Kazuto Ohtaka

Thrombosis in the Pulmonary Vein Stump After Left Upper Lobectomy as a Possible Cause of Cerebral Infarction

BACKGROUND Thrombus in the stump of the pulmonary vein (PV) is not a well-known complication after lung resection, and it has the potential to cause embolism to vital organs. To clarify the frequency, risk factors, and cause of this complication, a retrospective clinical study of patients who underwent lobectomy was performed. METHODS The study evaluated 193 patients with primary lung cancer who underwent lobectomy from 2005 to 2011 and contrast-enhanced chest computed tomography (CT) within 2 years after lobectomy. Contrast-enhanced CT was retrospectively interpreted to check for thrombus in the PV stump. RESULTS The operative procedures were 65 right upper lobectomies, 14 right middle lobectomies, 40 right lower lobectomies, 52 left upper lobectomies (LUL), and 22 left lower lobectomies. Thrombus developed in the PV stump in 7 of the 193 patients (3.6%) after lobectomy. All patients with thrombus had undergone LUL, and 13.5% of those who had undergone LUL developed thrombus. Univariate analyses revealed that LUL and operation time were significant risk factors and that adjuvant chemotherapy was marginally significant. It appears that thrombus may be attributable to the length of the PV stump. Measurement of the length of the PV stump using 3-dimensional CT images of the PV revealed that the stump of the left superior PV was longer than the others. CONCLUSIONS Thrombus in the PV stump occurred in 13.5% of patients after LUL. These findings suggest that contrast-enhanced CT should be recommended for patients after LUL to help identify those with a high risk for thromboembolism.

Pulmonary vein thrombosis after video-assisted thoracoscopic left upper lobectomy.

From the Division of Cancer Medicine, Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Sapporo, Japan. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication July 11, 2011; revisions received Aug 8, 2011; accepted for publication Sept 21, 2011; available ahead of print Oct 19, 2011. Address for reprints: Yasuhiro Hida, MD, PhD, Department of Surgical Oncology, Division of Cancer Medicine, Hokkaido University Graduate School of Medicine, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan (E-mail: yhida@med. hokudai.ac.jp). J Thorac Cardiovasc Surg 2012;143:e3-5 0022-5223/

Left upper lobectomy can be a risk factor for thrombosis in the pulmonary vein stump.

36.00 Copyright 2012 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2011.09.025

Blood stasis may cause thrombosis in the left superior pulmonary vein stump after left upper lobectomy

BackgroundThrombosis in the left upper pulmonary vein stump after left upper lobectomy is a very rare but important complication because it occurs in the systemic circulation system. We previously made the first ever report on the frequency and risk factors of thrombosis in the pulmonary vein stump after lobectomy. In this study, we conducted an investigation in a different hospital to determine whether this was a common complication.MethodsFrom 2008 to 2012, 151 patients who underwent lobectomy and following enhanced CT within 2 years after the operation were studied. Postoperative contrast-enhanced CT imaging was retrospectively checked.ResultsWe found thrombosis in the pulmonary vein stump in 5 of the 151 patients (3.3%). All 5 patients underwent left upper lobectomy (17.9% of the patients who underwent left upper lobectomy). These 5 patients did not have infarction of any vital organ. The thrombus was disappeared several months later on contrast-enhanced CT in 3 patients and followed in 2 patients. On univariate analysis, there was a significant difference only in the operative procedure (p < 0.001).ConclusionsThrombosis in the pulmonary vein stump occurred with high frequency in patients who underwent left upper lobectomy. Because the frequency of thrombosis in this study was the same as in our previous report, this might be a common complication.

Video-assisted thoracoscopic surgery using mobile computed tomography: New method for locating of small lung nodules

BackgroundWe previously reported that arterial infarction of vital organs after lobectomy might occur only after left upper lobectomy and be caused by thrombosis in the left superior pulmonary vein stump. We hypothesized that changes in blood flow, such as blood stasis and disturbed stagnant flow, in the left superior pulmonary vein stump cause thrombosis, and this was evaluated by intraoperative ultrasonography.MethodsFrom July 2013 to April 2014, 24 patients underwent lobectomy in the Steel Memorial Muroran Hospital. During the procedure, an ultrasound probe was placed at the pulmonary vein stump and the velocity in the stump was recorded with pulse Doppler mode. The peak velocity and the presence of spontaneous echo contrast in the stump were evaluated. After the operation, the patients underwent contrast-enhanced CT within 3 months.ResultsThe operative procedures were seven left upper lobectomies, four left lower lobectomies, seven right upper lobectomies, and six right lower lobectomies. Blood flow was significantly slower in the left superior pulmonary vein stump than in the right pulmonary vein stumps. However, that was not significantly slower than that in the left inferior pulmonary vein stump. Spontaneous echo contrast in the pulmonary vein stump was seen in three patients who underwent left upper lobectomy. Of the three patients with spontaneous echo contrast, two patients developed thrombosis in the left superior vein stump within 3 months after the operation. There was no patient who developed arterial infarction.ConclusionsIn patients who underwent left upper lobectomy, intraoperative ultrasonography to evaluate blood flow and the presence of spontaneous echo contrast in the left superior pulmonary vein stump may be useful to predict thrombosis that may cause arterial infarction.

Left lobectomy might be a risk factor for atrial fibrillation following pulmonary lobectomy

BackgroundThe O-arm is an intraoperative imaging device that can provide computed tomography images. Surgery for small lung tumors was performed based on intraoperative computed tomography images obtained using the O-arm. This study evaluated the usefulness of the O-arm in thoracic surgery.MethodsFrom July 2013 to November 2013, 10 patients with small lung nodules or ground glass nodules underwent video-assisted thoracoscopic surgery using the O-arm. A needle was placed on the visceral pleura near the nodules. After the lung was re-expanded, intraoperative computed tomography was performed using the O-arm. Then, the positional relationship between the needle marking and the tumor was recognized based on the intraoperative computed tomography images, and lung resection was performed.ResultsIn 9 patients, the tumor could be seen on intraoperative computed tomography images using the O-arm. In 1 patient with a ground glass nodule, the lesion could not be seen, but its location could be inferred by comparison between preoperative and intraoperative computed tomography images. In only 1 patient with a ground glass nodule, a pathological complete resection was not performed. There were no complications related to the use of the O-arm.ConclusionsThe O-arm may be an additional tool to facilitate intraoperative localization and surgical resection of non-palpable lung lesions.

Risk Factors for Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis

OBJECTIVE To identify risk factors for atrial fibrillation (AF) following lobectomy for a pulmonary malignant tumour. METHODS The outcomes of patients who underwent lobectomy from February 2005 to September 2010 were analysed with respect to the development of postoperative AF. RESULTS Among 186 patients, 20 developed AF and these had significantly higher preoperative B-type natriuretic peptide (BNP) than those without AF. A significantly high incidence of AF following pulmonary lobectomy was demonstrated in the group of patients who were male, underwent a thoracotomy, had a high preoperative value of BNP and underwent a left lobectomy. Multivariate analysis revealed that left lobectomy is the only independent risk factor. The area under the receiver-operating characteristic curve for BNP to predict postoperative AF following a left lobectomy for a pulmonary malignant tumour was 0.82 (95% confidence interval 0.70-0.93; P<0.05). A BNP level of 24.1 pg/ml had a sensitivity of 90.9% and a specificity of 56% for predicting postoperative AF following left lobectomy for a pulmonary malignant tumour. CONCLUSIONS Left lobectomy is the only independent risk factor for postoperative AF. Elevated BNP is the risk factor for postoperative AF in patients undergoing left pulmonary lobectomy.

Limited resection and two-staged lobectomy for non-small cell lung cancer with ground-glass opacity

Background and Objectives: Factors that contribute to difficult laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) that would affect the performance of early surgery remain unclear. The purpose of this study was to identify such risk factors. Methods: One hundred fifty-four patients who underwent LC for AC were retrospectively analyzed. The patients were categorized into early surgery and delayed surgery. Factors predicting difficult LC were analyzed for each group. The operation time, bleeding, and cases of difficult laparoscopic surgery (CDLS)/conversion rate were analyzed as an index of difficulty. Analyses of patients in the early group were especially focused on 3 consecutive histopathological phases: edematous cholecystitis (E), necrotizing cholecystitis (N), suppurative/subacute cholecystitis (S). Results: In the early group, the CDLS/conversion rate was highest in necrotizing cholecystitis. Its rate was significantly higher than that of the other 2 histopathological types (N 27.9% vs E and S 7.4%; P = .037). In the delayed-surgery group, a higher white blood cell (WBC) count and older age showed significant correlations with the CDLS/conversion rate (P = .034 and P = .004). Conclusion: In early surgery, histopathologic necrotizing cholecystitis is a risk factor for difficult LC in AC. A higher WBC count and older age are risk factors for delayed surgery.

Video-assisted thoracoscopic left lower lobectomy in a patient with lung cancer and a right aortic arch

BackgroundLung tumors showing ground-glass opacities on high-resolution computed tomography indicate the presence of inflammation, atypical adenomatous hyperplasia, or localized bronchioloalveolar carcinoma. We adopted a two-staged video-assisted thoracoscopic lobectomy strategy involving completion lobectomy for localized bronchioloalveolar carcinoma with an invasive component according to postoperative pathological examination by permanent section after partial resection.MethodsForty-one patients with undiagnosed small peripheral ground-glass opacity lesions underwent partial resection from 2001 to 2007 in Hokkaido University Hospital. Localized bronchioloalveolar carcinoma was classified according to the Noguchi classification for adenocarcinoma. Malignant lesions other than Noguchi types A and B were considered for completion lobectomy and systemic mediastinal lymphadenectomy. Perioperative data of completion video-assisted thoracoscopic lobectomies were compared with data of 67 upfront video-assisted thoracoscopic lobectomies for clinical stage IA adenocarcinoma performed during the same period.ResultsPostoperative pathological examination revealed 35 malignant and 6 non-malignant diseases. Histologically, all of the malignant diseases were adenocarcinomas of Noguchi type A (n = 7), B (n = 9), C (n = 18), and F (n = 1). Eleven of 19 patients (58%) with Noguchi type C or F underwent two-staged video-assisted thoracoscopic lobectomy. Three patients refused a second surgery. There was no cancer recurrence. The two-staged lobectomy group had a significantly longer operative time and more blood loss than the upfront lobectomy group. There was no surgical mortality or cancer recurrence.ConclusionsTwo-staged lobectomy for undiagnosed small peripheral ground-glass opacity lesions showed satisfactory oncological results. However, low compliance for and invasiveness of the second surgery are concerns associated with this strategy.

Noninvasive management for iatrogenic splenic injury caused by chest tube insertion: a case report

A right aortic arch is a rare congenital anomaly, with a reported incidence of around 0.1%. A patient with a right aortic arch underwent video-assisted thoracic surgery left lower lobectomy and mediastinal lymph node dissection for squamous cell carcinoma. There was no aortic arch or descending aorta in the left thoracic cavity, but the esophagus. There was no anomaly in the location or branching of the pulmonary vessels, the bronchi, and the lobulation of the lungs. The vagus nerve was found at the level of the left pulmonary artery. The arterial ligament was found between the left subclavian artery and the left pulmonary artery. The recurrent laryngeal nerve was recurrent around the left subclavian artery. A Kommerell diverticulum was found at the origin of the left subclavian artery. The patient experienced no complications. We conclude that video-assisted thoracoscopic lobectomy with mediastinal dissection is feasible for treating lung cancer with a right aortic arch.