Dyspnea is a major clinical problem that decreases the quality of life of many patients in the postoperative state. Postoperative dyspnea is not easily monitored by a quantitative assessment because there is no standardized measurement. The purpose of this study was to evaluate the reproducibility of the visual analog scale (VAS) and the relationship between the VAS and Hugh-Jones classification (H-J) for perioperative dyspnea. The VAS was a 15 cm horizontal line with bipolar opposite descriptors anchored on the left by “not at all breathless” and on the right by “extremely breathless”. The “VAS negative or VAS = 0” marked on the left tip indicated “not at all breathless”. The patients were instructed to mark the spot on the line that indicates the intensity of respiratory effort at that particular time. Between November 1, 1997 and September 30, 1998, 23 consecutive patients underwent a partial resection of the lung for bullous lung disease or lung nodule, excluding video-assisted thoracic surgery, and 27 patients underwent a lobectomy by standard thoracotomy for lung cancer. The relation between dyspnea assessed by the VAS and that classified by H-J in the preoperative periods and postoperative days (pod) 7, 14, 21, 28, 60, 90, and 120 was studied. Furthermore, the relation between dyspnea- assessed by the VAS and respiratory function measured in the preoperative periods and pod 60 was studied. The ratio of the patients with dyspnea (VAS positive) and the mean value of dyspnea assessed by the VAS reached a peak on pod 7. In the postoperative course, the ratio of H-J grade-I patients returned to that of the preoperative state quickly. However, the ratio of the VAS negative patients returned slowly to the preoperative state. These findings show that the quantitative assessment of dyspnea by the VAS can indicate a faint sensation more sensitively than the H-J classification. We conclude that the VAS measurement to assess dyspnea is useful for detecting faint sensations of respiratory effort at the perioperative state.
This study was designed to evaluate the incidence and clinical implications of immunohistochemical detection of micrometastases in the regional lymph nodes of patients with non-small cell lung cancer. The paraffin-embedded sections of 1, 024 regional lymph nodes from 56 patients with stage I non-small cell lung cancer who had undergone curative resection were studied. Immunohistochemistry with monoclonal antibody to cytokeratin 19 was used to detect micrometastases. We identified cytokeratin (CK)-positive cells in 15 (27%) of 56 patients, and in 22 (2.1%) of the 1, 024 lymph nodes. The frequency of micrometastases was more significantly in adenocarcinomas than in squamous cell carcinomas (p=0.041). Recurrence occurred more frequently in patients with micrometastases than without micrometastases (p=0.053). Survival was significantly shorter in the patients with micrometastases in the mediastinal lymph nodes than in patients with node-negative disease (p=0.037). These findings suggest that immunohistochemical staining for cytokeratin is useful for the detection of micrometastases to the regional lymph nodes, and can be a prognostic factor.
We experienced two patients with air leakage from lung parenchyma who were treated with omentoplasty. A 49-year-old man with rheumatoid arthritis and interstitial pulmonary fibrosis presented left pneumothorax. A 61-year-old man showed prolonged air leak after staged thoracostomy and decortication for empyema. In each patient, five times and three times, respectively, of thoracotomy using direct suture, fibrin glue spreading, application of sealants, polyglucolide sheet or combined fibrin glue and collagen (TachoComb ®), or muscle pedicle sealing failed to stop the leakage. The leakage eventually ceased after sealing of the lung with a transposed omentum pedicle. Such an omentoplasty may be indicated for patients with noninfective air leak from lung parenchyma which is otherwise difficult to cure.
We report here a rare case of traumatic lung rupture with pulmonary contusion undergone a left lower lobectomy with a heparin-coated percutaneous cardiopulmonary support system (PCPS). A 14-year-old boy, who was injured by jumping from the fifth floor of a building, was admitted to our hospital. Radiography and computed tomography revealed bilateral pulmonary contusions, bilateral hemopneumothorax, splenic rupture, and pelvic fractures. Interventional radiology was initially performed, and the bleeding in the spleen and pelvis was successfully treated by embolization. When the patient took the computed tomography, sudden cardiac arrest occurred. Chest drainage tube drained over 1000 ml of blood from the left chest. The patient was diagnosed as having traumatic lung rupture by computed tomography, and his condition was rapidly deteriorating. A heparin-coated PCPS was immediately used without heparinization. Left lower lobectomy was safely performed. The patient was weaned off PCPS 4 days after surgery.
We report a case of long-standing bronchial foreign body resected by video-assisted thoracic surgery (VATS). A 54-year-old man referred to our hospital because of the present of cough. A chest X-ray film and a chest CT scan showed a metallic foreign body associated with bronchiectatic change with infiltrative shadow of the right lower lobe. Based on these roentgenograms and interviews with the patient, the foreign body was deduced to be an air-gun lead bullet which he had accidentally aspirated at age 14. The foreign body located in a position which was difficult to approach by means of bronchoscope that was due to secondary changes around it. A pulmonary wedge resection was performed by VATS. We conclude that VATS is safe and useful in terms of surgical treatment for a bronchial foreign body in the peripheral lung field when its bronchoscopic removal seems to be difficult.
We experienced perioperative management with a vena cava filter for lung cancer complicated with polycythemia, deep vein thrombosis (DVT) and pulmonary embolism (PE). The patient was a 65-year-old man who was admitted to a local hospital due to DVT. Polycythemia and PE were diagnosed by further examination. Chest CT scan showed a lung tumor (3.5×2.5cm) in left S6. Bronchofiberscopy and biopsy revealed it to be a non small cell lung cancer. In preoperative management, we administered anticoagulant therapy and phlebotomy (total 1, 200 ml), and inserted a Greenfield vena cava filter for the prevention of PE. Following this management, he underwent a left lower lobectomy with R2b lymph node dissection for the lung cancer. After the operation the clinical course was uneventful. Because PE is an often lethal complication after operation, it is most important to prevent it in perioperative management for high risk patients. We concluded that the vena cava filter is beneficial for preventing PE.
A 59-year-old male with a complaint of hoarseness was referred to our hospital. Chest CT demonstrated a tumor located between the aorta and left main bronchus. The serum CEA level was 37.5 ng/ml. Mediastinal lymph node metastasis was suspected, however, primary lesion was not detected. The patient underwent surgery to establish a definite diagnosis. The tumor was located in the subaortic region, which invaded to the left recurrent nerve, aorta, left pulmonary artery, and left main bronchus. Incisional biopsy was performed and histological examination revealed poorly differentiated adenocarcinoma. The patient received 66 Gy of irradiation to the tumor. The serum CEA level returned to normal after irradiation. This is a rare case of idiopathic carcinoma of the mediastinal lymph node.
A 73-year-old man was performed total gastrectomy (D2) for gastric cancer, which was a poorly differentiated adenocarcinoma (ss, n2 (+), lyl, vl, ow (-), aw (-)). Three years after the operation, two abnormal nodules in S8 area in the right lung were found by chest computed tomography. Right lower lobectomy (ND2b) was performed because primary lung cancer was suspected preoperatively. The one lesion was a poorly differentiated adenocarcinoma which was compatible with metastasis from gastric cancer, and the other was bronchiolo-alveolar carcinoma which was compatible with primary lung cancer, histologically. When multiple lesions are found in gastric cancer patients, operation method should be selected with some considerations of both primary lung cancer and metastasis like in our case.
A 63-year-old male was referred to our hospital for further examination of a coin lesion of his left lung on a chest x-ray film. Radiologic examination revealed that the tumor was located in segment 6 and he had a right aortic arch with aberrant left subclavian artery. Although both the needle biopsy and TBLB could not indicate malignancy in the specimen, he underwent thoracotomy because of a suspicion of lung cancer from the radiological findings. As histological examination of frozen section of the resected specimen showed dysplasia, a left lower lobectomy with mediastinal lymph node dissection was carried out. The pulmonary artery and pulmonary vein ran in the normal anatomical position. The ligamentum arteriorsus was found between the left subclavian artery and the pulmonary artery. The left vagal nerve ran lateral to this ligamentum and branched into the recurrent nerve crossing under the ligamentum.
A fifty-four-year-old woman consulted our hospital because of sudden hemoptysis. A plain chest X-ray showed an abnormal shadow in the left lower lung field. Chest CT showed an aberrant artery supplying the left basal segments from the thoracic aorta, and the left basal pulmonary artery was not found. The aortogram demonstrated an aberrant artery supplying the left basal segments. Bronchoscopy disclosed a normal bronchial tree. There findings led us to the diagnosis of systemic origin of an aberrant artery to the basal segments of the left lung. At the operation, the normal appearance of the superior segment was clearly defined from the basal segments showing fibrous change. We, therefore, performed basal segmentectomy and preserved superior segment of the left lower lobe, where the bronchus the pulmonary artery and the pulmonary vein were normally set.
Benign mediastinal teratoma sometimes perforate adjacent organs. We report a case of benign mediastinal teratoma perforating the right lung. A 19-year-old female was admitted to our hospital exhibiting symptoms of hemoptysis 8 days before she was due to be admitted for an operation on a tumor that had been diagnosed from a tumor shadow in the anterior mediastinum 1 month previously by her physician. On admission, chest roengenogram revealed an abnormal shadow in the right hilum and middle lobe, and CT showed a right anterior mediastinal mass. It was speculated that the hemoptysis might have been caused by a perforation of the tumor into the lung, and she was operated on. The tumor was observed on the right side of the anterior mediastinum and adhered to the right middle lobe of lung so firmly that it was necessary to resect part of the right lung. The tumor and part of lung were removed en block. Pathological examination showed a mature teratoma and pancreatic tissue with Langerhans'islands. At 24 hours post-operatively, a bronchopleural fistula developed at the resection line of the right middle lobe. We performed emergency re-thoracotomy and right middle lobectomy. In conclusion, in a case of mature teratoma with hemoptysis, it is important in lobectomy or segmentectomy to completely close fistula.
This article reports a case of ACTH-producing thymic carcinoid with metastasis to the large pudendal lip after resection. A 26-year-old woman was admitted to our hospital because of hypertrichosis and moon face. The endocrinological examination revealed high plasma ACTH and serum cortisol levels, and Cushing syndrome was present. On CT scan, an anterior mediastinal tumor was detected. The tumor was totally resected with lymph node dissection through median stenotomy. Histologically, the tumor consisted of atypical thymic carcinoid with ACTH-production. After resection, clinical symptoms disappeared and ACTH and cortisol levels were normalized. The first recurrence involved the labia majora 15 months after surgery. The tumor was resected, and diagnosed as metastatic atypical thymic carcinoid histologically. ACTH-producing thymic carcinoid is extremely rare and its characterization is unclear. To date, there have been 15 reports regarding this tumor in Japan, and a collective review of this tumor was made.
We examined 5 cases of catamenial pneumothorax patients out of 43 female pneumothorax patients we operated on since 1982 to 1999. All patients had been subjected to thoracoscopic operation. 4 patients had right pneumothorax and we found many little sized fistulas on diaphragm. In 3 of 4 patients who had diaphragmatic fistulas we closed the fistulas to the extent possible. We performed pleurodesis therapy in all cases and pseudomenopausal (GnRH antagonist) therapy for 4-6 months in 4 cases postoperatively. When we suspect catamenial pneumothorax, we do not hesitate to recommend thoracoscopic operation. If catamenial pneumothorax is diagnosed, we should close any diaphragmatic fistulas and perform pleurodesis and GnRH antagonist therapy.
A 72-year-old woman with persistent idiopathic thrombocytopenic purpura visited our hospital because of an abnormal shadow on chest computed tomographic scan which showed a ground glass attenuation located in the S3 suggesting well differentiated adenocarcinoma of the lung. Because marked thrombocytopenia (0.9×104/mm3) was found on admission, we did not perform transbronchial lung biopsy or transthoracic needle biopsy for definitive diagnosis to avoid severe bleeding. After platelet counts increased to 8.8×104/mm3 following Preoperative high dose intravenous gammaglobulin therapy (400 mg/kg/day for 5 days), right upper lobectomy could be done with minimal blood loss. There were no postoperative complications such as bleeding. Preoperative high dose intravenous gammaglobulin therapy is useful in the lung cancer patient with idiopathic thrombocytopenic purpura to maintain a sufficient platelet count for achieving an uneventful course during the perioperative period.
A 72-year-old man with von Recklinghausen's disease before was urgently admitted to our hospital because of acute cardiopulmonary insufficiency. Several months prior to admission, he was not able to assume the supine position. Abnormal shadows on his chest X-ray and CT films revealed that a huge tumor compressed his heart and right lung. The tumor was surgically removed via a median sternotomy incision. The resected tumor was diagnosed as a solitary fibrous tumor by histopathological and immnohistochemical analyses using antibodies for CD34, NSE, Vimentin, S-100, Desmin, AE1/AE3 and α-smooth muscle actin. His postoperative course was satisfactory and he left our hospital 3 weeks after the operation.