Hirotoshi Kubokura

Video-assisted lobectomy in elderly lung cancer patients

OBJECTIVES We evaluated the pre-, intra- and postoperative outcome of video-assisted thoracic surgery lobectomy in elderly lung cancer patients to determine what factors may be disadvantageous. METHODS From June 1982 to May 2000, 707 patients underwent pulmonary resection for primary lung cancer. Of these, 87 patients with t1-2 peripheral lung cancer underwent lobectomy and postoperative pulmonary function tests and postoperative conditions at an average of 2.3 months postoperatively. Of these, 52 underwent video-assisted thoracic surgery lobectomy since 1994 and 35 lobectomy by standard thoracotomy. RESULTS Video-assisted thoracic surgery lobectomy offered advantages in blood loss, chest wall damage, and minimal performance deterioration status. The percent vital capacity, percent forced expiratory in 1 second, and percent maximum ventilatory volume were well preserved in patients who underwent video-assisted thoracic surgery lobectomy. Multivariate logistic regression analysis identified operation duration as an independent risk factor in morbidity and operative procedure as an independent risk factor in performance deterioration. In stage IA and IB patients, 3-year-survival was 92.9% and 5-year survival 53.8% in those undergoing lobectomy by standard thoracotomy and 84.2% at 3 years and 60.1% at 5-years in those undergoing video-assisted thoracic surgery lobectomy. CONCLUSION We thus consider video-assisted thoracic surgery lobectomy in this age group to be an effective procedure, but the long surgical duration is a risk factor in a poor clinical outcome.

Prediction of the Postoperative Pulmonary Function and Complication Rate in Elderly Patients

Abstract We analyzed the risk factors predisposing elderly patients to develop postoperative respiratory complications (PRCs) and investigated the possibility of predicting the postoperative pulmonary function and PRC rate. The postoperative pulmonary functions were predicted according to a simplified system, which we developed using plain chest roentgenograms from patients with primary lung cancer. Both univariate and multivariate analyses of PRCs were performed in 39 elderly patients with lung cancer from July 1982 to March 1991 (the early period). Based on the results obtained, the permissible extent of lung resection to achieve a predicted postoperative % forced expiratory volume in 1 s (ppo%FEV1.0) and a predicted postoperative % vital capacity (ppo%VC) of more than 55% was selected as the basic criteria for undergoing such an operation after April 1991 (the recent period). A ppo%FEV1.0 and/or ppo%VC of 55% or less was the most significant risk factor for developing PRCs. The PRC rate decreased from 33.3% to 9.8% (P = 0.0251) and the operative mortality rate decreased from 10.3% to 0%. The survival rates for stage I, II, and III cases were not significantly different between the early and recent periods. Decisions made on the operability and the permissible extent of lung resection based on our system using plain chest roentgenograms therefore appeared to reduce the PRC rate and operative mortality rate in elderly patients.

Thoracoscopic Enucleation of a Submucosal Bronchogenic Cyst of the Esophagus : Report of Two Cases

Thoracoscopic enucleation of a bronchogenic cyst of the esophagus was successfully performed in two cases. The first patient was a 26-year-old female complaining of dysphagia and retrosternal discomfort. The second patient was a 56-year-old female complaining of retrosternal discomfort. A close examination revealed a cystic lesion compressing the esophagus in both cases. Three trocars were employed under general anesthesia. Thoracoscopy offering excellent visualization allowed us to perform a precise anatomical dissection between the muscle layer and the mucosa. Both patients recovered uneventfully and the symptoms disappeared postoperatively. Thoracoscopic surgery is thus considered to be beneficial for the treatment of a benign esophageal tumor because of the small chest wall entry, which might positively contribute to a favorable postoperative course.

Lymphoepithelioma-like carcinoma of the lung: case in which the patient has been followed up for 7 years postoperatively.

Primary lymphoepithelioma-like carcinoma (LELC) of the lung is a very rare disease. There is very little long term follow-up data about this disease. A 60-year-old woman was found to have abnormalities according to a routine chest X-ray examination. She was admitted to our hospital in March 1998. Since a malignant tumor of the right lung was suspected, surgical resection was performed in April of the same year. Pathological diagnosis was LELC of the lung. Its pathological stage was T1N0M0 stage IA. It has been reported that this carcinoma is associated with Epstein-Barr virus (EBV) infection. However, the patients tumor cells were negative for EBV as examined with RNA in situ hybridization technique. She is alive and has been free from recurrence of the disease over 7 years postoperatively.

Characteristics of Multiple Primary Malignancies Associated with Lung Cancer by Gender

Background: There are gender differences in multiple primary malignancies associated with lung cancer (MPMLC) in terms of clinical characteristics. However, the importance of these differences in the management of patients has not been clarified. Objective: Differences in characteristics affected by gender were investigated in MPMLC to identify factors important for the proper management of the patients. Methods: Univariate and multivariate analyses were performed between 82 male and 34 female patients with MPMLC treated from August 1982 to March 2002. Results: In univariate analysis, the numbers of smokers or ex-smokers, smoking-related cancer and synchronous multiple primary malignancies were significantly increased in males with MPMLC (p < 0.0001, p < 0.05 and p < 0.05, respectively). In multivariate analysis, synchronous multiple primary malignancies and the number of smokers or ex-smokers were significantly different between male and female MPMLC. Gastric, lung and colon cancers were major constituents in male MPMLC, and 40.2% of all malignancies were smoking-related cancers. On the other hand, breast and uterine cancers were major constituents in female MPMLC, and only 20.6% of all MPMLC were smoking-related cancers. Conclusions: Male patients with MPMLC demonstrated significant smoking history and synchronous multiple primary malignancies, indicating the need for different approaches to properly manage and follow up male versus female MPMLC patients.

Factors Determining the Choice of Surgical Procedure in Elderly Patients with Non-Small Cell Lung Cancer

BACKGROUND In the elderly patients, optimal surgical treatment can be difficult to achieve, because of comorbidity. Therefore, we aimed to clarify the preferred surgical management in this patient group. METHODS A retrospective study was conducted between April 2008 and March 2015 that included patients with non-small cell lung cancer (NSCLC) aged ≥ 75 years. RESULTS We included 44 patients who underwent partial resection (n = 20) or lobectomy (n = 24). There were no significant differences between the two groups on most variables, except for some character. Survival analysis revealed a significant difference in overall survival (OS) between the two groups; however, no significant differences existed in the disease-free survival or in the OS for stage I disease. Postoperative complications led to poor prognoses. Cox regression analysis revealed statistical significance for the Brinkman Index, the ratio of the pulmonary artery diameter to the ascending aorta diameter (PA:A), and the alveolar-arterial oxygen gradient. Only the PA:A ratio remained significant after multivariate analysis, with a higher ratio associated with better survival. CONCLUSION In elderly patients with NSCLC, surgical resection should not be denied because of age alone. However, partial resection should be favored to lobectomy when possible.

Safe transection of aberrant arteries associated with pulmonary sequestrations

BackgroundVideo-assisted thoracoscopic surgery (VATS) lobectomy is increasingly used for pulmonary sequestration; however, there are few descriptions of safe handling of the aberrant artery. Here we clarify the safe handling of an aberrant artery using a clinical review and an experimental model.MethodsWe retrospectively reviewed the records of patients who underwent lobectomy for pulmonary sequestration with aberrant arteries at the Nippon Medical School between January 2008 and December 2010. This was supplemented by an experimental pressure test using vessels obtained from pigs.ResultsWe identified four patients with aberrant arteries that were successfully occluded via either stapling. In the experimental model, we divided pig vessels into small-diameter (S) and large-diameter (L) groups. The 1.0-mm-high staples were stronger in the S group than in the L group (p = 0.028). In the L group, the 2.0-mm-high staples were stronger than the 1.0-mm staples (p = 0.015). Leakage from the staple line was associated with a poorer B-shape of inserted staples.ConclusionsThe techniques described in this report are useful in successful minimally invasive transection of an aberrant artery (other than very thin vessels) when resecting a pulmonary sequestration by stapler only. A detailed investigation should be performed to determine the most appropriate stapler or cartridge.

Prognostic effect of incompletely lobulated fissures in p-Stage I non-small-cell lung cancer

OBJECTIVES Division of incompletely lobulated fissures is often performed during surgical resection of non-small-cell lung cancer (NSCLC); however, the effect of lobulation on tumour recurrence is unclear. This study aimed to assess the prognostic effect of lobulation in patients with NSCLC according to their preoperative and operative findings. METHODS A retrospective study of patients with p-stage I NSCLC who underwent lobectomy was conducted between April 2008 and April 2016. A receiver operating characteristic curve of the number of stapling cartridges was constructed to determine the optimal cut-off value. Patients who underwent division of the interlobar fissure using 2 or more stapling cartridges (H group) were compared with those who did not undergo division of the interlobar fissure or who underwent division of the interlobar fissure using only 1 cartridge (L group). RESULTS The study included 85 patients, and of these patients, 46 were included in the L group and 39 in the H group. Survival analysis showed better disease-specific survival (P = 0.0135) and disease-free survival (P = 0.0412) in the L group. Cox regression analysis showed better disease-specific survival in patients who underwent division of the interlobar fissure with few stapler cartridges than in those who underwent division with more stapler cartridges (P = 0.021). CONCLUSIONS The extent and status of incompletely lobulated fissures are significant risk factors for disease-specific survival in patients with resected p-stage I NSCLC.

Communication Site Ligation and Polyglycolic Acid Sheet Use for the Treatment of Hydrothorax in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Introduction: Hydrothorax due to pleuroperitoneal communication (PPC) can occur in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). We report our experiences of the safety and efficacy of the treatment of four patients with a novel video- assisted thoracoscopy method. Methods: Single-port video-assisted thoracoscopic surgery (VATS) was performed with a mini-thoracotomy of 5 cm in length. The PPC site was identified on the diaphragm and ligated using an endoscopic loop. The diaphragm was then covered using a polyglycolic acid (PGA) sheet, over which adhesive chemicals (OK432 and tetracycline) were sprayed. Results: We assessed the efficacy of our approach in four patients (one female and three males) aged 42–74 years (mean: 62.0 years). The hydrothoraxes were right sided in all the patients. The mean operation and postoperative drainage times were 92.5 min and 3.0 days, respectively. The hydrothoraxes did not recur in any patient during follow-up periods of 8–46 months. Conclusion: Our suture- and staple-free technique is not only easy to perform but also appears to be safe and effective for the management of hydrothorax in patients receiving CAPD. Larger scale studies are now indicated.

Mediastinal Neurofibroma Originating from the Pulmonary Branch of the Right Vagus Nerve in a Patient without von Recklinghausen Disease

Intrathoracic neurofibromas originating from the vagus nerve in patients without von Recklinghausen disease is rare and poses a problem in etiological diagnosis. Surgical resection is usually necessary for precise diagnosis of such tumors. We report the first case of a neurofibroma originating from the right pulmonary branch of the vagus nerve in a 34-year-old male without von Recklinghausen disease. The diagnosis was suggested by the radiological features and was confirmed histologically after resection.