Fibrin glue is one of the most frequently used surgical sealants and often combined with polyglycolic acid (PGA) to repair pulmonary air leaks. However, PGA pasting alone without fibrin glue is rarely discussed. We retrospectively reviewed the clinical records of patients who underwent pulmonary lobectomy with air leak repair using PGA alone between January 2001 and December 2012. PGA felt without fibrin glue both for therapeutic and prophylactic purposes was used in 199 patients. The postoperative drainage period was significantly longer in patients with than without PGA use (4.37 vs. 3.08 days, respectively, p<0.05). Among the therapeutic use group, the postoperative drainage period tended to be longer, and significantly more prolonged postoperative air leaks were seen in patients with an obstructive pulmonary function (34 vs. 16.2%, respectively, p=0.01). PGA pasting alone is not sufficient in patients with an obstructive pulmonary function and should be combined with fibrin glue. On the other hand, because the postoperative drainage period was 2.9 days on prophylactic use, the use of PGA alone might be a feasible option if the intent is prophylactic.
Patients with synchronous double cancer of the lung and esophagus who undergo surgical resection are rare, and the therapeutic strategy for such patients is unclear. Therefore, we retrospectively evaluated the surgical outcomes of 9 patients with synchronous double cancer of the lung and esophagus resected at Osaka City University Hospital from January 2008 to December 2014. The median age of the patients was 67 years. There were 6 males and 3 females. Five patients underwent one-stage surgery for the right lung and esophagus, and 4 patients underwent two-stage surgery. Regarding surgery for lung cancer, 5 patients underwent lobectomy, and 4 patients underwent segmentectomy. All patients underwent complete resection, and the in-hospital mortality rate was 0%. Among the 5 patients who underwent one-stage surgery, postoperative complications occurred in 2 patients (40%). In the patient who underwent right lower lobectomy, aspiration pneumonia, anastomotic leak of the reconstructed gastric tube, chylothorax, and pyothorax with bronchial stump fistula developed. In the other patient who underwent S6 segmentectomy, bronchial fistula developed following pneumonia and acute respiratory distress syndrome (ARDS). Among the 4 patients who underwent two-stage surgery, there were no postoperative complications. The overall 3-year survival rate was 76.2%, and the median survival period was 67.1 months. Surgical resection should be considered in patients with synchronous double cancer of the lung and esophagus who can undergo complete resection. When one-stage surgery is performed in patients with synchronous double cancer of the right lung and esophagus, the simultaneous occurrence of pulmonary complication and anastomotic leak should be noted.
Currently, complete video-assisted thoracoscopic surgery (VATS) lobectomy using a two-dimensional thoracoscopic (2D) system is performed worldwide. However, one of the disadvantages of the 2D system is the lack of spatial depth, but the three-dimensional thoracoscopic (3D) system, which resolves this problem, has recently been developed. We adopted the 3D system in 2015 for the treatment of patients who had primary lung cancer with tumors ≤30 mm (cN0). In this study, we investigated the efficacy of complete VATS lobectomy using the 3D system (n=34), compared with former consecutive cases of complete VATS lobectomy performed with the 2D system (n=73). The 3D system significantly reduced blood loss (30 vs. 60 g, respectively, p=0.002) and the operative time (202 vs. 224 min, respectively, p=0.029). The adaptation of the 3D system for complete VATS lobectomy might lead to safer surgeries compared with using the 2D system. However, its superiority needs confirmation by larger, prospective, multi-institutional studies, for the widespread adoption of the 3D system.
Objective) To investigate whether the combined use of a regular drip infusion of acetaminophen and constant fentanyl infusion could replace epidural anesthesia after thoracotomy.
Methods) We conducted a retrospective cohort study of patients receiving pain relief after thoracotomy procedures. Cases were classified into two groups based on the method of pain relief: an acetaminophen and fentanyl group (AF group) and epidural anesthesia group (Epi group). We compared and examined the analgesic effect and drug side-effects for each group.
Results) A total of 44 cases were included in the final analysis (AF group: 19 cases, Epi group: 25 cases). Compared with epidural anesthesia, the analgesic effect of combined acetaminophen and fentanyl was high, and only inferior with respect to coughing on postoperative day 1. The delay in getting out of bed following surgery did not differ between groups. However, during rehabilitation, a significantly larger drop in the blood pressure was observed in the Epi group, whereas nausea and vomiting were more frequent in the AF group. These side-effects caused a short delay in rehabilitation for both groups.
Conclusions) The combined use of a regular drip infusion of acetaminophen and constant fentanyl infusion had a comparatively high analgesic effect, although additional measures may be required to alleviate nausea, vomiting, and pain while coughing. Furthermore, the prevention of epidural complications, reduction of the anesthesia induction time, and an analgesic effect that is not dependent on the skill of the anesthesiologist can be expected. Therefore, this approach is an effective method for pain relief following thoracotomy procedures.
A solitary pulmonary capillary hemangioma is a benign tumor that develops simply from capillary endothelial cell proliferation, and affected patients generally have a good prognosis. However, chest CT findings occasionally reveal this tumor as a small nodule with ground-glass opacity, making it difficult to distinguish from well-differentiated lung adenocarcinoma. We treated a 42-year-old woman in whom chest CT showed a small nodule with ground-glass opacity (13 mm) in the right S9 segment. Suspected to be well-differentiated lung cancer, we performed a right basal segmentectomy using a total thoracoscopic surgical procedure for diagnosis and treatment. The histopathological diagnosis was solitary pulmonary capillary hemangioma. There have been no signs of recurrence on follow-up examinations following the operation.
We often find a consolidation around the staple line after pulmonary resection. We encountered cases of nodules around the staple line after pulmonary resection, and they enlarged, so we performed surgery. Case 1: A 77-year-old man had undergone right middle lobectomy and partial resection of the right lower lobe for Stage IA lung cancer 11 years ago. A nodule was detected around the staple line in the right lower lobe and it enlarged during the follow-up period. We performed right S6 segmentectomy, and the pathologic diagnosis of the nodule was an inflammatory tumor. Case 2: A 66-year-old man had undergone left superior segmentectomy for Stage IA lung cancer 4 years ago. A nodule was detected in the left lingular segment. We performed left lingular segmentectomy, and the pathologic diagnosis was nontuberculous mycobacteriosis. We should be aware of these kinds of inflammatory nodule after pulmonary resection.
Video-assisted thoracoscopic lobectomy in infants has not been widely performed because of the difficulty of one-lung ventilation. We report a pediatric case of complete video-assisted thoracoscopic right lobectomy for pulmonary arteriovenous fistula. In the one-lung ventilation approach, a bronchial blocker was placed in the right main bronchus before tracheal intubation. Bronchoscope entry into the lumen of the tracheal tube did not interfere with the bronchial blocker using this method. A bronchial blocker located outside the tracheal tube may maintain a good position and improve the operability of the bronchoscope and working space, compared with the common practice of bronchial blocker use.
A 62-year-old man was admitted to our hospital for squamous cell lung carcinoma. We performed video-assisted right pneumonectomy after the induction chemoradiation therapy. We used portable thoracic drainage systems: Thopaz® and 19-Fr blake drain®. The patient had a severe cough and showed progressive subcutaneous emphysema. Thopaz® showed little air leakage. We confirmed the absence of a fistula at the bronchial stump via bronchoscopy and the absence of air suction from outside the drainage tube. We removed the thoracic drain because we believed Thopaz® caused the subcutaneous emphysema, and the subcutaneous emphysema subsequently fully resolved.
Thopaz® regulates the mean intrathoracic pressure by supplying air to the thoracic cavity when there is an excessive negative intrathoracic pressure. The mechanism of the increased subcutaneous emphysema by Thopaz® was considered as follows: sudden elevation of the intrathoracic pressure caused by the cough moved intrathoracic air into the subcutaneous space, instead of the blake drain®. Thopaz® supplied air into the thoracic cavity to restore the excessive negative intrathoracic pressure. This cycle was repeated and the subcutaneous emphysema worsened.
Pleuroperitoneal shunts have been reported to be effective for the management of intractable pleural effusion. We report a patient with bilateral intractable pleural effusion in whom unilateral pleuroperitoneal shunt placement was effective.
A 79-year-old man underwent left lobectomy for lung cancer. Nine months postoperatively, he suffered from bilateral plural effusion due to heart failure and kidney disease, which required frequent thoracentesis. Therapies such as dialysis were ineffective, and his plural effusion worsened. A right pleuroperitoneal shunt was placed under local anesthesia, with 1.5 L of pleural effusion being drained every day from the thoracic to peritoneal cavity. The clinical course was good, and his bilateral pleural effusion, dyspnea, and edema improved.
Our case demonstrates that unilateral pleuroperitoneal shunt placement is useful for bilateral intractable pleural effusion.
An 83-year-old man with appetite and weight loss was referred to our hospital for further examination. Chest computed tomography (CT) showed pericardial effusion and bilateral pleural effusions. An echocardiogram demonstrated a decreased left ventricular diastolic function due to the pericardial effusion. Despite conservative treatment, cardiogenic shock due to cardiac tamponade developed 9 days after admission, and pericardial drainage was performed immediately. Polymerase chain reaction detected Mycobacterium tuberculosis DNA in the pericardial effusion, confirming the diagnosis of tuberculous pericarditis and bilateral tuberculous pleuritis. Because pericardial effusion at about 100 mL daily had continued even after drainage and the administration of anti-tubercular agents, video-assisted thoracoscopic pericardial fenestration with a left-sided transthoracic approach was performed under general and epidural anesthesia 20 days after admission. The parietal pericardium was markedly thickened with fibrinous adhesion to the visceral pericardium, and the parietal pericardium could be dissected from the edematous visceral pericardium. A pericardial window was created with a size of 4×3 cm. For residual multiple loculated pericaridial effusions, many incisions were made in the pericardium. Corticosteroid was also administered after the operation, and the thickness of the parietal pericardium had normalized on chest CT one month after the operation. The anti-tubercular agents were administered for 12 months, and no recurrence of pericardial effusion has been observed. Video-assisted thoracoscopic pericardial fenestration is a safe and effective technique for pericardial drainage and biopsy. Moreover, this procedure with the administration of corticosteroids for tuberculous pericarditis might prevent progression to constrictive pericarditis.
A 20-year-old man presented with left chest pain and fever lasting for one day. Hematological examination showed a marked inflammatory response and chest CT on admission revealed a multilocular and partially solid mass in the anterior mediastinum and left pleural fluid. We suspected a mediastinal teratoma with perforation or mediastinal abscess. Meropenem was administered, and biopsy via VATS was performed. Pathological findings during the operation detected atypical cells, but we could not make a definite diagnosis. Continuing the antibiotic, the inflammatory response reduced and the mass shrank. We considered it to be a mediastinal teratoma with perforation, and subsequently performed thymo-thymectomy. The pathological findings of the secondary surgery revealed no immature part, and the diagnosis was a mature teratoma.
A 43-year-old woman with cough was referred to our hospital. A nodule was detected in the left lung on chest computed tomography. Bronchoscopy did not reveal malignancy; thus, the patient was observed. However, the lesion showed low-level growth and malignancy was suspected. We therefore performed surgery. Histological examination of the tumor revealed that oval- and spindle-shaped cells with mild nuclear atypia formed a solid or lamellar structure, and mitosis was observed in 5 of 10 high-power fields. Immunohistochemically, the tumor cells expressed both epithelial and myoepithelial markers. These findings led to a diagnosis of myoepithelial carcinoma of the lung. Myoepithelial carcinoma of the lung is extremely rare.
Although the present case was classified as low grade, we need to conduct follow-up carefully.
The patient was a 36-year-old who was undergoing follow-up observation after a mediastinal mass was identified during a physical examination at a local clinic 3 years earlier. Over time, the mass showed a tendency to grow, and so the subject consulted our hospital for close examination and treatment. Chest CT revealed a mass shadow of 36 mm in the left middle mediastinum, and FDG-PET/CT revealed FDG uptake with an SUVmax of 4.93 at the same site. On suspicion of a mediastinal tumor such as a thymoma, video-assisted thoracoscopic surgery was performed; however, the lesion was a sessile intrapulmonary tumor. Rapid pathological diagnosis revealed low-grade malignancy, and left upper segmentectomy was performed. The postoperative pathology results led to the diagnosis of a benign perivascular epithelioid cell tumor (PEComa). PEComa is a rare condition, for which there are very few reports using PET/CT. We report a case of benign PEComa that showed elevated FDG uptake.
Exostosis is a benign bony tumor that occurs in the bones either sporadically or as a hereditary condition at multiple sites in infants and children. These are usually observed in the tubular bones of the extremities such as the femur, tibia, and humerus. Costal exostosis is rare, but pneumothorax, hemothorax, pericardial effusions, and diaphragm injury as intrathoracic complications can occur. To the best of our knowledge, this is the ninth report of pneumothorax caused by costal exostosis. We report a case of pneumothorax in a 13-year-old girl with exostosis of the left fifth rib. We performed resection of the injured lung and exostosis by video-assisted thoracoscopic surgery.
Lung metastasis from prostate cancer often shows systemic relapse and recurrence, with multiple lung nodules and elevated serum prostate-specific antigen (PSA) levels. Isolated pulmonary metastasis without extrapulmonary recurrence or an elevated serum PSA level is rare. A 71-year-old man with a history of radical prostatectomy for prostate cancer performed at the age of 59 years old was referred to us with a nodule detected on plain chest radiograph. The nodule showed an increasing size. While the serum Pro-GRP and NSE levels were elevated to 70.0 and 29.0 pg/mL, respectively, the serum PSA level was within the normal range. On the basis of these findings, lung cancer, cT1bN0M0, stage IA, was suspected, and video-assisted partial resection of the right upper lobe was performed. Intraoperative frozen-section examination revealed the diagnosis of adenocarcinoma; therefore, a right upper lobectomy with mediastinal lymph node dissection was performed. Histopathologically, the tumor was composed of high columnar epithelium, with the tumor cells forming fused glands. Immunohistochemical staining revealed positive staining for PSA, which led to the diagnosis of the lung nodule as solitary lung metastasis from prostate cancer. Postoperative follow-up showed no recurrence until at least 2 years and 3 months after the surgery. We report a rare case of isolated solitary lung metastasis occurring 12 years after radical prostatectomy in the absence of an elevation of the serum PSA level, with a review of the literature.
The intrathoracic seeding and chest wall implantation of lung cancer by CT-guided needle biopsy is rare, but when it does occur, it is a serious complication that adversely affects the prognosis. A 66-year-old male underwent CT-guided needle biopsy for a nodule in the left lung S3a region that was later diagnosed to be lung cancer. We performed left upper lobectomy with lymph node dissection by video-assisted thoracoscopic surgery. The postoperative histopathological diagnosis was adenosquamous carcinoma, pStage IB. At four months after surgery, chest CT revealed the presence of another tumor measuring 10 cm in diameter in the left pectoralis major and minor muscles. We performed percutaneous needle biopsy for this tumor, and its cytology was class V, but its histologic type could not be determined. For both a definitive diagnosis and treatment, we performed left chest wall tumor excision including second and third rib resection and chest wall reconstruction. The pathological diagnosis was adenosquamous carcinoma, and we diagnosed the occurrence of chest wall implantation by the biopsy needle due to the fact that the position of the chest wall tumor and biopsy needle track were consistent based on chest CT findings, and there had been no recurrence of lung cancer for one year and seven months after surgery. Needle track implantation by CT-guided needle biopsy is rare, but it is a significant complication that should be avoided as much as possible. As a result, when performing CT-guided needle biopsy, extreme care should be taken to avoid such an occurrence.
A 68-year-old woman underwent left upper lobectomy+ND2a-2. Postoperative pathological examination revealed and confirmed the diagnosis of adenocarcinoma, pT3N0M0, stageIIB. Six months after surgery, chest CT showed swelling of the left axillary lymph node and the tumor marker level was high. PET-CT revealed abnormal accumulation in the left axillary lymph node. Biopsy of the left axillary lymph node confirmed the presence of adenocarcinoma. After biopsy, she underwent chemotherapy and radiation therapy. The patient died of cancer 4 years after the axillary lymph node recurrence.
Cases of multiple lung cancer have been increasing because of improvements in technology for diagnosing lung cancer in recent years. We report a patient in whom surgery was performed in two stages for synchronous primary quadruple lung cancer.
A 79-year-old man underwent computed tomography (CT). A ground-glass opacity (GGO) of 40 mm was observed in the right upper lobe, which was diagnosed as an inflammatory change. Two years later, a solid component appeared inside the GGO. A 16-mm nodule was in contact with the mediastinum of the right upper lobe, an 8-mm nodule was in the middle lobe, and an 8-mm nodule was in the left upper division, as shown by CT. Fluorodeoxyglucose-position emission tomography showed that the patient had two lesions in the large intestine. They were diagnosed as colorectal cancer and endoscopically treated. The GGO was diagnosed by bronchoscopy as adenocarcinoma. Pulmonary metastasis could not be excluded for nodular lesions other than GGO. However, we performed surgery because we considered that complete resection of the four lesions was possible. First, the patient underwent thoracoscopic right upper lobectomy and partial resection of the middle lobe. Although the tumors were adenocarcinoma, pathological findings showed different subtypes and the patient was diagnosed with triple primary cancer. For the second time, thoracoscopic left partial resection was performed at the left upper division. The tumor was diagnosed as adenocarcinoma, which was different from any lesion in the right lung.
Therefore, this case was diagnosed as primary quadruple lung cancer. When lung cancer with multiple tumors is present, surgery should be considered if complete resection is possible.
A 68-year-old male was pathologically diagnosed with invasive thymoma by biopsy in 1993. He underwent surgery for the thymoma after preoperative chemo-radiotherapy, in which debulking resection was performed because the tumor had invaded the pulmonary artery trunk.
In 1996, the patient developed myasthenia gravis, which was well controlled by predonisolone. Pleural dissemination on his left side was noted in the same period, which gradually advanced. Macroscopic complete resection was performed in 2002.
Thereafter, a large volume of pericardial effusion was detected in 2007. The bloody fluid was drained, and thymoma cells were cytopathologically found.
In 2010, when the patient was screened for anemia, he was diagnosed with early rectal cancer and pure red cell aplasia (PRCA). After curative anterior resection for rectal cancer, PRCA remission was diagnosed on re-biopsy of the bone marrow.
In December 2010, the presence of a mediastinal tumor was detected using chest computed tomography, and thymoma recurrence was pathologically diagnosed by trans-bronchial needle aspiration biopsy through the carina of the trachea. Chemotherapy for treating the recurrence of thymoma was not effective: furthermore, anemia aggravation and PRCA recurrence were detected in the third biopsy of the bone marrow.
In 2012, hypogammaglobulinemia, known as Good's syndrome, was diagnosed owing to the onset of pneumonia, which was caused by immunodeficiency.
Nevertheless, these complications were well-controlled by intensive follow-up. However, the patient died of thymoma due to respiratory and cardiac failure caused by the increase of the mediastinal mass of the recurrent thymoma in 2016, 23 years after the first surgery.
A 20-year-old man presented with left pneumothorax. The pneumothorax was healed by thoracic drainage and he was discharged, but the disease soon relapsed. He had undergone thymectomy for a mature teratoma when he was 6 months old, and had an episode of left pneumothorax when he was 18 years old. Chest CT showed the left pneumothorax and metallic wires which immobilized the disected ribs. The wires on the fourth and fifth ribs were broken, and the fifth one had become embedded in the upper lobe of the left lung. We suspected the cause of repetitive pneumothorax to be the broken wire, and an operation was performed via VATS. Through the superior lingular segment, which joins with the chest wall, the head of the wire could be observed below the interlobar visceral pleura. The wire and a sharp bone chip projected from the fifth rib to the superior lingular segment. The wire and bone chip were removed, and the pulmonary fistula was repaired by fibrin adhesive. Wires that are used to immobilize fractured ribs can break and damage the neighboring organ, and so extra attention is needed.
A 65-year-old woman was found to have a 14-mm partially solid nodule (solid component of 5 mm) in the left upper division of the pulmonary vein (S1+2) on computed tomography (CT). We performed a left upper division segmentectomy for diagnosis and treatment. On the sixth day after surgery, CT showed a 16 mm thrombus of the vein stump. We started anticoagulant therapy (heparin by constant infusion and oral warfarin). Warfarin treatment was stopped after CT showed no evidence of a thrombus six months after the start of anticoagulant therapy, with no occurrence of thromboembolism (such as cerebral infarction). Pulmonary vein stump thrombus after lobectomy is an important complication that may cause fatal arterial embolism, and a pulmonary vein stump thrombus has often been reported after left or right upper lobectomy, or after intermediate lobectomy with the residual pulmonary vein. We encountered a thrombus of the pulmonary vein stump in a patient following left upper division segmentectomy. It is important to keep in mind that the vein stump on the nucleus side of a left upper division segmentectomy should be treated minimally.
We report a rare case of abnormal mediastinal A7a+8b branching. A 77-year-old man with bloody sputum was referred to our department. Thin-slice chest computed tomography revealed mediastinal A7a+8b branching from the right main pulmonary artery, passing between the superior and inferior veins and along the mediastinal side of the intermediate bronchus. The main lesion was a solid nodule measuring 26 mm. Suspecting lung cancer (cT1cN0M0), we planned a right lower lobectomy (ND2a-1). Intraoperative findings showed the aberrant branching of A7a+8b from the main pulmonary artery to right lower lobe (S7a+8b), passing the mediastinal side of the intermediate bronchus and interlobar fissure between the right middle and lower lobes. This aberrant artery was transected at the level of the major fissure. Mediastinal inferior lobar branching is rare, with only two prior case reports.
We encountered a rare case of localized malignant pleural mesothelioma (LMM) with the expression of granulocyte colony-stimulating factor (G-CSF). A 75-year-old male who presented with fever and left chest discomfort was referred to our hospital for examination. Chest CT showed a solitary mass attached to the costal bones. Laboratory findings showed an elevated inflammatory reaction, which was treated with antibiotics until surgery. As we did not make a definitive diagnosis based on intraoperative and rapid pathological findings, left upper lobectomy with resection of the chest wall (removal of the 1st and 2nd ribs) was performed. Immunohistochemical analysis revealed the tumor to be a sarcomatous-type LMM that was also partly positive for anti-human granulocyte colony-stimulating factor antibody. The patient was alive without recurrence at 20 months after surgery without any additional therapy. Because it is difficult to make a definitive diagnosis of LMM based on intraoperative findings, we should plan tissue examinations before surgery. The elevation of an inflammatory reaction with an undetectable focus should raise the suspicion of a G-CSF-producing tumor.
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