The Journal of the Japanese Association for Chest Surgery
Online ISSN : 1881-4158
Print ISSN : 0919-0945
ISSN-L : 0919-0945
Volume 32 , Issue 2
Showing 1-24 articles out of 24 articles from the selected issue
  • Ayaka Asakawa, Masahiko Harada, Takashi Yamamichi, Masayuki Okui, Hiro ...
    2018 Volume 32 Issue 2 Pages 130-135
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    Objective: The efficacy of video-assisted thoracoscopic surgery (VATS) in patients with acute empyema has been reported over the last several decades. The American Association for Thoracic Surgery (AATS) consensus guideline recommends VATS as the first-line treatment for all patients with stage-II acute empyema. The objective of this study was to evaluate the efficacy of VATS in patients with acute empyema in our hospital.

    Methods: From January 2003 to May 2017, 28 patients underwent the complete evacuation of potentially infected fluid and/or material, and they showed complete re-expansion of the lungs. We retrospectively analyzed the medical records and extracted information on clinical features, preoperative treatment, operation-related factors, and the outcome of each patient.

    Results: Of these 28 patients, 79% (n=22) were men, and the mean age was 67.3 years (31-80 years). The stages of empyema based on the ATS classification were I in 7% (n=2), II in 82% (n=23), and III in 11% (n=3). Preoperative cultures of pleural effusion were positive in 39% (n=11) of patients. VATS was chosen in all cases, and there was no conversion to open thoracotomy in any case. Postoperative complications occurred in 7% (n=2) of patients; gastric perforation, 1; and interstitial pneumonia, 1. The median durations of pre- and postoperative stays were 8 (range, 0-36) and 11 (range, 6-153) days, respectively.

    Conclusions: VATS in patients with acute pleural empyema was safe, and it reduced the length of stay, blood loss, and postoperative complications (including 30-day mortality). The therapeutic effect of VATS was very favorable in patients with stage-II empyema, and VATS may be indicated in some patients with stage-III empyema.

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  • Shuta Ohara, Toshiki Takemoto, Yoshihisa Kobayashi, Katsuaki Sato, Ken ...
    2018 Volume 32 Issue 2 Pages 136-140
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A 67-year-old man presented with bilateral hand and elbow joint pain and pitting edema of the hands. He was diagnosed with remitting seronegative symmetrical synovitis with pitting edema syndrome (RS3PE syndrome). Since RS3PE is known to often be associated with malignant disease, the patient was examined for malignancy, resulting in the diagnosis of right lung cancer. He was referred to our hospital for surgical treatment. Computed tomography (CT) showed a solid nodule of 1.3 cm in diameter in the right upper lobe of the lung. Bronchoscopic biopsy led to a diagnosis of adenocarcinoma. Positron emission tomography-CT did not show metastases to lymph nodes or other organs. Therefore, we performed thoracoscopic right upper lobectomy.After the surgery, his edema and joint pain improved. Although RS3PE syndrome is known as one of the paraneoplastic syndromes, that associated with lung cancer is very rare.

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  • Daiji Nemoto, Teppei Nishii, Kenji Kanno, Kenji Inui, Munetaka Masuda
    2018 Volume 32 Issue 2 Pages 141-146
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A 34-year-old man visited our hospital with hemoptysis. He had a history of cellular benign fibrous histiocytoma (CBFH) of the head, resected at 25 years of age. Computed tomography (CT) showed a cystic lesion with a partially thickened wall in the right upper lobe. We performed a right upper lobectomy for treatment of the hemoptysis and for definitive diagnosis of the cystic tumor. Histopathologically, there was a cystic air space lined with ciliated columnar epithelium, with partial squamous cell metaplasia. Around the cyst, a fibrohistiocytic tumor with no nuclear atypia proliferated in a storiform pattern. Because the histopathological findings of the tumor cells in the lung were similar to the tumor cells in the head, we diagnosed the cystic tumor of the lung as metastasis of CBFH. Six months after lobectomy, new multiple cystic lesions appeared on CT. Because the new lesions were similar to the preoperative lung lesion, we diagnosed these as multiple lung metastases of CBFH. However, during a 7-year observation period, these cystic lesions showed no growth, and no other new cystic lesions appeared. Lung metastases of CBFH may not grow aggressively. Therefore, we continued follow-up examination without further treatment in this case.

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  • Yuzuru Watanabe, Ryuzo Kanno, Hiroyuki Suzuki
    2018 Volume 32 Issue 2 Pages 147-152
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A 70-year-old woman was referred to our hospital because of cough and dyspnea. Computed tomography (CT) showed left pleural effusion with mediastinal deviation, and irregular diffuse thickening of the left pleura. Pleural effusion cytology did not confirm malignant findings, and tumor markers were negative. Malignant pleural mesothelioma and primary lung cancer were considered as differential diagnoses. Thoracoscopic pleural biopsy was performed. Pathologically, based on various immunostainings, renal cell carcinoma or uterine ovarian cancer was suspected. Abdominal contrast CT showed a left renal tumor. Left nephrectomy was performed. Although pulmonary metastasis of renal cell carcinoma is not rare, instances without pulmonary metastasis and only carcinomatous pleurisy, as in the present case, are limited to only six reported cases. We report this case along with a literature review.

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  • Kazuya Matsumoto, Shinichi Sumitomo
    2018 Volume 32 Issue 2 Pages 153-159
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    We report successful elective surgery for traumatic left disruption of the main bronchus that presented as complete atelectasis due to delayed airway obstruction. A 37-year-old man was injured in a traffic accident and admitted due to bilateral hemopneumothorax, pulmonary contusion, mediastinal emphysema, and hematoma, and fractures of multiple ribs, the right clavicle, and left scapula. Bilateral thoracic drainage was performed and the right lung was fully expanded. However, the left lower lobe did not inflate sufficiently. Although incomplete disruption of the left main bronchus was suspected, conservative observation was performed initially because his respiratory status was stable with spontaneous breathing under inhaled oxygen and the air leakage had stopped by the 4th hospital day. X-ray permeability of the left lung reduced gradually, and the left lung showed complete atelectasis on the 15th hospital day. Bronchoplasty of the left main bronchus was performed on the 36th hospital day. Postoperative airway stenosis was not observed, and the pulmonary function test results and left lung perfusion ratio had improved markedly by 3 months after surgery, and continued to improve for 2 years. For patients with tracheobronchial injury who can be observed conservatively during the acute phase and subsequently exhibit progressive airway stenosis, elective surgery may be considered depending on the general condition and other coexisting organ injuries, without symptoms of peripheral lung infection.

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  • Akitomo Kikuchi, Hiroyuki Adachi, Munetaka Masuda
    2018 Volume 32 Issue 2 Pages 160-165
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    Case 1: A 37-year-old woman with facial swelling after dental treatment (extraction of left lower third molar) was admitted to our hospital. Subcutaneous emphysema was observed in the cervical, facial, and supraclavicular areas, and computed tomography (CT) revealed that she had prominent mediastinal emphysema. She was diagnosed with mediastinal emphysema caused by dental treatment and was promptly administered antibiotic therapy. Consequently, she was discharged without any inflammatory complications. Case 2: A 68-year-old woman with dyspnea during dental treatment was admitted to our hospital. Cervical subcutaneous emphysema was palpable, and mediastinal emphysema was also detected on CT. She was diagnosed with mediastinal emphysema, and prophylactic antibiotics were administered for mediastinitis. She was discharged without any complications.

    Considering the mechanism and process of the occurrence of mediastinal emphysema caused by dental treatment, we consider prophylactic antibiotics to be essential in the treatment of these patients.

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  • Masataka Segawa, Yoshinori Doki, Yoshifumi Shimada
    2018 Volume 32 Issue 2 Pages 166-171
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    We report two cases of pulmonary actinomycosis diagnosed by surgical resection.

    Case 1: A 69-year-old male was admitted to our hospital with hemoptysis. Chest computed tomography (CT) revealed a mass in the upper lobe of the right lung upon admission. Transbronchial lung biopsy showed inflammatory changes.

    Chest CT revealed spontaneous remission of a mass, cavity formation in the mass, and dilatation of a bronchus near the mass during the clinical course.

    The patient underwent a right upper lobectomy to control life-threatening hemoptysis, and was subsequently diagnosed with pulmonary actinomycosis.

    Case 2: An 81-year-old male presented for consultation following a chest CT that revealed a gradually swelling nodule with pleural tail sign and spiculation in the upper lobe of the right lung. The patient had undergone a segmentectomy (S6) of the lower lobe of the right lung for adenocarcinoma 4 years earlier.

    The nodule showed high-level accumulation of fluorodeoxyglucose on positron emission tomography. Based on a suspected diagnosis of another lung cancer, partial resection of the right upper lobe was performed, and he was subsequently diagnosed with pulmonary actinomycosis.

    In both cases, there has been no recurrence of symptoms.

    Pulmonary actinomycosis is uncommon, and it is difficult to distinguish it from lung cancer. Moreover, lung cancer and pulmonary actinomycosis can co-exist in a patient. Surgery for pulmonary actinomycosis is suggested as an important adjunctive option for patients with recurrence, an uncertain diagnosis of cancer, or those who may need complication management. Cases of pulmonary actinomycosis with life-threatening hemoptysis or pulmonary nodules may require early surgical intervention.

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  • Koh Uyama, Takanori Miyoshi, Hiroyuki Sumitomo, Ryo Yamada, Naoki Hino
    2018 Volume 32 Issue 2 Pages 172-177
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A 70-year-old-man presented to our hospital because of an abnormal lung shadow identified during a medical checkup. Preoperative chest computed tomography revealed a mediastinal pulmonary artery branching from the right main pulmonary artery. It flowed into the lower lobe after passing between the bronchus and right superior pulmonary vein. The primary lesion located in the right lower lobe was a solid mass measuring 3.5 cm. Based on the results of a transbronchial biopsy, he was diagnosed with lung cancer (adenocarcinoma, cT2aN0M0), and a video-assisted right lower lobectomy was performed. A7+8+10 descending between the bronchus and the right superior pulmonary vein was identified. He underwent successful resection without any intraoperative complications. A right mediastinal basal pulmonary artery is a rare anatomical variant, and this is the fourth case reported in Japan. To prevent intraoperative injury, it is important to accumulate information pertaining to rare anatomical anomalies and accurately interpret preoperative computed tomography findings.

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  • Takashi Yamamichi, Hirotoshi Horio, Ayaka Asakawa, Masayuki Okui, Masa ...
    2018 Volume 32 Issue 2 Pages 178-182
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    Most cases of malignant pleural mesothelioma develop diffusely, but rarely in a localized pattern. We herein report a patient with localized malignant pleural mesothelioma who survived without relapse for almost 5 years with only local resection.

    A 60-year-old man had been exposed to asbestos for over 30 years. An abnormal shadow was noted on the left side of the chest, and abnormal uptake in the left fourth rib was observed with FDG-PET. We performed tumor resection, and 3rd and 4th rib resection with thoracoscopy. We submitted the specimens for rapid diagnosis. As malignant fibrous histiocytoma was suspected, we additionally resected approximately 3 cm. On pathology, the tumor cells were lace-to-spindle shaped and polymorphous. Anisonucleosis and irregular shapes were noted, and large nuclear bodies and necrosis were also observed. On immunostaining, the epithelial marker was positive, but the mesothelioma marker was negative; however, our diagnosis was malignant mesothelioma. Four years and ten months have passed without signs of recurrence. In some cases of malignant pleural mesothelioma, long-term survival is possible, but reports of non-chemotherapy cases are rare, and continued follow-up is necessary.

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  • Hiroyuki Osawa, Kohei Ando
    2018 Volume 32 Issue 2 Pages 183-186
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A 65-year-old man underwent an esophagectomy for esophageal cancer and esophageal reconstruction using the stomach through the retrosternal route. Ten years later, he consulted our hospital with sudden-onset dyspnea. A chest roentgenogram showed a bilateral pneumothorax and chest CT detected pleuro-pleural communication in the posterior mediastinum. We observed him conservatively; however, after three months, he presented with simultaneous bilateral pneumothorax again. Because the degree of pneumothorax on the left side was worse than on the right side, we inserted a chest drain tube into the left pleural cavity. The bilateral pneumothorax improved, but a persistent air leakage was revealed. We considered that the left pneumothorax had spread to the right side through the pleuro-pleural communication. A left thoracoscopic procedure was performed, and bullae in the apex of the left upper lobe of the lung and a defect of the pleura of the posterior mediastinum were revealed. A bullectomy was performed, and the resected edge was covered with a polyglycolic acid sheet and polydioxanone thread. The postoperative course was uneventful, and the patient remained free of any recurrent pneumothorax at one year after surgery. In the case of simultaneous bilateral spontaneous pneumothorax after esophagectomy, the possibility of a pleuro-pleural communication should be considered.

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  • Kenichi Kobayashi, Masaru Takenaka, Ayako Hirai, Naoko Imanishi, Yoshi ...
    2018 Volume 32 Issue 2 Pages 187-191
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A 50-year-old man was referred to our hospital because of an abnormal shadow on a chest radiograph. Chest CT demonstrated a tumor at the T4-T5 level that extended into the spinal canal via the intervertebral foramen, measuring 4.0 cm in diameter. MRI showed a hypointense mass on T1-weigtted and hyperintense mass on T2-weighted imaging. Dumbbell-type schwannoma was suspected. We decided to perform surgical treatment for therapeutic purposes. First, Th4 laminectomy was performed in a prone position using an orthopedic surgical procedure, and it was confirmed that there had been no infiltration of the tumor into the dura mater. The Th4 nerve root was dissected and the tumor was detached from the spinal canal. Then, we removed the mediastinal tumor using a left thoracoscopic approach. The tumor was difficult to dissect from the sympathetic trunk and fourth intercostal nerve. The tumor readily bled but the bleeding volume was only 120 cc. The histopathological diagnosis was cavernous hemangioma. Surgical removal could be performed safely after treating the nerve roots adjacent to the hemangioma growing into the spinal canal from the intervertebral foramen.

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  • Kazuhisa Matsumoto, Norihito Okumura, Chiaki Nakazono, Keiji Yamanashi ...
    2018 Volume 32 Issue 2 Pages 192-197
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    We report a patient with intralobar pulmonary sequestration treated by video-assisted thoracoscopic lobectomy. The patient was a 3-year-old boy. He was diagnosed with pulmonary sequestration based on a fetal ultrasound scan. Chest CT showed an aberrant artery arising from the descending aorta and supplying the left basal segment. Because he had no serious symptoms, we planned elective surgery. We performed video-assisted thoracoscopic left lower lobectomy and closure of an aberrant artery at the age of 3 years. The postoperative course was uneventful. It is considered safe and minimally invasive in an infant to perform complete video-assisted thoracoscopic lobectomy for intralobar pulmonary sequestration.

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  • Masayuki Shitara, Masayuki Tanahashi, Haruhiro Yukiue, Eriko Suzuki, N ...
    2018 Volume 32 Issue 2 Pages 198-202
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A 67-year-old man was referred to our hospital for further evaluation and treatment after hospitalization for pneumothorax and left empyema in another hospital. Examinations revealed a gastric lymphoma presenting with a gastropleural fistula. He underwent surgery through a left thoracoabdominal incision. A large amount of pus had accumulated in the pleural cavity and the visceral pleura was significantly thickened. The tumor was located in the gastric fundus and invaded the diaphragm, spleen, and pancreas. We performed a total gastrectomy, splenectomy, distal pancreatectomy, decortications, and diaphragmatic reconstruction with a latissimus dorsi flap. Although the patient developed a pancreatic fistula, he was discharged 60 days after the surgery. With the excellent exposure it provides for thoracoabdominal surgery, enabling diaphragmatic reconstruction using the same incision, the left thoracoabdominal incision was an ideal approach for this case.

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  • Mariko Takemura, Shinnosuke Watanabe, Yukiko Hosono, Masafumi Mitsui
    2018 Volume 32 Issue 2 Pages 203-210
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    We selected different anticoagulation therapies for two patients with pulmonary vein stump (PVS) thrombosis after left upper lobectomy. In both cases, Tegafur/Uracil (UFT) was prescribed for adjuvant chemotherapy, and enhanced computed tomography of the two patients showed PVS thrombosis at four and three postoperative months, respectively. Warfarin (Wf) was selected for case 1, but the interaction between UFT and Wf made it difficult to maintain the prothrombin time-international normalized ratio (PT-INR) within the therapeutic range. In case 2, we selected Apixaban for PVS treatment. There is no interaction of UFT with direct oral anticoagulants (DOAC), and so it was safer and free from dose adjustment. Both therapies successfully resolved the thrombosis, and there were no complications such as bleeding or thrombotic organ infarction. Most reports of PVS thrombosis involved the selection of Wf for anticoagulation therapy, but DOAC like Apixaban could be considered to play an important role in treatment for PVS thrombosis, especially for patients prescribed UFT.

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  • Naoya Kitamura, Takahiro Homma, Yushi Akemoto, Yoshifumi Shimada, Tosh ...
    2018 Volume 32 Issue 2 Pages 211-215
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    We report a case of lung torsion (LT) of the lingula following segmentectomy of the upper division of the left lung. A 67-year-old man underwent segmentectomy of the upper division of the left lung for primary left upper lobe lung cancer (cT1bN0M0, Stage IA2). Blood sputum appeared on the second postoperative day. We suspected LT of the lingula and performed bronchoscopy and chest enhanced computed tomography (CT). Bronchoscopy did not reveal occlusion of B4+5 but enhanced CT showed interruption of V4+5. We diagnosed the patient with LT of the lingula and decided to perform an emergency operation. The lingular segment showed congestion and swelling; therefore, we performed lingulectomy. The patient was discharged on postoperative day twelve. Since the pathological diagnosis was hemorrhagic infarction, it did not contradict LT. LT is defined as rotation of the bronchovascular pedicle with resultant airway obstruction and vascular compromise. Effective examinations for evaluating bronchi and vessels are different. It is considered that early diagnosis and treatment by bronchoscopy and enhanced CT are important because LT can sometimes be a serious complication.

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  • Kei Matsubara, Takahiko Misao, Shin-ichi Kawana, Yuuya Kokita, Takeshi ...
    2018 Volume 32 Issue 2 Pages 216-220
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A 26-year-old man was transported to our hospital after being involved in a car accident. A chest roentgenogram after endotracheal intubation showed right tension pneumothorax. We immediately performed thoracic drainage; however, the right lung was still collapsed, with continuous and massive air-leakage. We urgently performed bronchoscopy and observed no abnormal findings in the trachea or primary bronchi. A suspicion of airway injury remained due to a large amount of air-leakage. Accordingly, we decided to perform an emergency operation. The middle-lobe bronchus had been completely transected at the root. Consequently, we could not avoid performing middle-lobe lobectomy. Tracheobronchial injuries have been reported to make up 1% of blunt thoracic traumas, and middle bronchial ruptures make up approximately 1% of them. In general, traumatic airway injuries are rare and occasionally difficult to diagnose early. Whenever a large amount of air-leakage is observed after tube drainage, we should take into consideration the possibility of tracheobronchial injuries and perform thoracotomy without delay.

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  • Naohisa Chiba, Yasuaki Tomioka, Toshiya Toyazaki, Yuichiro Ueda, Masas ...
    2018 Volume 32 Issue 2 Pages 221-225
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A decreased pleural fluid level on a chest radiograph after pneumonectomy suggests the existence of a bronchopleural fistula (BPF) in the bronchial surgical margin. A rare asymptomatic etiology, known as benign emptying of the postpneumonectomy space (BEPS), has been reported to exist when BPF is not detected. We report a suspected case of BEPS after left pneumonectomy.A 65-year-old male underwent left pneumonectomy after the diagnosis of squamous cell lung cancer in the left lower lobe. A decreased fluid level in the left thoracic space was detected on a radiograph at 47 postoperative days (POD). However, the patient had no related respiratory symptom and bronchoscopy revealed no fistula in the bronchial surgical margin. Exploratory video-assisted thoracic surgery was performed at 99 POD, but no sign of BPF was noted. During the follow-up period, the fluid level began to increase at 175 POD and the air space in the left thoracic cavity had completely disappeared at 225 POD. No decrease in the pleural fluid level was seen at one year and nine months after the operation. We should take into consideration BEPS that does not necessitate medical treatment if a decreased pleural fluid level is detected on a chest radiograph after pneumonectomy.

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  • Yuichiro Ueda, Tatsuo Nakagawa, Yasuaki Tomioka, Toshiya Toyazaki, Mas ...
    2018 Volume 32 Issue 2 Pages 226-231
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    Pulmonary cacinosarcomas are extremely rare tumors, accounting for only 0.1~0.3% of all lung malignancies. Although surgical resection is the primary treatment, it is difficult to obtain a definitive diagnosis before surgery. We report a surgically treated case of pulmonary carcinosarcoma requiring the differential diagnosis of a solitary fibrous tumor. 【Case】A 54-year-old female with a high fever was admitted to a hospital and a mass lesion was pointed out in her left chest cavity. A definitive diagnosis could not be obtained with a bronchoscopic examination. She consulted our hospital and underwent surgical resection with a suspected solitary fibrous tumor. The tumor extensively adhered to the diaphragm and lower lobe of the left lung and was resected with a left basal segment of the lung and part of the diaphragm. Although a solitary fibrous tumor was pathologically suspected by intraoperative examination, the final diagnosis was carcinosarcoma of the lung. She developed multiple metastases of the bone, lung, liver, and muscle of the hip during the follow-up period and died at 11 postoperative months.

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  • Kaoru Ochi, Satoshi Fumimoto, Takayuki Kataoka, Yoshio Ichihashi, Kiyo ...
    2018 Volume 32 Issue 2 Pages 232-237
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    This case involved a 46-year-old man. Anemia had been indicated at previous health checkups, but had been left untreated as there were no symptoms. Two months ago, the patient started experiencing lightheadedness and visited a local physician. He was diagnosed with hypogammaglobulinemia and pure red cell aplasia after a detailed examination. Furthermore, a well-circumscribed 36-mm (long diameter) tumor lesion was detected at the anterior mediastinum on chest computed tomography. The patient was subsequently referred to our department to undergo surgery for the anterior mediastinal tumor and underwent thoracoscopic tumor resection. The tumor was determined to be a type B1 thymoma based on the WHO classification according to histopathological examination, and the patient was diagnosed with Good syndrome accompanied by pure red cell aplasia based on the concurrence of hypogammaglobulinemia and pure red cell aplasia. Postoperative infection was not observed. The patient is currently undergoing cyclosporine therapy at the Hematology Department and is showing improvements in anemia. Good syndrome accompanied by pure red cell aplasia is rare, with only six reported cases in Japan since 1990. Postoperative infection is a serious complication of this disorder that accompanies immunodeficiency, and appropriate selection of the surgical procedure is imperative. Good syndrome is a disorder associated with a poor prognosis and it requires careful follow-up.

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  • Toshihiro Ikeda, Tetsuhiko Go, Jun Nakano, Tomohito Okubo, Naoya Yokot ...
    2018 Volume 32 Issue 2 Pages 238-243
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    Airway injury is a rare complication of intubation and esophageal surgery. We report two cases of tracheal injuries managed without direct suturing. Case 1: A 75-year-old man underwent chemoradiotherapy after surgery for esophageal cancer, and developed a gastric tube bronchial fistula after the first surgery. The membranous wall of the trachea was injured during surgery to repair a reconstructed gastric tube bronchial fistula. Although direct suturing of the injured trachea was considered, there was a marked risk of suture failure owing to impaired blood flow secondary to radiation therapy. Therefore, we did not suture the tracheal injury and performed pectoral major muscular flap plombage for dead-space closure. The postoperative course was uneventful. Two weeks after the injury, bronchoscopic evaluation showed granulation at the site of the tracheal injury.

    Case 2: A 74-year-old woman showed acute-onset respiratory distress. The patient was diagnosed with bronchial asthma attack, intubated, and placed on a respirator for observation. One day after intubation, marked subcutaneous emphysema was observed from the neck to anterior chest. Computed tomography (CT) and bronchoscopy showed injury of the membranous portion of the lower trachea. Two weeks after conservative medical management of the patient on a respirator, bronchoscopic evaluation showed granulation around the injured portion of the trachea.

    In cases of membranous injury of the trachea, suturing the torn tissue is generally conducted for repair. However, if it is difficult to suture owing to the patient's condition, plombage for dead-space closure or conservative medical management is an option.

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  • Hitoshi Suzuki, Shin Shomura, Kentaro Inoue, Shinji Kanemitsu, Akira S ...
    2018 Volume 32 Issue 2 Pages 244-249
    Published: March 15, 2018
    Released: March 15, 2018
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    Pleural well-differentiated papillary mesothelioma (PWDPM) is an extremely rare subtype of epitheloid mesothelioma. Herein, we report a case of PWDPM. A 51-year-old man who had a history of occupational asbestos exposure was referred to our hospital for the evaluation of pleural effusion. Thoracoscopic pleural biopsy was performed, and pathological examination established a diagnosis of PWDPM. Pleural effusion was observed again 2 years after the biopsy. The thoracoscopic findings revealed tumor enlargement, but there was no evidence of malignant cells. Severe pleural effusion was not observed after the pleurodesis. We considered that intensive follow-up and the selection of therapy were needed for multiple WDPM because there is a risk of recurrence or malignant transformation.

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  • Chiaki Nakazono, Norihito Okumura, Tomoaki Matsuoka, Takashi Nakashima ...
    2018 Volume 32 Issue 2 Pages 250-255
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    We report a surgical case of lung cancer with pulmonary embolism confirmed during induction chemotherapy. A 73-year-old woman was referred to our hospital for the examination of a pulmonary opacity. Computed tomography (CT) showed a 25-mm tumor in the right S8 and mediastinal lymphadenopathy. We performed a biopsy of the subcarinal lymph node by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), leading to a diagnosis of lung adenocarcinoma, cStageIIIA. She subsequently received induction chemotherapy (Cisplatin, Pemetrexed, and Bevacizumab). After 3 courses, she underwent CT. It showed broadly ranging pulmonary thrombosis on the right side and deep venous thrombosis. The pulmonary thrombosis was distant from the primary tumor.

    At that time, D-dimer suddenly rose, but there was nothing of note. She received anticoagulant therapy for 33 days and we could perform lobectomy for lung cancer. There was no postoperative complication. Pulmonary thrombosis often occurs in patients undergoing chemotherapy. We should always keep the possibility of its development in mind.

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  • Kazuto Sugai, Yukinobu Goto, Naohiro Kobayashi, Shinji Kikuchi, Yukio ...
    2018 Volume 32 Issue 2 Pages 256-260
    Published: March 15, 2018
    Released: March 15, 2018
    JOURNALS FREE ACCESS

    A 75-year-old man presented with bloody sputum. Chest computed tomography (CT) showed a tumor shadow in the superior segment of the right lung, which occluded the inferior lobar bronchus and infiltrated the center of the right main bronchus. Bronchoscopic biopsy results confirmed the diagnosis of a poorly differentiated lung adenocarcinoma (cT3N1M0, Stage IIIA). Right pneumonectomy was performed with curative intent. Stapling of the right main bronchus using an automatic suture instrument at a point 1 bronchial cartilage ring peripheral to the tracheal bifurcation was attempted. However, intraoperative air leakage from the staple line was identified, due to excessive tension of the suture applied to the bronchial stump.

    Therefore, after a second resection of the stump, additional wedge resection of the trachea was performed. This led to the natural alignment of the bronchial and tracheal stump, Facilitating easy anastomosis, without requiring operative field intubation.

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