Kenji Tetsuka

Inhibition of IL-6 overproduction by steroid treatment before transsternal thymectomy for myasthenia gravis : does it help stabilize perioperative condition?

Overproduction of interleukin (IL)‐6 plays an important role in the pathophysiology of myasthenia gravis (MG), and thymectomy can cause myasthenic crisis because of surgically induced overproduction of IL‐6. Preoperative steroid therapy is beneficial in preventing MG crisis during the perioperative period. The purpose of this study was to clarify the effect of preoperative steroid therapy on proinflammatory mediators during the perioperative period of transsternal thymectomy for MG. The study group comprised 20 consecutive MG patients undergoing transsternal thymectomy during the period March 2002 through March 2004. Seventeen of these patients received dose‐escalated steroid therapy before thymectomy (steroid treatment group) and three did not (non‐steroid treatment group). Serum concentrations of C‐reactive protein (CRP) and IL‐6 were determined during the perioperative period; clinical outcomes were reviewed, and the results were compared between the two groups. Peak serum IL‐6 and CRP concentrations were significantly lower in the steroid treatment group than in the non‐steroid treatment group. Amongst perioperative variables subjected to multiple regression analysis, preoperative steroid treatment were found to be the most significant independent predictor of inhibited IL‐6 production on postoperative day 1. No postoperative respiratory failure occurred in the steroid treatment group, but it did occur in the non‐steroid treatment group. Preoperative steroid therapy can ameliorate IL‐6 overproduction and may help stabilize the patients postoperative condition.

Dangerous mediastinal basal pulmonary artery during left upper lobectomy

Anatomical variations in the pulmonary vessels present a potential risk for intraoperative bleeding and damage to the pulmonary circulation during pulmonary resection. Here, we present a patient who underwent left upper lobectomy for lung cancer. The patient had a dangerous mediastinal basal pulmonary artery variation that could be mistaken for the mediastinal lingular pulmonary artery and be divided during left upper lobectomy.

Predictors of postoperative complications after radical resection for pulmonary aspergillosis.

ObjectiveAlthough surgery has proven to be the best treatment for pulmonary aspergillosis, with the highest chance of achieving complete remission, it is difficult to determine the surgical indications for this disease because of the high incidence of postoperative complications. We conducted this study to identify some predictors of postoperative complications, in an attempt to reduce the morbidity rate.MethodsWe retrospectively analyzed the medical records of 31 patients (18 men, 13 women; median age 53 years) who underwent radical resection for pulmonary aspergillosis between 1976 and 2004. The clinical manifestations, surgical procedures, and postoperative complications were reviewed to clarify the predictors of postoperative complications.ResultsThe morbidity rate associated with major complications such as intrapleural bleeding, bronchopleural fistula, and empyema, resulting in further surgery, was 19%. Univariate analysis revealed the predictors of major complications to be sex, severe preoperative symptoms, and extensive pulmonary resection. Multivariate analyses also indicated that preoperative symptom severity was an independent predictor of major complications.ConclusionsPulmonary aspergillosis should be resected before the symptoms become too severe if the patient is a surgical candidate.

Extraction of mediastinal teratoma contents for complete thoracoscopic resection

Objectives Video-assisted thoracic surgery is widely applied for resection of mediastinal tumors. The mediastinal mature teratoma, however, is usually operated on via an open approach because it is generally large, making it difficult to dissect under a thoracoscopic view and remove it from the thoracic cavity. We attempted to extract intracystic material during video-assisted thoracic surgery to facilitate dissection and removal of the tumor from the thoracic cavity. Methods From January 1998 to April 2013, 13 patients (9 women, 4 men; mean age 33 years, range 17–54 years) with mediastinal mature teratomas were operated on via video-assisted thoracic surgery. Intracystic contents of the tumor were aspirated before dissection or after the teratoma was dissected and placed in the retrieval pouch. Results None of the patients required conversion to an open procedure. Operating time was 95–184 min (mean 132 min). Blood loss during the operation amounted to 10–300 mL (mean 78 mL). The tumor size ranged from 5 to 12 cm (mean 8 cm). In all cases, the tumors were confirmed pathologically to be mature cystic teratomas with no malignant components. During and after follow-up, all patients continue to do well without recurrence. Conclusion Extraction of intracystic contents enabled thoracoscopic resection of large mature mediastinal teratomas.

Surgical Outcome of Video-Assisted Thoracoscopic Surgery vs. Thoracotomy for Primary Lung Cancer >5 cm in Diameter

OBJECTIVES The indications for video-assisted thoracoscopic surgery (VATS) for advanced-stage lung cancer are expanding, but the criteria vary among institutions. This study compared the minimal invasiveness and oncologic validity of VATS lobectomy and thoracotomy lobectomy for the treatment of large-diameter primary lung cancer. METHODS We retrospectively reviewed clinical features and surgical outcomes of 68 patients who underwent anatomical pulmonary resection for primary lung cancer of >5-cm diameter from July 2006 to March 2013. The patients were divided into a VATS group (Group V, n = 35) and a thoracotomy group (Group T, n = 33). RESULTS Group V exhibited less intraoperative bleeding (p = 0.012) and had a shorter length of postoperative hospital stay (p = 0.024). The 1- and 5-year overall survival rates were 91.3% and 39.3% in Group V and 84.8% and 56.9% in Group T, respectively (p = 0.48). Multivariate analysis showed that limited lymph node dissection contributed to local recurrence. The extraction bag lavage cytology in Group V revealed that the positivity rate was 35.7%. CONCLUSIONS VATS for primary lung cancer of >5-cm diameter is similar to thoracotomy in terms of surgical outcomes. Large tumors must be carefully maneuvered during VATS to prevent cancer cell spillage.

Massive haemothorax after pulmonary endostapling preloaded with bioabsorbable tissue reinforcement material

Reinforced endostapling can prevent postoperative air leakage from surgical stumps. We herein present a 58-year old woman with idiopathic interstitial pneumonia who developed lethal haemothorax after a thoracoscopic lung biopsy with the use of an endostapler preloaded with bioabsorbable tissue reinforcement material. This lethal haemothorax, which occurred on the day after the lung biopsy, required an emergency operation. The bleeding point was an intercostal artery of the inferior chest wall adjacent to the surgical stump. The operative findings suggested that the reinforced material on the surgical stump scratched the chest wall through respiratory movement.

Extralobar pulmonary sequestration presenting as hemothorax

Symptomatic extralobar pulmonary sequestration (EPS) is extremely rare. Herein, we report two male patients (3 and 16 years of age) with EPS presenting as hemothorax. Thoracotomic resections of the sequestrated lungs were uneventful. Pathologic examinations revealed hemothorax caused by circulatory disorders within the EPSs.

Asymptomatic localized pleural amyloidosis mimicking malignant pleural mesothelioma: report of a case

We herein report an asymptomatic 65-year-old male with localized pleural amyloidosis mimicking malignant pleural mesothelioma. He had a history of exposure to asbestos and was admitted for investigation of an abnormal pleural thickness detected by chest radiography. Positron emission tomography showed elevation of standardized uptake value corresponding to the pleural thickness. Partial pleurectomy including the tumor was performed for the purpose of diagnosis and local disease control. The pathological examination showed that the tumor was pleural amyloidosis. The tumor was diagnosed as localized primary amyloidosis, because serum monoclonal protein concentration did not increase. Pleural amyloidosis should be considered as a differential diagnosis from pleural mesothelioma.

Extraction bag lavage cytology during video-assisted thoracoscopic surgery for primary lung cancer

OBJECTIVES Sample extraction from the thoracic cavity through an intercostal space during video-assisted thoracoscopic surgery can result in cancer cell contamination by tumour crushing and tumour cell extravasation, and may have adverse effects on the surgical outcome. Lavage cytology of the sample extraction bag was investigated to clarify the risk of cancer cell spillage and identify the clinicopathological features associated with susceptibility to cancer cell spillage during extraction. METHODS Lavage cytology of the sample extraction bag was investigated in 464 patients with negative pleural lavage cytology who underwent lung resection for primary lung cancer via video-assisted thoracoscopic surgery between January 2010 and December 2012. The surgical procedures, pathological findings and clinical course were evaluated by hospital record review. RESULTS The incidence of positive bag lavage cytology (BLC) was 13.6%. Statistically significant factors associated with susceptibility to BLC positivity were tumour size, standardized uptake value of positron emission tomography, pathological features such as pathological N score, pleural invasion, vascular invasion and papillary-predominant adenocarcinoma. Among patients with Stage I lung cancer, the survival rate was significantly lower in the BLC-positive group than in the BLC-negative group. CONCLUSIONS BLC positivity can be related to oncological characteristics such as tumour invasiveness and adhesiveness as opposed to tumour size and surgical margin, and may help to determine the prognosis of Stage I lung cancer. The sample extraction bag must be carefully manoeuvred through the intercostal space to prevent cancer cell dissemination to the chest wall or thoracic cavity.

Thoracoscopic findings of an asymptomatic solitary costal exostosis: is surgical intervention required?

We report a case of a 21-year old male with an asymptomatic solitary costal exostosis incidentally detected on a chest X-ray. The exostosis originated from the costochondral junction of the left fourth rib and protruded into the thoracic cavity. Exploratory thoracoscopy showed that the exostosis had scratched the adjacent pericardium and visceral pleura. A 5.5-cm long rib segment including the exostosis was excised. This report describes that the thoracoscopic findings of an asymptomatic costal exostosis originate from the costochondral junction, demonstrating that this condition may cause more extensive thoracic organ injury than expected.