Makoto Endoh

Anatomic thoracoscopic pulmonary segmentectomy under 3-dimensional multidetector computed tomography simulation: A report of 52 consecutive cases

OBJECTIVE The purpose of this retrospective study was to evaluate the efficacy of anatomic thoracoscopic pulmonary segmentectomy performed under the guidance of 3-dimensional multidetector computed tomography simulation. METHODS Between September 2004 and June 2009, 52 patients (median age, 68 years; range, 16-85 years) underwent thoracoscopic segmentectomy without mini-thoracotomy. Images were obtained by using 64-channel multidetector computed tomography and a contrast agent. The pulmonary arteriovenous structure was mainly determined using a 3-dimensional volume-rendering method. The preoperative simulation was performed at the initial stage of the study and the intraoperative at a later stage. The simulated images were used to identify the venous branches in the affected segment for division and the intersegmental veins to be preserved. Four 5- to 20-mm ports were used. Segmentectomy was performed by separating the pulmonary arteries and bronchi followed by dissection along the intersegmental plane. RESULTS Fifty-one patients underwent a complete thoracoscopic segmentectomy. A mini-thoracotomy was performed in 1 case because of arterial bleeding. The success rate of segmentectomies under complete thoracoscopy was 98%. The procedure was classified into 3 categories according to the degree of surgical difficulty. Before introducing the simulation, there were 4 easy cases and 1 fairly difficult case. After introducing preoperative simulation, 7 cases were classified as fairly difficult among 12 segmentectomy cases. Furthermore, 7 cases of difficult segmentectomy were performed using intraoperative simulation. No local recurrence or metastasis and no mortality were observed during the follow-up. CONCLUSIONS Thoracoscopic pulmonary segmentectomy under 3-dimensional multidetector computed tomography simulation is a safe technique.

Demethylation of the Synuclein γ Gene CpG Island in Primary Gastric Cancers and Gastric Cancer Cell Lines

Purpose: Whereas synuclein γ (SNCG) gene expression is usually highly tissue-specific and restricted to the nervous system, SNCG is expressed in advanced-stage breast and ovarian cancers. When overexpressed, SNCG stimulates cancer cell proliferation and metastasis. It is thought that the molecular mechanism of CpG island demethylation may underlie aberrant SNCG expression. To determine whether aberrant SNCG expression and demethylation play a role in gastric carcinogenesis, we examined the expression and methylation status of SNCG in primary gastric cancers, gastric cancer cell lines, and non-neoplastic gastric mucosal tissues. Experimental Design: Ten gastric cancer cell lines, 105 primary gastric cancers, and 10 non-neoplastic gastric mucosal tissues were examined. SNCG expression and methylation status were examined by reverse transcription-PCR and bisulfite-single-strand conformational polymorphism followed by direct sequencing, respectively. The relationship between SNCG methylation status and various clinicopathological factors of the primary gastric cancers was then analyzed. Results: SNCG mRNA expression was observed in 5 of 10 cell lines. Analysis of cell lines positive for SNCG expression revealed that most of the SNCG CpGs were demethylated. SNCG mRNA was not expressed in the 10 non-neoplastic gastric mucosal tissues, although several CpGs were demethylated. Of the 105 primary gastric cancers, 40 (38.1%) showed apparent SNCG demethylation, similar to the result obtained using cell lines. SNCG demethylation was more frequent in primary gastric cancers positive for lymph node metastasis (51%; 26 of 51) than in cancers without lymph node involvement (26%; 14 of 54; P < 0.05), and also more common in stage II-IV (48%; 27 of 56) than in stage I (27%; 13 of 49) cancers (P < 0.05). Conclusions: Aberrant SNCG gene expression can occur via CpG island demethylation, and tends to occur during the more progressive stages of gastric carcinogenesis.

Total thoracoscopic pulmonary segmentectomy

OBJECTIVE In lung resection, thoracoscopy has been mainly used for wedge resection and lobectomy. There have been very few reports on pulmonary segmentectomy, mainly because of its complex nature. The present report evaluates the safety and efficacy of thoracoscopic pulmonary segmentectomy for the treatment of benign lung diseases or small lung carcinomas. METHODS The study involved 30 patients who underwent thoracoscopic segmentectomy without a minithoracotomy from September 2004 to March 2008. The median age of the patients was 69 years (range, 16-81 years). Four 5-20 mm ports were used. The pulmonary vessels were ligated, and the bronchi were closed using a stapler. An electrocautery was used for intersegmental dissection. Chest tubes were inserted in all cases. RESULTS Twenty-eight patients underwent complete thoracoscopic segmentectomy. A minithoracotomy was created in one case because of arterial bleeding, and open lobectomy was performed in another case owing to the diagnosis of small cell carcinoma. The operative time ranged from 147 to 425 min (median time, 216 min). The inserted chest tubes were maintained in position for 1-7 days (median duration, 1 day). One patient developed subcutaneous emphysema that spontaneously resolved. No mortality was observed for 30 days after the surgery. Further, no local recurrence or metastases were observed during follow-up in cases of malignancy. CONCLUSIONS Thoracoscopic pulmonary segmentectomy is a feasible and safe technique. Reduced postoperative pain and an improved cosmetic outcome are considered advantages of this minimally invasive procedure.

Anatomical Lung Segmentectomy Simulated by Computed Tomographic Angiography

We describe the benefits of simulating lung segmentectomy by using multi-detector computed tomographic angiography. Preoperative determination of the anatomical, intersegmental plane is possible by visualizing the branches of the pulmonary veins. This new technique could be useful in thoracoscopic segmentectomy of the lung.

Quantitative assessment of RUNX3 methylation in neoplastic and non-neoplastic gastric epithelia using a DNA microarray.

Silencing of the RUNX3 gene by hypermethylation of its promoter CpG island plays a major role in gastric carcinogenesis. To quantitatively evaluate RUNX3 methylation, a fiber‐type DNA microarray was used on which methylated and unmethylated sequence probes were mounted. After bisulfite modification, a part of the RUNX3 promoter CpG island, at which methylation is critical for gene silencing, was amplified by polymerase chain reaction using a Cy5 end‐labeled primer. Methylation rates (MR) were calculated as the ratio of the fluorescence intensity of a methylated sequence probe to the total fluorescence intensity of methylated and unmethylated probes. Five gastric cancer cell lines were analyzed, as well as 26 primary gastric cancers and their corresponding non‐neoplastic gastric epithelia. MR in four of the cancer cell lines that lost RUNX3 mRNA ranged from 99.0% to 99.7% (mean, 99.4%), whereas MR in the remaining cell line that expressed RUNX3 mRNA was 0.6%. In primary gastric cancers and their corresponding non‐neoplastic gastric epithelia, MR ranged from 0.2% to 76.5% (mean, 22.7%) and from 0.7% to 25.1% (mean, 5.5%). Ten (38.5%) of the 26 gastric cancers and none of their corresponding non‐neoplastic gastric epithelia had MR >30%. Most of the samples with MR >10% tested methylation‐positive by conventional methylation‐specific polymerase chain reaction (MSP). This microarray‐based methylation assay is a promising method for the quantitative assessment of gene methylation.

Slip knot bronchial ligation method for thoracoscopic lung segmentectomy.

We report a novel monofilament slip knot technique for bronchial ligation and for visualization of the anatomic plane during lung segmentectomy. After threading the bronchus, a slip knot is made outside the thorax. During lung ventilation, one end of the string is pulled, and the knot slips to reach the bronchus without a knot-pusher. Bronchial ligation is then performed to block the outflow of segmental air while the segment remains expanded, whereas the other segments become collapsed. This technique allows identification of the anatomic intersegmental plane, facilitating thoracoscopic anatomic lung segmentectomy.

Techniques to define segmental anatomy during segmentectomy

Pulmonary segmentectomy is generally acknowledged to be more technically complex than lobectomy. Three-dimensional computed tomography (3D CT) angiography is useful for understanding the pulmonary arterial and venous branching, as well as planning the surgery to secure adequate surgical margins. Comprehension of the intersegmental and intrasegmental veins makes the parenchymal dissection easier. To visualize the segmental border, creation of an inflation-deflation line by using a method of inflating the affected segment has become the standard in small-sized lung cancer surgery. Various modifications to create the segmental demarcation line have been devised to accurately perform the segmentectomy procedure.

Posterior approach to thoracoscopic pulmonary segmentectomy of the dorsal basal segment: A single-institute retrospective review

Objective: Anatomic resection of the dorsal area of the basal segment of the lower lobe is difficult because of the deep location of vessels and bronchi in the parenchyma. This study aimed to describe a novel technique for port‐access thoracoscopic segmentectomy of the dorsal (S10) and lateral dorsal segments (S9+10). Methods: This retrospective study analyzed 20 patients who underwent S10 and S9+10 thoracoscopic segmentectomy via a posterior approach between January 2004 and March 2016. In this approach, the lung parenchyma between S6 and S10 was divided along V6b,c from the dorsal side of the lower lobe, which exposed the targeted bronchus (B10, B9+10) and artery (A10, A9+10) and enabled anatomic S10 and S9+10 segmentectomy. Results: Of the 20 patients, 15 had lung cancer, 3 had metastases, and 2 had benign nodules. The number of segmentectomies of the right S10, right S9+10, left S10, and left S9+10 was 5, 5, 1, and 9, respectively. Median operative time was 165 minutes (range, 107‐276 minutes). The median duration of chest tube insertion was 1 day (range, 1‐2 days). One patient had atelectasis. Median hospital stay was 6 days (range, 3‐11 postoperative days). No recurrence or mortality was observed during the median follow‐up period of 46 months. Conclusions: The posterior approach for port‐access thoracoscopic segmentectomy at S10 or S9+10 is technically challenging, but in our hands it has been feasible. It exposes the targeted bronchus (B10, B9+10) and artery (A10, A9+10) and enables anatomic S10 and S9+10 segmentectomy while avoiding inessential parenchymal splitting from the major fissure.

Removal of foreign bodies from the respiratory tract of young children: Treatment outcomes using newly developed foreign-body grasping forceps

BACKGROUND Although a foreign body in the airway of children constitutes a medical emergency, most available therapeutic tools are insufficient, and treatment can be difficult. Herein, we evaluated the outcomes of various treatment methods of foreign body removal from the respiratory tract. METHODS We retrospectively analyzed 24 children (13 boys, 11 girls; median age, 18months [range, 9-60months]) treated for airway foreign bodies from January 1994 to December 2013 by examining their preoperative diagnoses and anesthesia and surgical methods. RESULTS The foreign body was a peanut, green soybean, almond, chestnut, dental prosthesis, and bead in 15, 3, 3, 1, 1, and 1 cases, respectively. General anesthesia was used in all cases, and flexible bronchoscopy was performed under airway maintenance using a laryngeal mask in 23 cases. The mean operation time was 51±32min. Grasping forceps, basket forceps, and a Fogarty catheter were used in 14, 7, and 2 cases, respectively. In July 2003, 3-pronged foreign-body grasping forceps with a 2.0-mm diameter designed for use with a thin bronchoscope were introduced. Of 16 treated cases, 9 were successfully treated with only forceps. The mean operation time was significantly shortened to 38±24min (range, 7-91min) compared to the traditional operation time of 82±42min (range, 23-147min) (p=0.01). CONCLUSIONS These novel forceps are useful for reducing the operation time and are suitable for removing airway foreign bodies from children with a narrow tracheobronchial caliber.

Hemorrhage of a pancreatic metastasis from lung adenocarcinoma after osimertinib therapy

Osimertinib is an epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI). It is used as anti-cancer therapy in patients with EGFR-TKI sensitizing mutations and EGFR T790M mutations and is recommended for treatment of patients with EGFR T790M-positive advanced non-small cell lung cancer (NSCLC) after progression on first-line EGFR-TKIs or frontline treatment in EGFR mutation-positive (exon 19 deletion or L858R) advanced NSCLC (1,2). Common adverse effects of osimertinib are similar to other EGFR-TKIs and are generally mild in severity and reversible (1). Previous reports have suggested an association between gefitinib or erlotinib treatment and organ bleeding or tumor hemorrhage (3-8). But to date there have been no reports of a similar association between osimertinib and tumor hemorrhage. Herein, we report an unusual case of hemorrhage of a pancreatic metastasis from lung adenocarcinoma after osimertinib therapy.