Atsushi Suga

Importance of preoperative assessment of pulmonary venous anomaly for safe video-assisted lobectomy

During the treatment of 86 patients with video-assisted thoracoscopic surgery (VATS) anatomical resection (include segmentectomy) within the last two years, we have encountered five patients (5.8%) with anomalous venous returns. Anomalous returns included: 1) common trunk of the left pulmonary vein; 2) right middle pulmonary vein (V4) draining into the inferior pulmonary vein (IPV); 3) left lingular vein (V4+5) draining into the IPV; 4) right posterior pulmonary vein (V2) draining directly into the left atrium; and 5) left upper lobe vein draining into the left innominate vein. If a surgeon were to perform VATS lobectomy without paying attention to these anomalies according to the affected lobe, serious surgical complications might result. Multi-detector row angiography is useful for recognizing such anomalies before surgery and allow safe VATS lobectomy.

Surgical risk of vessel injury: an unusual anatomical variant of the right medial basal segmental pulmonary artery

Video-assisted right basal segmentectomy was successfully performed on a 72-year-old man with an anomalous pulmonary artery. Multidetector row angiography showed the A7 branch arising from the right main pulmonary artery proximal to the branches of the superior trunks, lying under the middle bronchus, and reaching segment S7. Metastatic tumor (diameter 7 mm) was identified in the periphery of this vessel. This anomaly appears to be rare but seems also to be easily overlooked and could cause serious vessel injury even for video-assisted thoracoscopic right lower lobectomy.

Lung metastasis of transitional cell cancer of the urothelium, with fungus ball‑like shadows closely resembling aspergilloma: A case report and review of the literature

The present study reports the case of a 67-year-old female patient who was initially diagnosed with pulmonary aspergilloma. This diagnosis was based on a chest computed tomography (CT) scan showing a cavitary lesion of 3.5 cm in diameter, with fungus ball-like shadows inside, and an air crescent sign in the right upper lung. At 63 years old, the patient was treated for transitional cell cancer of the urothelium (non-invasive, pT1N0M0) by total cystectomy, ileal conduit diversion and urostomy. For 4 years post-operatively, the patient was healthy and had no clinical symptoms, and the air crescent sign was not identified by chest CT until the patient had reached 67 years of age. However, a final diagnosis of lung metastasis of transitional cell cancer of the urothelium was histopathologically identified subsequent to video-assisted thoracic surgery. Although it is rare that transitional cell cancer moves to the lung and makes a cavitary lesion, a differential diagnosis of cancer is necessary, even when examining infected patients with air crescent signs that are characteristic of aspergilloma. The physician must be mindful of metastatic pulmonary tumors that closely resemble aspergillomas, not only in infectious diseases, but also in oncological practice. Primary surgical removal should be considered.

Planned pulmonary resection for metastatic pulmonary tumor with video-assisted thoracoscopic surgery using multidetector row angiography

PurposeFor video-assisted thoracic surgery (VATS) on metastatic pulmonary tumors, wedge resection using an endo-stapler is the standard procedure in many institutions. However, this procedure can miss lesions or compromise surgical margins, particularly with small, deep lesions. The planned pulmonary resection in this study is a surgical method for pulmonary resection aimed at a previously assigned pulmonary area. We determine the pulmonary area for anatomical or nonanatomical resection before surgery on the basis of tumor location in relation to the anatomical distribution of pulmonary vessels.MethodsMultidetector row computed tomography (MDCT) angiography contributed to preoperative planning for 12 patients with single (n = 11) or dual (n = 1) pulmonary metastases (diameter <3 cm) in the same lobe.ResultsPlanned surgical procedures were nonanatomical stapling resection (partial resection) (n = 6) or segmentectomy (n = 6). One patient required conversion to lobectomy from segmentectomy, but all patients underwent curative pulmonary resection.ConclusionPreoperative planning of VATS pulmonary resection using MDCT angiography allows reliable pulmonary resection for metastatic tumors.

A case of an elderly patient treated for descending necrotizing mediastinitis

We report a case of descending necrotizing mediastinitis (DNM). DNM is a serious infection, and preventing death requires early diagnosis and draining of the infection focus. An 84-year-old man was admitted to our hospital complaining of a swollen neck and pain when swallowing. He had had a tooth extracted at a neighboring dental clinic 2 days previously. Cervicothoracic computed tomography (CT) scan demonstrated gas bubbles and unencapsulated abscesses in the cervical spaces and anterosuperior and posterior mediastinum, extending below the carina. He was diagnosed as DNM caused by odontogenic infection. Cervical drainage was performed, in addition to mediastinal drainage using video-assisted thoracic surgery (VATS). Complications were sepsis, disseminated intravascular coagulation (DIC), and heart failure after surgery, but he recovered following intensive care. This was a lifesaving case of DNM for which mediastinal drainage was performed with VATS.

A ruptured mature teratoma in which follow-up computed tomography observation at short intervals was useful for a definitive diagnosis.

Rupture of mature mediastinal teratomas occasionally occurs, necessitating prompt surgical treatment. However, the clinical presentation of a ruptured teratoma can resemble that of pneumonia and/or pleuritis. We report a case of mediastinal teratoma rupture, in which follow-up computed tomography (CT) a short-interval after the first CT was useful for definitive diagnosis. The patient was a 29-year-old male who presented with chest pain. CT-revealed a fat-containing cystic tumor in the left anterior mediastinum and a small pleural effusion with consolidation of the lower lobe of the left lung. The diagnoses of pneumonia, pleuritis and teratoma rupture were considered, and antibiotic therapy was initiated to begin with. Eighteen hours later, a repeat CT-revealed an increase in the soft tissue area of the chest wall adjacent to the tumor, which led to the definitive diagnosis of ruptured teratoma, and immediate resection was performed. The histological diagnosis was a mature teratoma, and rupture was confirmed by the high lipase level in the pleural fluid. The patients postoperative course was uneventful.

L-shaped mini-sternotomy combined with videoscopic approach for thymoma with invasion of major veins

Abstract It might be possible to remove thymic tumors with minimal invasion of the left brachiocephalic vein (BCV) using an advanced videoscopic technique; simple resection of this vessel can be achieved via such an approach. However, tumor invasion of the superior vena cava or right BCV requires angioplasty or reconstruction, both of which are difficult to perform in videoscopic procedures. We report a case of invasive thymoma with localized invasion of the great vessels at the junction of the left BCV and superior vena cava. An L-shaped mini-sternotomy combined with a videoscopic approach allowed thymectomy with safe vesselplasty of the involved vessels.