Akinori Akashi

Non-Hodgkin's lymphoma of the pleural cavity developing from long-standing pyothorax

Malignant lymphomas developing in tissue affected by a long‐standing severe inflammatory process of nonautoimmune nature are presented. Two men and a woman aged 50, 58, and 73 years, were admitted after 22 to 30 year histories of pyothorax resulting from artificial pneumothorax for the treatment of pulmonary tuberculosis or tuberculous pleuritis. The diagnoses at admission were chronic pyothorax associated with a lung mass. Microscopically, tumors diffusely or locally proliferated with thickened pleura were present. A histologic examination showed that all the tumors were diffuse non‐Hodgkins lymphomas (NHL) of immunoblastic type with (one case) or without (two cases) plasmacytoid differentiation. Immunohistochemistry on paraffin sections revealed restricted expression of immunoglobulin light chains in one case showing plasmacytoid differentiation. A review of the literature showed that malignant lymphomas of this type have been reported exclusively from Japan but never from Western countries.

Prediction of Postoperative Respiratory Failure in Patients Undergoing Lung Resection for Lung Cancer

To evaluate the correlation between predicted postoperative lung function and postoperative respiratory morbidity, 156 patients with lung cancer who underwent resection were classified into four groups based on the degree of postoperative problems: Group 1--no problems (116 patients); Group 2--retention of sputum or atelectasis requiring bronchofiberscopy two or more times (17 patients); Group 3--tracheostomy or mechanical ventilation for more than 2 days or both (14 patients); and Group 4--postoperative death (9 patients). The mean ages of Groups 2, 3, and 4 were significantly (p less than 0.05) higher than the mean age of Group 1. The predicted postoperative lung function (F) was assessed by the formula F = [1-(b-n)/(42-n)] x f, where f is the preoperative vital capacity or forced expiratory volume in one second, b is the number of subsegments of the resected lung lobe, and n is the number of subsegments obstructed by the tumor, which was assessed by the findings on the chest tomogram, on the bronchogram, at bronchofiberscopy, or a combination of these. The total number of subsegments was assumed to be 42. The predicted postoperative % FEV1 was 65.1 +/- 19.3% in Group 1,55.3 +/- 10.6% in Group 2,37.6 +/- 12.1% in Group 3, and 42.3 +/- 18.4% in Group 4. It was significantly (p less than 0.05) different between all the groups except between Groups 3 and 4. All 10 patients with a predicted postoperative % FEV1 of less than 30% were in Groups 3 and 4. We conclude that special attention to postoperative management is needed for patients whose predicted postoperative %FEV1 is lower than 30%.

Complete versus assisted thoracoscopic approach: a prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques

BackgroundVideo-assisted thoracoscopic surgery (VATS) lobectomy does not represent a unified approach, but rather a spectrum of operative techniques ranging from a complete endoscopic thoracotomy to a minithoracotomy. A prospective randomized trial was conducted to compare the differences in these techniques and their results to determine the best of VATS lobectomy for lung cancer.MethodsThis study randomized 39 consecutive patients with clinical stage I lung cancer to undergo either a complete (C-VATS, n = 20) or an assisted (A-VATS, n = 19) VATS approach for pulmonary lobectomy.ResultsThe operating time was longer (p = 0.002) and blood loss was less (p = 0.004) with C-VATS than with A-VATS. Although there was no significant difference in analgesic use or duration of thoracic drainage between the groups, a shorter hospitalization was observed after C-VATS. Serum peak levels of postoperative inflammatory markers (white blood cell count, C-reactive protein, creatine phosphokinase) were lower with C-VATS and an earlier return to normalization than with A-VATS.ConclusionVarious differences exist among the VATS lobectomy techniques, and complete VATS lobectomy as a purely endoscopic surgery may be technically feasible and a satisfactory alternative to the conventional procedure for stage I lung cancer.

A new tissue-sealing technique using the ligasure system for nonanatomical pulmonary resection: preliminary results of sutureless and stapleless thoracoscopic surgery

PURPOSE We present our initial evaluation of a new surgical technique of lung tissue sealing for nonanatomical pulmonary resection composed of sutureless and stapleless thoracoscopic surgery. DESCRIPTION Twelve patients who required therapeutic thoracoscopic pulmonary resection from April 2001 to April 2002 were recruited for this study. Resection of lung parenchyma was performed with an ultrasound-driven scalpel, and the cut end was sealed using LigaSure, a new bipolar system. Measurement of the cut surface after resection during the surgery and assessment of LigaSure sealing strength was performed. EVALUATION There were no deaths or major intraoperative complications. The mean operation time was 65 minutes, and mean hemorrhage volume was 46 mL. Average chest drain duration was 3 days, and average hospital stay was 6 days. One patient with a giant bulla and cut surface diameter of 50 mm experienced persistent air leak for 1 week. Late complications did not occur over the 8-month follow-up period. CONCLUSIONS Video-assisted thoracoscopic surgery pulmonary resection using LigaSure instead of staplers appears technically feasible and easy, and produces satisfactory preliminary results. Although further studies are required to confirm the sealing strength and reliability of LigaSure, this technique should be considered for use in nonanatomical pulmonary resections.

Preoperative assessment of the pulmonary artery by three-dimensional computed tomography before video-assisted thoracic surgery lobectomy

OBJECTIVE Our aim was to evaluate the efficacy of 3D imaging using multidetector row helical computed tomography (MDCT) in the preoperative assessment of the branching pattern of pulmonary artery (PA) before complete video-assisted thoracoscopic lobectomy (complete VATS lobectomy) for lung cancer. METHODS Forty-nine consecutive patients with clinical stage I lung cancer scheduled for complete VATS lobectomy were evaluated about branching pattern of PA on 16-channel MDCT. Intraoperative finding of the PA branching pattern were compared with the 3D-CT angiography images obtained using MDCT. RESULTS According to the intraoperative findings, 95.2% (139 of 146) of PA branches were precisely identified on preoperative 3D-CT angiography. All of the seven undetected branches were within 2mm in diameter. There was not a case that needed conversion to open thoracotomy because of intraoperative bleeding. CONCLUSION A 3D-CT angiography using MDCT clearly revealed individual anatomies of pulmonary artery and could play an important role in safely facilitating complete VATS lobectomy procedure. However, we were unable to detect several thin branches with this technique. So, more care should be taken to avoid bleeding from these small vessels.

Ipsilateral recurrence frequency after video-assisted thoracoscopic surgery for primary spontaneous pneumothorax

OBJECTIVE We retrospectively evaluated the results of video-assisted thoracoscopic surgery for primary spontaneous pneumothorax and recurrence. METHODS A series of 424 patients with primary spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery-289 with an ipsilateral recurrent episode, 88 with persistent air leakage for 7 days or longer, 34 with a contralateral episode, 9 with hemopneumothorax, and 4 with tension pneumothorax. The commonest management was stapling of an identified bleb, undertaken in 375 patients (88.4%). Pleural abrasion was conducted in 250 (59.0%), but the abraded area was one-third or less of the thoracic cavity in 187 (74.8%). RESULTS No operative deaths occurred. Revisional thoracotomy was required in 1 patient with postoperative bleeding and another with incomplete postoperative lung reexpansion; 26 had prolonged air leakage, but none required revisional thoracotomy. During a mean follow-up of 31.4 months, ipsilateral pneumothorax recurred in 40 patients (9.4%), with 26 (65.0%) having recurrence within 1 year postoperatively. A video-assisted thoracoscopic surgery was conducted again in 8, and thoracotomy in 14. CONCLUSIONS The ipsilateral recurrence of primary spontaneous pneumothorax after video-assisted thoracoscopic surgery was high at 9.4%. If video-assisted thoracoscopic surgery is to be considered as a treatment for spontaneous pneumothorax, we must therefore reduce postoperative ipsilateral recurrence by training practitioners not to overlook blebs during the procedure and/or consider widening the area of pleurodesis.

ATTENUATION OF WARM ISCHEMIC INJURY OF RAT LUNG BY INFLATION WITH ROOM AIR-ASSESSMENT OF CELLULAR COMPONENTS AND THE SURFACTANT IN THE BRONCHOALVEOLAR LAVAGE FLUID IN RELATION TO CHANGES IN CELLULAR ADENOSINE TRIPHOSPHATE

Studies were made on the effects in rat lungs of aerobic and anaerobic conditions on the intracellular levels of adenosine triphosphate and its related metabolites, the releases of intracellular enzymes, and the secretion of pulmonary surfactant. After warm ischemia for 120 min, the ATP content of lungs inflated with air was significantly higher (8.0±1.2 μmol/g dry weight) than those of deflated lungs and lungs inflated with nitrogen (0.8±0.7 μmol/g dry weight and 2.0±0.7 μmol/g dry weight, respectively; P<0.001). The amounts of intracellular enzymes, such as lactate dehydrogenase, cyto-solic and mitochondrial aspartate aminotransferase, and protein in the bronchoalveolar lavage fluid (BALF) of air-inflated lungs were significantly less than those in BALFs of deflated and nitrogen-inflated lungs (P<0.001). The BALF-contents of dipalmitoyl phosphatidylcholine (DPPC), the main component of alveolar surfactant of aerobic and anaerobic ischemic lung were, however, similar. During 120-min warm ischemia after lavage, air-inflated lungs secreted significantly more DPPC into the alveolar space than nitrogen-inflated lungs did (P<0.001). We conclude that cell membranes in the lungs are damaged under anaerobic conditions, but that inflation of ischemic lungs with air is effective for protecting them from cell injury and for maintaining the intracellular level of ATP and the ability of the cells to secrete pulmonary surfactant.

Laparoscopic reconstruction of vagina using sigmoid autograft

Abstract. With the advent of advanced laparoscopic techniques in surgery, new applications have been found, which have expanded the role of laparoscopy in the gynecological field. The aim of this paper is to introduce our laparoscopic technique of taking a sigmoid colon autograft for colpopoiesis in a patient with congenital agenesis of the vagina. This technique is less invasive and is easy to perform, and it may be the best choice of operation in respect to the naturalness and the permanency of the vagina that results. The success of this laparoscopic technique of taking a sigmoid autograft for colpopoiesis suggests diverse possible applications in the future.

Stage III thymoma: Relationship of local invasion to recurrence

OBJECTIVES We investigated the relationships of recurrence site with the involved organ and cell type in patients with Masaoka stage III thymomas. METHODS Records of 84 patients who underwent a complete resection of stage III thymomas between 1957 and 2005 were reviewed and then divided according to involved organ. The number of patients with cell types determined according to World Health Organization criteria were 2, 5, 7, 37, and 7 for types A, AB, B1, B2, and B3, respectively, whereas type was not determined in 25 patients. RESULTS Lung invasion occurred in 58 patients, followed by invasion of the pericardium in 47 and invasion of the great vessels in 23. Recurrence occurred in 23 patients, which included 12 with pleural dissemination and 8 with distant metastasis, mostly in the lung. Lung invasion was seen in 8 of the 12 patients with pleural recurrence, whereas vascular invasion was seen in 6 of the 8 patients with distant metastasis. Local recurrence was less common. Disease-free survival after 10 years for all subjects was 74.2%, whereas it was lower for those with vascular invasion (46.1%) compared with those without invasion (87.1%, P < .05). Of the 23 patients with recurrence, World Health Organization cell types B1, B2, and B3 were seen in 2, 11, and 3 cases, respectively, whereas type was not determined in 7 patients. CONCLUSIONS The pleural cavity and lung are common sites of recurrence of Masaoka stage III thymomas. It is important to establish an inclusive therapeutic strategy that considers the relationships of involved organs and sites of recurrence in these patients.

Clinicopathological investigation of 20 cases of primary tracheal cancer

OBJECTIVE Primary tracheal cancer is considered to be relatively rare. Its epidemiology, therapeutic strategy and prognosis are not well understood. METHODS We retrospectively investigated the clinicopathological aspects of 20 patients with primary tracheal cancer. RESULTS Patients included 11 men and nine women with a mean age of 57.3 years. There were 12 squamous cell carcinomas and eight adenoid cystic carcinomas. Four patients received only palliative therapy. Sixteen patients underwent surgical treatment such as segmental tracheal, laryngotracheal, or carinal resection. One patient with squamous cell carcinoma died of postoperative mediastinitis. Although resected specimens from five patients had tumor positive margins, only one of those patients died after local recurrence and only three patients had postoperative treatment. The 5-year survival rate for patients who underwent surgery was 72.3%. CONCLUSIONS Surgical treatment is the first choice therapeutic modality for primary tracheal cancer in consideration of its prognosis. While performing the operation, safety of the anastomosis should take precedence over completeness of resection.