Objective: We retrospectively investigated the effectiveness of the combined approach using PGA felt and frictional spraying in comparison with other closure methods in lung surgery. Methods: Among lung surgery patients treated during six years, two hundread sixty six patients who underwent lung excision, showed air leakage confirmed by intraoperative sealing test. The usefulness of three different pulmonary fistula closing approaches using fibrin adhesives was examined in this series. Patients were classified into the following three groups: Group A, consisting of 65 patients treated by the combination of PGA felt and frictional spraying; Group B, consisting of 166 patients treated by frictional spraying of fibrin glue; and Group C, consisting of 27 patients treated with TachoComb®. Results: The results showed the superiority of the combination method among the three methods tested. Compared with groups B (frictional spraying) and C (TachoComb®), Group A (The combination of PGA felt and frictional spraying) received significantly higher evaluation scores, showing significantly faster postoperative disappearance of air leakage. The air leakage closure rate after surgery was higher at all of the time frames examined. Conclusions: The combination method using PGA felt and frictional spraying can be easily applied to thoracoscopic surgery and now seems to be the most useful methods for treating pulmonary fistula.
There is an increasing number of elderly lung cancer patients. We clinicopathologically studied elderly surgical lung cancer patients. We reviewed 32 pulmonary resection for lung cancer in patients aged 75 years or over (mean age 77.8, range 75-85) operated on from April 1996 to May 2004. There were 22 male and 10 female. The comorbidity rate was 81.2%. Thirty two patients underwent resection: 22 lobectomies, 2 segmentectomies, 8 wedge resections. There was one perioperative death (3.1%) due to stroke. The postoperative complication rate was 37.5%. The postoperative complications were 4 delirium, 4 pulmonary events, 4 atrial fibrilation, 3 stroke, and 2 others. Overall 5-year survival rate was 61.6%. There were 8 outpatient death, 4 cancer and 4 non-cancer death (2 pneumonia). The results of surgical therapy for elderly lung cancer patients were favorable. Advanced age alone should not be a contraindication to pulmonary resection.
We studied sealants for preventing alveolar air leakage after lung resection. We analyzed results from three types of sealants, fibrin glue only (group G, n=18), fibrin glue with polyglycolic acid felt (group S+G, n=24), and polyglycolicacid felt only (group S, n=20) for a persistent alveolar air leakage after suturing pulmonary parenchyma. Mean lengths of the air leakage after operation were 1.6 days in group G, 2.1 in group S+G, and 1.8 in group S (notsignificant). Incident rates of prolonged air leakage longer than 7 days after operation were 5.6% in group G, 4.2 in group S+G, and 5.0 in group S (not significant). Among these three kinds of sealants, no difference in the results of preventing alveolar air leakage was observed. We concluded that using absorbable polyglycolic acid felt alone might be best, with respect to cost and material.
We report a case of pulmonary injury due to fusion resin jetted at high pressure. A 28-year-old man, who worked in a casting factory, was shot in the chest with a high pressure of fusion resin. Chest CT scan visualized foreign substances and blood in the thoracic cavity and the lung. Penetrating trauma of the lung was suspected and emergency surgery was performed the same day. During surgery, the foreign body was removed and partial lung resection was performed. The patient's postoperative course was uneventful. Such an injury is very rare, and for such case, it was important to clarify the course and a range of traumatic injury by image diagnosis preoperatively. We must choose an adequate surgical method by considering the complication in such procedures.
A 70-year-old man was found to have a posterior mediastinal mass on chest CT scan. Tumor resection was performed through left posterolateral thoracotomy. The tumor was 65×55×50mm. Immunohistochemical findings showed tumor cells stained positive with smooth muscle actin antibodies and desmin. Antibodies for myoglobin, α1-antitripsin and S-100 protein were negative in most of the tumor cells. Electron microscopic examination was not performed. Pathological diagnosis was pleomorphic leiomyosarcoma. To our knowledge, leiomyosarcoma of the posterior mediastinum is rare and only 15 cases of mediastinal leiomyosarcoma have been reported in the Japanese literature.
A 45-year-old man complaining of left shoulder-back pain was diagnosed with invasive left apical lung cancer. He recived preoperative CCRT (RT: 40Gy/20Fr: Cisplatin, Vindesine), resulting in tumor regression. We performed left upper lobectomy, partial resection of the left clavicle and the first rib, reconstruction of the left subclavian artery and vein by artificial vessel, fixation the left clavicle by implant of self-tendon, and reconstruction of the chest wall using Composix mesh®. Pathlogical examination demonstrated that the lesion did not contain any malignant cells (Ef. 3). The patient was doing well without any tumor recurrence 2 yaers and 2 months postoperatively.
We report a case of double mediastinal bronchogenic cysts in a 53-year-old female patient. In 1993, an abnormal shadow was pointed out on medical examination and was followed conservatively. In June 2003, she consulted a hospital for coughing and chest pain. On detailed examination, double mediastinal cysts were detailed under the tracheal region and in front of the ascending aorta. At surgery to remove the cysts, one was located under the tracheal region and the other in the thymus. On histological diagnoses, both were bronchogenic cysts.
A 48-year-old man was admitted to our hospital with an abnormal shadow on a chest roentgenogram. Chest CT scan and MRI showed a tumor 10cm in size on the left diaphragm, suggesting a lipoma. Video-assisted thoracic surgery (VATS) was performed. At surgery, the tumor was shown connecting with the inferior pulmonary ligament. The tumor, weighing 380grams, was diagnosed pathologically as a well-differentiated liposarcoma, of the lipoma-like type. This is the first case, to our knowledge, of liposarcoma originating from the inferior pulmonary ligament. We report this case with reference to the literature.
In cases of patients with small pulmonary nodules it is occasionally difficult to differentiate between malignant and benign diseases using CT. The sensitivity and specificity of FDG-PET in differentiating between lung cancer and benign disease are higher than those of CT, but previous studies have shown instances of false negative malignant tumor and false positive benign results. We report two cases of peripheral small pulmonary nodules in which preoperative FDG-PET was performed to identify the pathological characteristics of the lesions. Case 1 was a 58-year-old man with an abnormal shadow 20mm in size at left S9. Chest CT demonstrated an irregularly shaped fibrous shadow with a small nodule around the bulla. We suspected inflammation based upon the CT. FDG-PET showed an accumulation with an SUV of 2.6 corresponding to the lesion, indicating a possible malignancy. We initially performed a left upper wedge resection. Intraoperative diagnosis was squamous cell carcinoma. We performed a left lower lobectomy and mediastinal lymph node dissection. Case 2 was a 31-year-old man with a small nodular shadow 15mm in diameter with accompanying spicula and ground-glass opacity at the left S1+2. CT examination led us to suspect small adenocarcinoma. FDG-PET showed an accumulation with an SUV of 2.3 corresponding to the lesion. We performed a left upper wedge resection. Pathological diagnosis was pulmonary tuberculoma. For case 1, FDG-PET provided useful information for the preoperative diagnosis of lung cancer. However, we could not exclude lung cancer from the differential diagnosis by FDG-PET in case 2, because small adenocarcinoma could show an accumulation with an SUV of less than 2.5.
Surgical reconstruction of the osseous chest wall is sometimes need following resection for benign diseases such as empyema and malignant diseases such as lung cancer or chest wall tumor. We reviewed 6 cases of chest wall reconstruction using autogenous rib grafts at our hospital between December 2001 and June 2004. Primary diseases were empyema (3 cases), chest wall invasion of lung cancer (1 case), metastasis of lung cancer in the chest wall (1 case) and sternal tumor with unknown primary disease (1 case). We performed chest wall reconstruction using free rib grafts in 3 cases and pedicled rib grafts in 3 cases. Reconstructed chest walls were stable with well fixed rib grafts in all patients at discharge except in one patient with fatal postoperative pneumonia. Reconstruction of the osseous chest wall using autogenous rib grafts is considered a useful procedure because of its natural stability, lower foreign body reaction and lower incidence of infection compared with reconstruction using artificial prosthesis.
A previously healthy 53-year-old man presented with cavity lesion in the left middle lung field. Chest computed tomography (CT) showed a thin-walled cavity lesion, 28 mm in diameter, in the left lower lobe. Because transbronchial lung biopsy did not enable the diagnosis of the lesion, the patient was evaluated by thin-section CT 4 months, 7 months, and 9 months later. The lesion had enlarged to 30 mm in diameter at 7 months, but had decreased to 26 mm at 9 months. The thickness of the cavity wall decreased from 3 mm to 2 mm at 9 months. Because positron emission tomography (PET) was positive, video assisted thoracic surgery (VATS) biopsy was performed, from which a frozen section was used to diagnose the lesion as squamous cell carcinoma. VATS lobectomy was performed. The pathological stage was T1N0M0. We suggest that even if the cavity shows a contraction of size and wall thickness during follow-up, the examination for definitive diagnosis is necessary for lesions having malignant findings on CT or PET.
We present a rare case of mediastinal cyst infiltrating into the lung which clinical and pathological findings suggest originated from the esophagus. The patient was a 66-year-old female who had been found to have a cystic lesion measuring 7×5 cm in the posterior mediastinum 3 years before, and had complained of persistent pyrexia, cough, and sputum for 5 months. Chest CT scans on admission revealed a large cystic mass with an air fluid level. The cyst was resected with adhered S10 of the lung, leaving a part of the wall abutted on the esophagus and the aorta. Pathologic examination showed remarkable infiltration of inflammatory cells into the cystic wall and the epithelium was exhausted due to the inflammation. Those findings didn't provide us definitive diagnosis. We concluded, however, that inflammation occurred in the esophageal cyst followed by infiltration into the lung, because the cyst was adjacent to the esophagus and foreign body-like remnants of food were found in the resected specimen.
We reported a case of solitary fibrous tumor of the pleura that recurred 7 years after the initial surgery. The patient was 84-year-old female, who consulted our hospital complaining of chest pain. She had undergone surgical extirpation for mediastinal tumor in September 1995. At that time the mediastinal tumor was diagnosed as Masaoka stage 2 thymoma. Seven years later, a pleural tumor had developed in the right thoracic cavity. Under thoracoscopy, partial resection of the lung including the tumor was performed, a tumor with a pedicle arose from the visceral pleura of the right upper lobe. Histopathological examination demonstrated that tumor was a malignant solitary fibrous tumor. Thereafter, the initial resected tumor was histopathologically reviewed, and the two lesions shared a similar histology. We concluded that this case involved the recurrence of malignant solitary fibrous tumor of the pleura after an interval of 7 years.
A 9-year-old male presented to our hospital due to blunt chest trauma sustained in a motor vehicle accident. Fiberoptic bronchoscopy under general anesthesia demonstrated right main bronchial injury, which we successful repaired by bronchoplasty. In pediatric cases, it is difficult to diagnose tracheo-bronchial injuries. If suspected, it is essential to perform fiberoptic bronchoscopy and subsequent surgery if necessary, as soon as possible.
Two cases of endobronchial hamartoma are reported. Both cases presented with obstructive pneumonia and were treated by surgical resection, middle lobe lobectomy for case 1 and bronchotomy of left upper bronchus for case 2. Pathologic diagnosis of chondromatous hamartoma in case 1 and lipomatous hamartoma in case 2 was not available preoperatively despite repeated endobronchial biopsy. Retrospectively, the lesion in case 2 appeared to have been resectable endoscopically, while lobectomy was inevitable in case 1. The intent to perform snaring of an endobronchial lesion seems to be helpful in evaluating not only the characteristics of the lesion but also the pathology, which would facilitate selection of the best strategy to remove endobronchial hamartoma.
A 20-year-old female was referred to another hospital because of hemoptysis. Chest CT showed an aberrant artery arising from the thoracic aorta and supplying the left basal segment, but the bronchial tree was normal. Aortogram and MRI angiography demonstrated flow from the aberrant artery to normal left lung vein and absence of the left lower lung artery except for A6. Based on these findings, we diagnosed this case as having an anomalous systemic arterial supply to the normal basal segment of the left lower lobe. We performed a left lower lobectomy and closure of the anomalous systemic artery by video-assisted thoracic surgery (VATS). The aberrant artery measuring 13mm in diameter coursed along the left pulmonary ligament into the left lower lung from the descending aorta. The patient had uneventful postoperative course and was discharged on postoperative day 8. We collected reports of 32 cases of similar anomalies in Japan and discussed the characteristics of this disease and technical problems of closure using surgical stapling devices.
A 19-year-old mail was hospitalized with recurrent hemoptysis and vascular murmur accompanied by an abnormal shadow in the pulmonary lung field on chest x-ray. Chest 3D-CT and angiography demonstrated absence of the pulmonary artery of the left basal segment which was replaced by an aberrant artery arising from the descending thoracic aorta. In addition, bronchoscopy demonstrated an almost normal bronchial structure of the left lung. The diagnosis of Pryce type I intrapulmonary sequestration was established, and left lower lobectomy was performed successfully with division of the aberrant artery 13mm in diameter arising from the descending aorta. No postoperative complication was encountered. Because of this type of sequestration causes hemoptysis and infections, surgical intervention is indicated.
A 65-year-old male admitted to hospital with complaints of productive cough and chest pain. He had received steroid therapy for 3 months for the treatment of membranous nephropathy. Chest x-ray showed an infiltrative lesion in the left middle lung field. Chest CT scan revealed a 2-cm-diameter nodule with a cavity in the left S6. One month later, chest CT scan showed an increase in the mass size (4.2cm diameter). Since the lesion could not be diagnosed by sputum examination or transbronchial biopsy, surgery was performed. Intraoperative examination through thoracotomy revealed the possibility of malignancy; therefore, left lower lobectomy with lymphadenectomy was performed. The resected specimen showed inflammatory disease with no signs of malignancy. Nocardia species was detected by bacterial culture of the specimen.
A 71-year-old female with a history of artificial pneumothorax for pulmonary tuberculosis at the age of 19 was admitted to our hospital because of hemoptysis. She had empyema with bronchopleural fistula. Although tube drainage of the thoracic cavity was performed, the empyema cavity remained and infection persisted. Fenestration of the empyema cavity was done, and a tumor of 1cm diameter was recognized in the pleural cavity. Diagnosis of pyothorax-associated malignant lymphoma (PAL) was obtained by pathological examination. After radiation therapy with a total dose of 40 Gy was performed, pleuropneumonectomy was carried out. The malignant lymphoma did not remain in the resected specimen. The patient is alive with no evidence of tumor recurrence or empyema at 1 year and 8 months after the operation.