The outcome of complete resection for non-small-cell lung cancer was assessed in 29 patients equal or over 80 years old. We compared 12 patients who underwent limited operation and 17 patients who underwent standard operation . No significant differences were observed in preoperative concomitant disease or morbidioy between the two groups . However, a good prognosis was obtained in the patients with limited operation compared with those receiving standard operation (p=0.0131). We concluded that limited operation should be considered in patients equal or over 80 years old with non-small-cell lung cancer.
Between 1988 and 1999, we performed operations for 22 patients with pulmonary tuberculosis; lobectomy 14, pneumonectomy 5, lobectomy+segmentectomy 2, segmentectomy 1. The indications for surgery in our hospital include multidrug resistant tuberculosis (MDRTB), hemoptysis, and destroyed lung. The operative mortality rate was 0%, and the major complication rate was of 17.6%, including 2 patients with air leaks that lasted longer than 7 days and 1 patient with wound infection. Of the patients who underwent operations as part of the therapeutic regimen for MDRTB, 15 (88.2%) of 17 had obtained culture negative and 2 patients did not; 1 patient had a remaining lesion and the other had a contralateral cavity lesion. Surgical resection is indicated in patients with MDRTB who have a poor prognosis with medical treatment if it is performed early, if the disease is localized and if there is adequate pulmonary reserve.
Of 1, 337 patients with primary lung cancer undergoing surgical resection from August 1984 through December 1999, there were four kinds of perioperative complications for which we had trouble to manage the patients. In this study we reported the clinical outcomes and the methods of management of the patients with preoperative acute inflammatory pulmonary diseases (AINP), preoperative idiopathic interstitial pneumonia (IIP), postoperative empyema (EM) and post-operative interstitial pneumonia (PIP) without preoperative IIP. The number of operative deaths within 30 days was three (0.2%) of all cases. AINP (n=20) was defined preoperatively as inflammatory pulmonary diseases (CRP≥5) related to extention of the tumors. 8 patients suddenly changed for the worse, 4 of whom (obstructive pneumonia in 2, total atelectasis of one lung in 1 and acute growth of the tumor in 1) required emergent operations. There were no deaths in any of these 4 patients. Of 10 patients with IIP, 3 patients in the early period of this series died of acute exacerbation of IIP. The latest 7 patients had an uneventful postoperative course owing to low-dose O2 administra tion during operation, steroid pulse therapy perioperatively and long-term antibiotics. EM broke out in 15 patients. There were no deaths in 9 patients in the early stage within 30 postoperative days, but 2 of 6 patients in the late stage, all of whom had received induction therapy, died in hospital. PIP shadows on chest X-P appeared in 11 patients, with 5 early patients dying of respiratory failure. Since we recognized that mostly this lethal complication had ocurred in patients with advanced lung cancer on the right side associated with complete dissection of mediastial lymph nodes, an initial vague shadow had started in the lower field on the left side and immediate initiation of steroid pulse therapy had determined the prognosis, the latest consecutive six patients recovered from the grave complication of PIP.
Video-assisted thoracoscopic surgery (VATS) has been widely used in the treatment of spontaneous pneumothorax. However, the rate of postoperative recurrence in VATS is higher than in conventional thoracotomy. It is suggested that the stapling device may be concerned with recurrence of pneumothorax. We compared patients undergoing thoracoscopic bullectomy using a stapling device and thoracoscopic loop ligation for primary spontaneous pneumothorax. A total of 204 video-assisted thoracoscopic surgeries was performed in 197 patients with primary spontaneous pneumothorax, including 77 thoracoscopic bullectomies using a stapling device and 127 thoracoscopic loop ligations, from September 1994 to September 2000. Postoperative recurrence of pneumothorax was observed in 16 patients (20.8%) in the bullectomy-group and 5 patients (3.9%) in the ligation-group.rThe rate of postoperative recurrence in ligation-group was significantly lower than in the bullectomy-group (p=0.0001). Reoperation was performed in 9 of 16 patients with recurrence in the bullectomy-group.rFindings on reoperation consisted of new bullae on the previous staple line in 4 patients, missed bullae in 1 patient and unknown cause of recurrence in 4 patients. On the other hand, one of 5 patients with recurrence in the ligation-group underwent reoperation, and missed bulla on previous operation was found. It may be suggested that thoracoscopic loop ligation is a useful method to reduce the recurrence rate of spontaneous pneumothorax and to prevent new bullae.
We report a rare case of carcinoid of the lung that developed in an old focus of tuberculosis. The patient was a 75-year-old woman in whom a coin lesion 2 cm in diameter was detected by chest X-ray. The lesion was diagnosed as a typical carcinoid by CT-guided biopsy, and right middle lobectomy (ND 2a) was performed under thoracoscopy . The tumor was brown on cut section, 1.1×0.9×0.5 cm in size, and located in the right S4a, with dearly demarcated borders. The center of the tumor was an old focus of tuberculosis, and typical carcinoid was noted scattered on the circumference of the wall of the tumor. The tumor was p-Stage I, p-T1N0M0, p0d0e0pm0, and the postoperative course has been satisfactory, without evidence of recurrence 6 months after surgery. Since even typical carcinoid may develop lymph node metastasis, in cases of carcinoid lymph node dissection with minimally invasive thoracoscopic surgery should be considered.
A 50-year-old man was diagnosed with lung cancer and sternal metastasis. The patient had no metastasis of mediastinal lymphnode and the sternal metastasis was a solitary lesion. So we decided to operate for lung cancer and sternal tumor concomitantly. We employed a prosthesis composed of Marlex polypropylene mesh and acrylic resin for reconstruction of the sternum (Marlex resin sandwich method). This method proved to be satisfactory for maintaining stability and respiration. Despite systemic chemotherapy after operation, he died of the recurrence 1 year after the operation.
A 69-year-old woman was admitted because of an abnormal shadow on chest X-P . CT scan revealed a round tumor 2.5 cm in diameter close to proximal of V3. Because a preoperative diagnosis was not made, intraoperative needle biopsy was attempted instead of excisional biopsy. After the biopsy specimen was turned out to be adenocarcinoma from the pathological findings of the frozen-section, standard right upper lobectomy was performed . However, cancer cells and simultaneous bronchial epithelium were observed in pleural lavage due to dropout of cancer cells through the needle tract. Care should be taken during the procedure not to disseminate cancer cells when needle biopsy is chosen.
We reported an extremly rare case of ruptured thymic carcinoid. A 63-year-old man was referred to our hospital for suspicion of rupture of mediastinal teratoma with a widened mediastinum and right hemothorax. But the chest X-ray and the chest CT on admission revealed decrease of the size of the mass, disappearance of widened mediastinum and right pleural effusion. A right axillar approach revealed an anterior mediastinal tumor contiguous to the right thymus. Pathological findings revealed typical thymic carcinoid, but insufficient surgical margin. A median stemotomy for complete thymectomy was performed later, the operatile findings revealing no tumor in the residual thymus and with almost normal mediastinum. In the literature, except teratoma only seven cases including the present one with ruptured mediastinal tumor were encountered. This is the first ruptured case noted in the natural course of thymic carcinoid. At 21 months after the surgery, the patient is doing well, and these is no evidence of recurrence.
A 54-year-old male complaining of lower abdominal pain consulted our hospital. He was initially treated for a digestive disorder associated with Chilaiditi syndrome. However, his complaint gradually became aggravated with time and he was admitted to our hospital for treatment. His chest X-ray and CT scans revealed pleural effusion and pneumothorax in the right thorax. After admission, a tube was inserted at once for drainage. The pleural effusion was contaminated with bile juice. A chest CT was unable to diagnose traumatic diaphragmatic hernia in the early posttraumatic period. We diagnosed a diaphragmatic hernia complicated by strangulation of the digestive canal. Surgical treatment was performed immediately, and revealed that the transverse colon and great omentum had projected into the thoracic cavity through the hernia hiatus which was a laceration in the diaphragm about 5cm in diameter. The great omentum had strictly adhered to the lung. Intraoperative findings indicated that the mechanism of the delayed presentation of traumatic diaphragmatic hernia was caused by plug in the lung. These protruding organs were returned to the abdominal cavity without any resection. The laceration of the diaphragm was closed directly using an interrupted suture. He recovered quickly and left our hospital 4 weeks after the operation.
Hughes-Stovin syndrome (H-S) is a rare disease, characterized by multiple pulmonary artery aneurysms and venous thrombosis with poor prognosis because of recurrent and massive hemoptysis as a rule. No optimal treatment has yet been defined for this often-fatal disease. We present a patient with this disease, who has been successfully treated by lobectomy and administration of steroid and colchicine. A 61-year old man was referred because of an increasing pulmonary artery aneurysm in size and massive hemoptysis, under a diagnosis of H-S syndrome made at a previous hospital. His past history included venous thrombosis. Chest X-ray and CT scan revealed bilateral multiple pulmonary nodules, one of which was a huge node in the right lower lobe connected with the right pulmonary artery. Pulmonary arterial angiography showed multiple pulmonary artery aneurysms and mural thrombosis of the right lower pulmonary artery. Under the diagnosis of H-S syndrome right lower lobectomy was performed. The postoperative course was unremar kable. Prednisolone and colchicine were started following the pulmonary resection. This systemic corticosteroid and colchicine resulted in abolishing hemoptysis and disappearance of the remaining pulmonary artery aneurysms. The patient is living well without evidence of recurrent hemoptysis one and half years after the operation. This case report emphasizes the necessity of surgical resection of the pulmonary artery aneurysms and effectiveness of steroid and colchicine for Hughes-Stovine syndrome.
A 43-year old man complaining of hemosputum and recurrent pneumonia was admitted. Chest CT demonstrated a 12 cm diameter multicentric cystic mass at the right lower lung lobe with effusion. Multiple peripheral small nodules and bronchiectasis were also seen at the right lung and left lower lung lobe. Aortography and CT-angiography showed that an aberrant artery originated from the thoracic discending aorta and penetrated the right lower lobe of the lung. Mycobacterium intracellulare was isolated from sputum. The patient received RFP+EB+CAM therapy. Right middle and lower lung lobectomy was performed 2 months after chemotherapy.
A 64-year-old male patient who had undergone radical surgery for esophageal cancer was admitted to our hospital for radical resection of right lung cancer. He underwent right upper lobectomy after which a cavity of 200 ml remained at the right apex. Significant pulmonary air leakage was detected immediately after the surgery and persisted. Intrathoracic instillation of OK432 (5 times in total) or autologous blood, obliteration of the fistula with fibrin glue under thoracoscope and coverage of the fistula with an intracostal muscular flap were attempted. However, none of these procedures were effective. The filling of the cavity with a free myocutaneous flap of right abdominal rectal muscle was performed to obliterate the fistula. A pedicle of right inferior epigastric artery and vein was anastomosed to the right thoracoa crominal artery and vein, respectively. The flap was sutured to the fistula and was inserted to fill the cavity. After the filling, the patient had a good course. The filling of the cavity with a free myocutaneous flap was effective to treat a persistent pulmonopleural fistula after lung resection.
The case of a 61-year-old male who was diagnosed with left lung cancer with scapula metastasis is reported. His chest X-ray and CT scan showed a well-defined shadow with pleural indentation in the left lung S4. Laboratory data on admission showed high level of CEA (96.8 ng/ml), and bone scintillation scan showed a single area of increased accumulation in the left shoulder joint. Left upper wedge lobectomy and left scapulectomy were performed. Postoperative adjuvant chemotherapy and irradiation to the mediastinum were done. Follow -up chest CT scan detected a small nodule in the left S6, which gradually increased in size. So partial resection of the left S6 was performed and it was proved to be pulmonary metastasis. It is considered that the prognosis of non small cell lung cancer (NSCLC) with bone metastasis is very poor, but there is a report of a long-term survival case after surgery for NSCLC with single bone metastasis. The cases of NSCLC with single bone metastasis like this case have the possibility to be cured by local treatment including surgical therapy.
A 39-year-old male, suffering from severe flail chest due to multiple rib fractures, was successfully treated with surgical stabilization by the use of orthopedic A-O metallic plates, which are called reconstruction plates. These long and narrow metallic plates with many perforations were applied directly to the external surface of his segmentary-fractured ribs over their entire length as an external brace. The patient was removed from the respirator one day after the operation, and complete stability of the chest wall was observed. This plate was long enough to cover the whole length of the fractured ribs and moderately soft enough to be bent or twisted by hand in order to be appropriately fitted to the natural curve of the ribs. Moreover a number of holes in it allowed the suture to pass through the plate and rib, avoiding displacement of the prosthesis. While many previous methods of surgical fixation of fractured ribs using intramedullary pins and bars required dissection of the periosteum of the ribs and widening of the fracture sites, our technique of external stabilization of the ribs with the use of the reconstruction plates is a simple and reliable method without the need for any formidable operative procedures.
A 45-year-old woman had experienced repeated episodes of right-sided pneumothorax. The last recurrent pneumothorax occurred after onset of menstruation with elevated serum CA125 level, suggesting catamenial pneumothorax. Thoracoscopy revealed 3 punchout like perforations in the right diaphragm. Partial resection of the diaphragm was performed under VATS. Microscopic findings of the resected diaphragm showed endometrial tissue. Post operation serum CA125 level was normal.
The patient was an 80-year-old woman who underwent surgery for right breast cancer at the age of 67 in 1987. In August 2000, chest X-ray showed a mass shadow in the right inferior lung field. In addition, chest CT revealed a non-calcified tumor with a flat margin measuring 1 cm in diameter located just below the right S10 pleura. In November 2000, thoracoscopic partial resection of the lung was performed to diagnose and treat the tumor. Although malignant cells were not detected by intraoperative histological examination, a diagnosis of pulmonary dilofilariasis was established after the histological examination of tissue specimens. Since the preoperative diagnosis of pulmonary dilofilariasis is difficult to establish, it is frequently detected by open lung biopsy. Therefore, since it is important to differentiate this lesion from other nodular lesions in the peripheral lung field, less invasive thoracoscopic lung biopsy is useful for establishing the definitive diagnosis of pulmonary dilofilariasis.