cystic bronchiectasis has not previously been reported. In a case of hemoptysis with a pulmonary cavity lesion, endobronchial actinomycosis in the localized cystic bronchiectasis should be considered.
A 65-year-old male was referred to our hospital because of subphrenic abscess and bronchial fistula associated with hepatectomy. The bronchial fistula could not be resolved with conservative treatment, and so surgery was conducted. Resection of the fistula and repair of the diaphragm with a reverse latissimus dorsi muscle flap was performed. After the operation, the bronchial fistula showed immediate improvement, and at the 2-year follow-up, the patient was doing well with no complications.
A muscle flap is effective for infection, and the latissimus dorsi muscle is one of the largest muscles in the body. The latissimus dorsi muscle has double vascularization and a reverse latissimus dorsi muscle flap is fed by thoracic vertebrae. It is easy to expand it inferiorly; therefore, it is useful to repair the diaphragm.
A 63-year-old male with a chief complaint of persistent coughing underwent CT, which demonstrated a left lower lung mass, of 72 mm in the longest diameter. A bronchoscopic needle biopsy revealed poorly differentiated carcinoma, and a whole-body examination resulted in a diagnosis of cT3N2M0, stage IIIA. Induction chemotherapy with cisplatin and TS-1 was initiated, and on day 7, a chest radiograph revealed multiloculated pleural effusion with niveau. The patient developed pyopneumothorax due to rupture of the lung cancer, and an emergency operation was performed. The histopathological diagnosis was pleomorphic carcinoma. Necrosis of the tumor reached the visceral pleura. After the diagnosis, 3 cycles of CDDP+TS-1 were administered, and there has been no recurrence for two years since the surgery. Induction chemotherapy for carcinomas that easily necrotize may induce self-destruction and rupture of tumors, and emergency surgery is one of the treatment options in that situation.
A 61-year-old man underwent left lower lobectomy for stage IB lung adenocarcinoma. Pleural dissemination, hilar lymph nodes, and liver metastases developed at ten months after the operation. Because the patient complained of a headache, nausea, and appetite loss, chemotherapy was discontinued. It was suspected that the patient had cancer cachexia. Brain MRI showed a thickened pituitary stalk and body, and laboratory data showed low values of anterior lobe hormones of the pituitary gland. Finally, the patient was diagnosed with hypopituitarism caused by pituitary metastasis. He underwent hormonal replacement therapy, and his symptoms improved. As a result, he was able to resume chemotherapy. Hypopituitarism by pituitary metastasis of lung cancer is rare, and sometimes shows similar symptoms to cancer cachexia. Hormonal replacement therapy is effective for hypopituitarism. The possibility of pituitary metastasis of lung cancer and the utility of treatment should be considered.
Thymoma often leads to complications such as autoimmune disease, and symptoms of autoimmune disease are sometimes observed in patients even after thymothymectomy. Here, we encountered a case of aplastic anemia after thymothymectomy. A 73-year-old woman was admitted to our hospital for the treatment of an anterior mediastinal tumor. We performed thymothymectomy by median sternotomy. Histopathological findings showed type B1 thymoma when classified according to the World Health Organization system, and stage I thymoma when classified according to the Masaoka system. Six months after the surgery, the patient had pneumonia, and her hemogram showed pancytopenia; however, it had been normal before surgery. Puncture of the bone marrow showed the presence of fatty marrow, a cell density of 10-20%, and a myeloid/erythroid ratio of more than five. The patient was diagnosed with a very severe grade of aplastic anemia. Cyclosporine and supportive therapy were administered. However, the patient died of multiple organ failure 4 months after the onset of aplastic anemia.
The occurrence of aplastic anemia after thymothymectomy is a very rare complication. However, this complication is likely to be fatal since the patient becomes immunocompromised. Therefore, it is important to be careful regarding not only the recurrence of thymoma in the patient, but also the occurrence of autoimmune disease during follow-up after thymothymectomy.
Case. A 72-year-old man with a right lung tumor was referred to our hospital. The clinical diagnosis was lung cancer cT4N1M0 stage IIIA with interruption of the pulmonary vein. Right middle and lower lobectomy combined with resection of the left atrium was performed.
Anticoagulation therapy with heparin for atrial fibrillation was started within 3 hours after surgery, and switched to the oral administration of apixaban at 10 mg/day five days after surgery. Fifteen hours after switching, the patient showed severe bleeding and required blood transfusion. The bleeding was stopped after the interruption of apixaban.
Conclusion. In the management of postoperative anticoagulation treatment, the advantages and disadvantages of anticoagulants should be considered.
We report the multidisciplinary treatment of a rare case of nontuberculous mycobacteria (NTM) complicated by empyema with a pleural fistula. A 71-year-old woman was referred to us due to chest pain and fever in April 2013. Computed tomography (CT) revealed the pleural effusion and pneumothorax, for which chest drainage was performed. Pleural fluid cultures yielded NTM, and PCR was positive for Mycobacterium-intracellulare. Therefore, chemotherapy was started, but was subsequently discontinued due to a decrease in the platelet count. Air leakage was fully resolved and the patient was discharged, but pleural effusion and pneumothorax were observed again in June. Since the air leakage continued untill August, thoracoscopic surgery for lung fistula closure was performed. However, since air leakage continued, open window thoracostomy was conducted. Since NTM was negative on culture and the air leakage continued, left lower lobectomy was performed in November. During the three years since the operation, NTM have not recurred.
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