Kenji Tsuboshima

Pleural lavage cytology in non-small cell lung cancer: Lessons from 1000 consecutive resections

OBJECTIVE Intraoperative pleural lavage cytology for lung cancer has not been widely accepted. The prognostic significance of this procedure has yet to be intensively analyzed because the reports published thus far have involved small patient populations. We therefore performed a large prospective trial of pleural lavage cytology to elucidate its importance. METHODS Cytologic status of pleural lavage fluid before any manipulation of the lung was examined in 1000 consecutive patients with non-small cell lung cancer but no pleural effusion who underwent tumor resection. RESULTS Forty-five (4.5%) of 1000 patients had positive cytologic findings. Positive cytologic findings were observed more frequently in patients with adenocarcinoma, advanced stage, higher involvement of lymph nodes, pleural involvement of the tumor, lymphatic permeation, vascular invasion, high level of serum carcinoembryonic antigen, and male sex. The survival rate for 5 years was 28% in patients with positive findings and 67% in patients with negative findings (P <.0001). Among 587 patients with stage I disease, 13 (2.2%) had positive findings, and their 5-year survival was 43%, which was significantly poor compared with that of patients with negative findings (81%, P =.0009). Multivariable analysis demonstrated that pleural lavage cytology was an independent prognostic determinant (P =.0290). Regarding the recurrence pattern in patients with positive findings, distant metastases (19/45 [42.2%]) were observed more frequently rather than local recurrences (19/45 [22.2%]). CONCLUSIONS Cytologic status of pleural lavage fluid immediately after thoracotomy, an independent significant prognostic factor, constitutes valuable information to detect patients at a high risk of recurrence. Therefore cytology should be performed at the time of curative resection for non-small cell lung cancer.

Modified Chest Wall Pulley for Lung Excision during Single-Incision Thoracoscopic Surgery for Primary Spontaneous Pneumothorax

We reported the feasibility of single-incision thoracoscopic surgery bullectomy using a chest wall pulley for lung excision (PulLE) in patients with primary spontaneous pneumothorax (PSP). PulLE has many merits including comfort of manipulation, cosmetic advantages, etc., compared to other procedures. However, our method was utilized for relatively straightforward cases. The PulLE was contraindicated for PSPs with multiple or comprehensive bullae. Therefore, we developed the modified PulLE (mPulLE) to treat such cases in February 2015. Although one chest wall pulley is placed in the thoracic cavity for a PulLE, two are used for an mPulLE. Herein, we describe the mPulLE technique.

Novel paravertebral block during single-incision thoracoscopic surgery for primary spontaneous pneumothorax

Recently, the use of paravertebral block (PVB) during thoracic surgery has been re-evaluated, as it is not inferior to epidural anaesthesia for postoperative pain control, and has been associated with fewer complications (e.g., hematoma of epidural, hypotension, urinary retention, postoperative nausea and vomiting). No reports have described intraoperative catheterization for PVB during single-incision thoracoscopic surgery (SITS) as distinct from thoracotomy or multi-ports video-assisted thoracoscopic surgery. We describe a case of SITS bullectomy using a chest wall pulley for lung excision to treat primary spontaneous pneumothorax and 25 catheterizations for PVB during SITS that have been performed since June 2013. Our novel technique is both easy and safe. It is ideal to combine PVB with SITS because both methods are less invasive.

Association between postoperative bulla neogenesis at the staple line and resected lung weight for primary spontaneous pneumothorax: a retrospective study using the inverse-probability of treatment weighted method in patients grouped according to age

BACKGROUND Bullectomy using autosutures is the standard procedure in patients with primary spontaneous pneumothorax (PSP). However, postoperative bulla neogenesis (POBN) along the staple line is relatively common and promotes PSP recurrence. We have previously reported the relationship between POBN and resected lung weight (LW). However, recently published data indicate that young patients with PSP have a high postoperative recurrence rate. Therefore, we evaluated the relationship between POBN and LW in PSP patients, subdivided according to age. METHODS Between February 2011 and April 2016, 96 lung-resection sites in 67 patients who underwent bullectomy were evaluated. Patients were subdivided into two groups by age: Y group (<25 years, 56 sites) and O group (≥25 years, 40 sites). We used the inverse-probability of treatment weighted (IPTW) method to adjust for the heterogeneity in their backgrounds. POBN was diagnosed by computed tomography. RESULTS Cox regression analysis for the O group indicated that LW ≥3.0 g was a significant risk factor for POBN (P=0.049). For the Y group, no association between lung weight and POBN was observed. CONCLUSIONS A LW ≥3.0 g is a significant risk factor for POBN in individuals aged ≥25 years.

Postoperative Exercise Tolerance After Extended Segmentectomy-Analysis Based on a Conventional Treadmill Test-

目的. われわれは1992年以来, 肺葉切除耐術者における末梢の小型非小細胞肺癌 (径2cm以下) に対して積極的な縮小手術 (拡大区域切除) を実施し, 本術式が標準手術 (葉切除) に比して予後を損なわないこと, 肺機能低下の軽微なことを報告してきた. しかしながら呼吸機能温存の評価には安静時における肺気量のみでは不十分と考え, 運動負荷時の酸素摂取量を指標とした耐運動能を検討した. 対象と方法. 縮小手術が施行された拡大区域切除術群の46例と, 肺葉切除術群の156例を対象とし, 術前と術後2か月目にトレッドミル運動負荷試験による耐運動能の変化を比較した. 結果. 拡大区域切除術は術後, 術前値の872±0.2%を維持したのに対し, 肺葉切除は78.8±0.1%に低下した (p<0.0001). 担癌肺葉別の検討でも拡大区域切除術は有意に良好な術後耐運動能を保持した. 結論. 拡大区域切除術は術後の耐運動能に与える影響が葉切除にくらべて軽微な術式であることが判明した.