Purpose: To minimize wound complications on chest tube removal, we changed the wound closure method following pneumothorax surgery. The new method is summarized as follows: (1) longitudinal direction on skin incision and (2) horizontal mattress suture with absorbable materials at the end of surgery and closure on chest drain removal. Method: We analyzed surgical cases from April 2010 to December 2018. We enrolled 130 male and 24 female patients, with an average age of 40.5 years, in this study for the time period from April 2010 to December 2018. Results: Wound complications developed in 19 cases (12.3%). Univariate analysis showed that patients with a body mass index of more than 19 (p=0.038) and the new method (p=0.003) showed significantly reduced wound complications. Multivariate analysis showed that the only significant factor was the new method (Hazard ratio: 0.135, 95% CI: 0.029-0.611, p=0.009). Wound complications caused by the chest drain decreased from 17 (18.9%) to 2 (3.1%) cases after changing to the new method. Conclusions: The new method was simple, and based on the findings, was useful for reducing wound complications after chest tube removal.
Background. Simple aspiration therapy is recommended for the initial treatment of pneumothorax, and it is important to identify the presence of pulmonary fistula in such cases for optimal treatment outcomes. This study aimed to identify the presence of and risk factors associated with pulmonary fistula in patients with pneumothorax through machine learning using a predictive model called a decision tree classifier. Methods. We retrospectively identified 55 patients who underwent simple aspiration for pneumothorax at our hospital from July 2015 to September 2018, and machine learning was used to analyze the risk factors associated with simple aspiration therapy and to predict the presence of pulmonary fistula in 11 of the patients using the decision tree classifier. Results. Based on our study, we found that the overall prevalence of pulmonary fistula was 61.8% (34 of 55 cases), and univariate analysis revealed that the collapsed area ratio before aspiration and the aspiration volume were significant risk factors correlated with pulmonary fistula (p=0.02 and 0.01, respectively). The prediction accuracy of the test data was 81.8% (9 of 11). Conclusions. Our findings in this study may help identify pulmonary fistula in patients with pneumothorax through machine learning using the decision tree classifier.
Adolescent primary spontaneous pneumothorax (PSP) occurs with greater frequency in tall and thin patients. We investigated chest CT scans and compared the CT number of adolescent PSP patients with that of healthy adolescent individuals to investigate the hypothesis that adolescent PSP occurs due to pulmonary-thoracic disproportion. All male patients between the ages of 15 and 25 years undergoing chest CT scans at Hamamatsu Medical Center from January 2017 through January 2019 were enrolled in this study. Their chest CT scans were extracted and analyzed retrospectively. They were divided into 105 healthy individuals and 35 pneumothorax patients. The following parameters were measured for each individual bilaterally: intrathoracic volume (mL) and mean CT number (HU) of the parenchymal field. The mean CT number was significantly lower in pneumothorax patients than healthy individuals (Right: −846.8/−819.9; p=0.005, Left: −843.1/−812.1; p=0.002, respectively), and there was no significant difference in the intrathoracic volume (Right: 2353.2/2191.3; p=0.23, Left: 2242.5/1942.7; p=0.13, respectively). The CT number and intrathoracic volume showed a significant negative correlation in each group. These facts reveal that the alveolar size of adolescent pneumothorax patients is larger than that of healthy individuals. This may be caused by pulmonary-thoracic disproportion and attributable to the occurrence of PSP. Thus, we should aim to conserve normal parenchyma as much as possible during bullectomy, so as not to worsen the disproportion of adolescent pneumothorax patients.
We have performed uniportal VATS (U-VATS) since its introduction in November 2018. The aim of this study was to analyze the short-term results of U-VATS compared with multiport VATS (M-VATS). Forty-one patients with primary lung cancer underwent U-VATS anatomical pulmonary resections between November 2018 and April 2019, and 33 patients underwent M-VATS anatomical pulmonary resections between May and October 2018. The two groups were similar in terms of clinicopathological features. U-VATS led to a significantly shorter operative time (126 vs. 152 min, respectively) and less postoperative pain (NRS 0 vs. 2, respectively) than with the M-VATS approach. There was no significant difference in blood loss, drainage duration, complications, or number of dissected lymph nodes on comparing U-VATS vs. M-VATS. U-VATS is a feasible and safe approach, and may be a less invasiveness alternative to M-VATS because of its effectiveness to reduce the operative time and postoperative pain.
The approach to bullae in azygoesophageal recess (AER) is difficult. We reviewed surgically treated cases of bullae in AER. Between January 2005 and December 2018, 342 patients received the operation for pneumothorax in our hospital, and bullae in AER were found in 14 (4.1%). All patients were male. The mean age of patients was significantly higher and they had emphysema as a complication more frequently than in the others. We could recognize that the bulla was responsible for pneumothorax in only 8 patients. In the operation, we could not easily recognize the bullae in 4 patients (28.6%). The resection of bullae was performed in 12 patients, bulla ligation was done in 1, and bulla ablation was done in 1. The site of stapler insertion was the lower inter-costal space (ICS) in 8 patients. Reinforcing sheets attatched to staplers were used in 6 patients. The median operative time was 70.5 min (33-120), and bleeding was 5 mL (5-10 mL). The median drainage period was 1 day (1-4 days), and length of hospital stay was 7 days (4-26 days). The approach to bullae in AER is difficult for the following reasons: 1: The bulla is in the deepest part of the thoracic cavity. 2: Poor mobilization. 3: Near the vertebra. 4: Coexisting emphysema. In our patients, the insertion of a stapler with a reinforcing sheet from the lower ICS was useful.
A 38-year-old man presented to our hospital with chest pain and abnormality detected in a chest radiograph. Computed tomography (CT) of the chest revealed a 16×13×9-cm mass shadow in the anterior mediastinum. The tumor abutted the left brachiocephalic vein and superior vena cava. The patient was diagnosed with a yolk sac tumor by CT-guided core needle biopsy. Preoperative chemotherapy consisted of bleomycin, etoposide, and platinum (BEP), which was later discontinued because of drug-induced lung injury. He underwent tumor resection, in which his first right upper and middle lung were partially resected because of adhesion to the tumor, and the phrenic nerve was subsequently separated from the tumor by video-assisted thoracic surgery (VATS) in the left lateral decubitus position. After converting to the supine position, the tumor was resected by median sternotomy. The pericardium and left brachiocephalic vein were resected because of suspicious invasion, and he could undergo complete resection of the tumor. His postoperative course was uneventful. We encountered a case of a yolk sac tumor completely resected after partial resection of the lung and preservation of the phrenic nerve by VATS.
Adrenocortical carcinoma is a rare disease associated with a poor prognosis because it is often found in advanced stages. A female patient in her late 60s presented with an abnormality based on a chest image acquired during a medical examination, and bilateral multiple pulmonary nodules and an adrenal mass in the left adrenal gland were noted. Left adrenalectomy was performed, resulting in the diagnosis of adrenocortical carcinoma. In addition, bilateral partial resection of the lungs for the bilateral multiple pulmonary nodules led to the diagnosis of lung metastases. Although mitotane was administered as postoperative chemotherapy, new nodules were observed bilaterally in the lungs. Four additional bilateral partial resections were performed; the nodules were identified as metastases of adrenocortical carcinoma. She remains alive 5 years and 10 months after the initial adrenalectomy, suggesting that long-term survival could be achieved in those with adrenocortical carcinoma with bilateral multiple pulmonary metastases by proactively removing metastatic lesions in the lungs in addition to the primary lesion.
Pulmonary dirofilariasis is barely distinguishable from lung cancer, metastatic lung tumors, and other benign tumors. We herein report a case of pulmonary dirofilariasis. A 52-year-old male was referred to our hospital for detailed examination and treatment of a left lung tumor.
Chest CT revealed a 28×22-mm nodule with a clear border at the outer edge of the lower left lobe. The tumor had to be differentiated from malignant tumors, such as a metastatic tumor. For a definite diagnosis, the left lung was partially resected under a thoracoscope.
Histopathologically, the patient was diagnosed with obsolete pulmonary infarction due to parasite embolism using the resected specimen. Pulmonary dirofilariasis spontaneously remits. However, it should be differentiated from malignant tumors. Therefore, aggressive surgical resection is recommended.
Since first being reported in 1991, methotrexate-related lymphoproliferative disease (MTX-LPD) has been extensively investigated and established as an independent disease entity. This disease is rarely associated with lung lesions and even more rarely with solitary lung lesions. Here, we report the case of a 68-year-old woman treated with methotrexate (MTX) for rheumatoid arthritis who was referred to our hospital with suspected primary lung cancer in the left lower lobe measuring 27 mm. Bronchoscopy failed to establish a definitive diagnosis, but the lesion was suspected to be lung malignancy based on findings from different imaging studies and was then removed by video-assisted thoracoscopic left lower lobectomy. The resected specimen was pathologically diagnosed as diffuse large B-cell lymphoma. The patient was diagnosed with MTX-LPD because EBV-encoded small RNA in situ hybridization (EBER ISH) added from patient information was positive. MTX-LPD can be ameliorated or resolved by the discontinuation of MTX. For patients who develop a lung tumor during MTX treatment, the treatment plan should be decided in consideration of MTX-LPD as a differential diagnosis.
A 23-year-old man underwent thoracoscopic surgery for the relapse of left spontaneous pneumothorax. During the surgery, we found massive parietal subpleural emphysema spreading to the mediastinum. Chest computed tomography just after the thoracoscopic bullectomy with pleural covering showed subpleural emphysema in the left-side chest wall, but not in the right-side chest wall. Pneumomediastinum was scattered only at the operative site. On bronchoscopy under laryngeal-mask ventilation, there was no injury of the trachea or bronchi. He was doing well after surgery and discharged from our hospital without other complications. To our best knowledge, this is the first report of parietal subpleural emphysema that may have been caused by endobronchial suction before thoracotomy for thoracoscopic surgery.
Patients with neurofibromatosis type 1 may develop massive hemothorax due to blood vessel fragility. A 43-year-old woman with neurofibromatosis type 1 was emergently transferred to our hospital because of left back pain. On dynamic computed tomography and thoracic puncture, a massive left hemothorax was noted. Since the circulation of the patient was stable, transcatheteric arterial angiography was performed. An intercostal arterial aneurysm was pointed out and transcatheteric arterial embolization was performed for it. However, the intrathoracic bleeding was not controlled, and the patient entered a hemorrhagic shock state. Emergency thoracotomy was performed, and a wide range of intercostal arteries were ligated based on the findings of angiography. However, it was difficult to achieve hemostasis because the fragility of the patient's blood vessels. The coils embolized in the intercostal artery were easily exposed in the surgical field. Finally, bleeding was controlled by pressure hemostasis using various surgical dressings. In past reports, seventy-seven patients with neurofibromatosis type 1 developed massive hemothorax. A total of eighty-three episodes of hemothorax occurred, and the life-saving rate was 74.4%. If the circulation of a patient is stable, transcatheteric arterial embolization may be the first-choice treatment. However, patients with neurofibromatosis type 1 have fragile blood vessels, and there are some cases whereby it is difficult to stop bleeding with transcatheteric arterial embolization.
An 86-year-old man with a poor performance status underwent the removal of an asymptomatic thymoma by video-assisted thoracoscopic surgery via the left thoracic cavity. The histopathological diagnosis of the tumor was a type B2 thymoma (Masaoka typeII). Chest CT one year later revealed an enlarging, flattened nodule with a sharp margin on the left side of the left pulmonary trunk. This tumor was diagnosed as a multiple thymoma or recurrence. His performance status improved relative to that at time of the initial surgery, so we resected the thymoma with sorrounding thymic tissue via a median sternotomy. The histopathological diagnosis of the tumor was a type B3 thymoma (Masaoka typeI). The histological types of this and the previous tumor differed; therefore, we considered it to be of multiple origin. Thymothymectomy should be the procedure of choice for a thymoma to avoid the possibility of multiple thymomas.
We report a left middle and lower sleeve lobectomy for lung cancer in a patient with complete situs inversus. A 76-year-old man complaining of bloody sputum was suspected of having lung cancer following sputum cytology. After computed tomography and bronchoscopy, the patient was diagnosed with squamous carcinoma cT2aN2M0 stage IIIA, which occluded the left lower bronchus and invaded the truncus intermedius. Differential ventilation was facilitated by inserting an inverted left double lumen tube into the right main bronchus, because the right and left bronchi were inverted, and left middle and lower sleeve bilobectomy was planned. Posterolateral thoracotomy with thoracoscopy was performed. Intraoperative observations revealed a complete mirror image of the right thorax, which meant we had to pay more attention to the abnormal intrathoracic structures. However, once we had taken this anomaly into account, we were able to perform a bilobectomy without encountering any other difficulties. The operative time was 398 minutes, and blood loss was 438 mL without transfusion. In this case, the most important considerations were careful management during the operation due to the mirror image of the right thorax, and successful execution of the intubation method to enable bronchoplasty and bronchoscopic observation.
Hepatic hydrothorax is the retention of transudative pleural effusion in patients with liver cirrhosis. One of its etiologies is the continuous influx of ascites to the thoracic cavity through a fistula of the diaphragm. Here, we present a case of hepatic hydrothorax involving a patient in whom contrast-enhanced ultrasonography with the intraperitoneal injection of perflubutane revealed a right diaphragmatic fistula several days before surgical disclosure under videothoracoscopic surgery. We resected the fistula using a surgical stapler with polyglycolic acid felt. Hepatic hydrothorax showed no recurrence 3 months after the surgery. Contrast-enhanced ultrasonography is easily performed and may be useful to prove the existence and location of a fistula.
Here, we report two cases of pulmonary granuloma difficult to differentially diagnose from resection stump recurrence following segmentectomy for primary lung cancer. Case 1: A 65-year-old woman had undergone segmentectomy of the right S6 for primary lung cancer 10 years ago. CT revealed a new pulmonary nodule along the staple-line. During follow-up, the size of the nodule increased and we performed a right S2 segmentectomy. Pathologically, the nodule was diagnosed as a granuloma. Case 2: A 67-year-old man had undergone segmentectomy of the left S6 for primary lung cancer 6 years ago. CT revealed a new pulmonary nodule along the staple-line. During follow-up, the size of the nodule decreased and the results of bronchoscopy and CT-guided needle biopsy were negative for malignancy. Hence, we diagnosed it as a granuloma and continued to follow-up the patient. Pulmonary granuloma should be considered in the differential diagnosis of cases showing a nodule along the pulmonary staple-line of primary lung cancer surgery.
A male patient in his 70's was admitted to our department with a nodular shadow measuring 22 × 15 mm in the right upper lobe of the lung on chest CT. Bronchoscopy revealed a protruding lesion originating from the orifice of the right B2, and the tumor was diagnosed as lung adenocarcinoma by transbronchial biopsy. The tumor was staged as IA3, and right upper lobectomy was performed thoracoscopically. The microscopic findings showed a salivary gland-type tumor with features of malignancy, and it was finally diagnosed as carcinoma ex pleomorphic adenoma. Salivary gland-type pleomorphic adenomas originating from the trachea, bronchus, and lung are rare diseases. Most of these tumors have been reported to be benign, and tumors with malignant features are very rare, with only eighteen cases being reported in the Japanese literature so far.
We report a 71-year-old male who was referred to our department because of an abnormal chest shadow. Chest computed tomography (CT) revealed a tumor shadow with a diameter of 7.2 cm in the upper right lobe, for which bronchoscopy was performed. Based on the findings of transbronchial lung biopsy, the tumor was diagnosed as a non-small cell carcinoma (grade cT4aN0M0 stage IIIA). We performed upper right lobectomy and lymph node dissection (ND 2a-2) using video-assisted thoracic surgery. Pathological examination revealed a high-grade fetal lung adenocarcinoma (H-FLAC). The pathological stage was evaluated as T4aN0M0 stage IIIA. The patient was treated with adjuvant chemotherapy (cisplatin+pemetrexed) and discharged 8 days after the surgery. He is now alive with no evidence of recurrence 3 months after the surgery. H-FLAC is a very rare lung adenocarcinoma with very few reported cases in the literature.