Koji Chihara

Successful thoracoscopic debridement of descending necrotizing mediastinitis.

Descending necrotizing mediastinitis results from odontogenic, deep neck infection that spreads along fascial planes into the mediastinum. Although the optimal surgical approach remains controversial, nearly half of the cases require mediastinal debridement by thoracotomy. We report a case of successful thoracoscopic debridement for descending necrotizing mediastinitis due to odontogenic infection that failed to be drained by transcervical approach. Because of less invasiveness as compared with standard thoracotomy, the thoracoscopic approach should be used as early as possible in case of unsuccessful transcervical approach.

Position of a Chest Tube at Video-Assisted Thoracoscopic Surgery for Spontaneous Pneumothorax

Background:Video-assisted thoracoscopic surgery (VATS) is a good therapeutic option for young patients with primary spontaneous pneumothorax (PSP), but there sometimes exists unexpected prolonged hospital stay due to air leak after the operation. Objectives: The goal of this retrospective study was to clarify if the position of the chest tube placed at VATS for PSP affected the periods of postoperative hospital stay. Methods: Seventy-one cases with PSP under age 40 who undertook VATS from January 1994 to February 2001 were examined for several factors. They were classified into two groups by the location of the tip of the chest tube placed at VATS as follows: upper medial pleural space (group I) and outside of there (group II). Results:Fifty-three of the 71 cases (75%) were classified in group I and 18 (25%) were in group II. Between the two groups, there were no differences as to preoperative characteristics of the patients and intraoperative findings of blebs or bullae. On the other hand, postoperative air leak-related complications were more frequent in group II than in group I (p = 0.004). Mean postoperative hospital stay was 5.1 ± 1.9 days in group I and 8.4 ± 4.3 days in group II (p < 0.0001). Conclusions:Patients with the tip of the chest tube in the upper medial pleural space at VATS could be discharged earlier than the other patients. The chest tube placement is one of the important factors for the outcome of VATS for PSP.

Thymic Atypical Carcinoid with Cushing's Syndrome Manifesting in the Terminal Stage

A 56-year-old man with recurrent thymic atypical carcinoid presented with Cushings syndrome only in the terminal stage. Eighteen months after the resection of an anterior mediastinal mass, he presented with hypernatremia and hypokalemia with high serum levels of adrenocorticotropic hormone and cortisol, and died two months later. An autopsy demonstrated multiple metastases of the tumor to the mediastinum, lungs, heart, liver, kidneys, bone, pituitary gland, and ocular muscles. The adrenocorticotropic hormone level of the tumor tissue was 26,000 pg/g.

Sudden hemothorax following lobectomy caused by staple

A 74-year-old female with lung cancer underwent a right lower lobectomy by video-assisted thoracic surgery (VATS), and suddenly developed hemothorax soon after discharge. The bleeding point was an intercostal artery which faced a stump of the right lower vein divided by a stapler. Operative finding suggested that it was caused by an incidental injury of the artery by a staple.

Diaphragmatic elevation of a patient with chronic obstructive pulmonary disease after left upper lobectomy

Among postoperative pleural space problems after pulmonary resections, it is more difficult and troublesome to manage this space after left upper lobectomy in patients with chronic obstructive pulmonary disease (COPD). We performed a retrospective study focusing on the elevation of ipsilateral hemidiaphragm of the 36 patients with or without COPD after left upper lobectomies, by measuring diaphragmatic dome length (DDL) with a plain posteroanterior roentgenogram. They were divided into two groups: group I (forced expiratory volume in 1 s (FEV1) % predicted < 70%, n = 5); and group II (FEV1) % predicted > or = 70%, n = 31). Of each group, we investigated the trend of both left and right DDLs perioperatively, calculating DDL index (DDL divided by height, DDLI), and also analyzed several perioperative parameters. The trend of left DDLI after surgery was different in the two groups (P=0.012). In group I, left DDLI became larger gradually in proportion to the postoperative weeks, while in group II it became the largest 2 weeks after surgery and decreased gradually. Left DDLI in group I was smaller than that in group II 2 weeks after surgery (P=0.007). We found that the diaphragm of COPD patients does not elongate easily after left upper lobectomy.

Right ventricular infarction during a lung lobectomy in a patient with chronic obstructive pulmonary disease: report of a case.

A 63-year-old man with a low forced expiratory volume in 1 s underwent a wedge resection for peripheral lung cancer; however, it relapsed in the residual lobe. We decided that a lobectomy was feasible after further examinations focusing on gas exchange. During the lobectomy right ventricle myocardial infarction occurred, possibly due to coronary spasm, and it was successfully treated with intra-aortic balloon pumping. The patient has been doing well without relapse for 7 years. Our findings indicate that some patients with low spirometry data may therefore be candidates for a lobectomy.

Pulmonary vein thrombosis after lobectomy with vein stump closure by ligation

Objectives Thrombosis in the pulmonary vein stump after a left upper lobectomy is a rare but potentially life-threatening complication, and the pulmonary vein stump length plays an important role here. We assessed the frequency and risk factors for thrombosis in patients undergoing lobectomy with division of the superior pulmonary vein using ligation. Methods We retrospectively reviewed 425 patients with primary lung cancer who underwent lobectomy or bilobectomy in our institution from 2008 to 2016, with contrast-enhanced chest computed tomography within a year after lobectomy. The superior pulmonary vein was divided by thread ligation, while the inferior pulmonary vein was divided using a linear stapler. The pulmonary vein stump length was measured using contrast-enhanced chest computed tomography. Results Four (0.9%) of the 425 patients experienced thrombosis in the pulmonary vein stump within 6 months after lobectomy. All 4 patients had undergone a left upper lobectomy, and 4.1% of this subset developed thrombus. One patient with a thrombus in the pulmonary vein stump experienced renal and cerebral infarction after a left upper lobectomy. The left superior pulmonary vein stump was significantly longer than the other pulmonary vein stumps. Conclusions Thrombosis in the pulmonary vein stump occurred in 4.1% of patients undergoing a left upper lobectomy with pulmonary vein stump closure by thread ligation, which is a relatively low frequency. Superior pulmonary vein stump closure using thread ligation might help prevent pulmonary vein stump thrombus after a left upper lobectomy.