Masafumi Hiratsuka

Totally Thoracoscopic Surgery and Troubleshooting for Bleeding in Non-Small Cell Lung Cancer

BACKGROUND Although accumulating data support the feasibility and efficacy of video-assisted thoracic surgery anatomic resection, few studies have reported on intraoperative complications, such as vessel injury. The purpose of this study was to evaluate intraoperative vessel injury and to analyze troubleshooting. METHODS Twenty-six of 557 patients with non-small cell lung cancer who underwent thoracoscopic anatomic lung resection were identified as having intraoperative vessel injury between January 2004 and December 2011. The injured portion, devices used, recovery approach, and hemostatic procedure were analyzed. The perioperative outcomes in patients with and without vessel injury were compared. RESULTS The most commonly used devices were ultrasonic coagulation shears in 9 cases, followed by scissors in 5 and an endostapler in 4. Seventeen of the 26 cases were injured at the branches of the pulmonary artery, and the others were at major vessels. Half of the patients were converted to thoracotomy, and 6 were treated by minithoracotomy. Hemostatic procedures were primary closure in 17 and sealant in 7. The perioperative outcomes, including operative time and blood loss, were significantly different between the two groups, but duration of chest tube drainage, length of hospital stay, and morbidity rate were not. No mortality was identified in the patients with vessel injury. CONCLUSIONS Video-assisted thoracic surgery anatomic resection was feasible and safe, regardless of the intraoperative vessel injury. Although surgeons should pay attention to avoid unexpected bleeding, the magnitude of injury and effectual step-by-step management should lead to a safe operation.

Outcome of living-donor lobar lung transplantation using a single donor

OBJECTIVE Living-donor lobar lung transplantation usually requires 2 healthy donors who donate either a right or a left lower lobe; however, finding 2 healthy donors is difficult. Several case reports have been published on successful living-donor lobar lung transplantation using a single donor; however, little is known about its outcome. METHODS We retrospectively investigated 14 critically ill patients who had undergone single living-donor lobar lung transplantation at 3 lung transplant centers in Japan. There were 10 female and 4 male patients, including 10 children and 4 adults. Size matching was assessed by estimated graft forced vital capacity and 3-dimensional computed tomography volumetry. The diagnoses included complications of allogeneic hematopoietic stem cell transplantation (n = 6), pulmonary hypertension (n = 4), and others (n = 4). RESULTS At a mean follow-up of 45 months (range, 2-128), the 3- and 5-year survival rate was 70% and 56%, respectively. There were 4 early deaths, for a hospital mortality of 29%, with 1 additional death at 40 months. The main cause of early death was primary graft dysfunction, most likely related to size mismatching. The survival among these 14 patients was significantly worse than the survival in a group of 78 patients undergoing bilateral living-donor lobar lung transplantation during the same period (P = .044). CONCLUSIONS Single living-donor lobar lung transplantation provides acceptable results for sick patients who would die soon otherwise. However, bilateral living-donor lobar lung transplantation appears to be a better option if 2 living donors are found.

Tracheal resection for malignant and benign diseases: Surgical results and perioperative considerations

PurposeTracheal surgery is an established treatment for various diseases; however, it is still a potentially challenging procedure. We herein discuss the safety of this procedure with regard to the coordination with airway interventional and anesthetic support.MethodsA tracheal resection was performed on 18 patients. The dyspnea due to pre-existing severe airway stenosis, which was considered to be a risk factor for the safe induction of general anesthesia, was present in 12 (66.7%) cases.ResultsSeven of the 12 patients with pre-existing airway obstruction required interventional airway treatment before surgery. One case with a polyp-like tracheal tumor required venoarterial percutaneous cardiopulmonary support to establish adequate oxygenation before surgery. All 18 cases underwent a segmental resection of the trachea, with the average length of 3.6 rings. Postoperative recovery was uneventful for all but one patient with postintubation tracheal stenosis, who died 17 days after surgery due to a methicillin-resistant Staphylococcus aureus infection. Complications in the other patients included four cases of laryngeal nerve palsy, three of aspiration, and one patient with Horner syndrome, with a total morbidity of 27.7%.ConclusionsA tracheal resection is currently a safe procedure; however, cooperation with sophisticated airway interventional treatment teams, cardiopulmonary bypass support, or a well-trained anesthesiologist is essential for obtaining a successful outcome, especially for the cases with pre-existing severe airway obstruction.

New technique for the cystic mediastinal tumor by video-assisted thoracoscopy

Thoracoscopic operations for benign mediastinal tumors have been useful. However, it is difficult to remove cystic mediastinal tumors completely because of their cystic structure. We herein describe a useful technique of tumor cannulation that allows for the simple and safe removal of these tumors.

Tracheal transplantation for carinal reconstruction in dogs

BACKGROUND Experimental carinal allotransplantation has been performed with tracheocarinal Y-shaped allografts in dogs. In this study we tried canine carinal reconstruction with cylindrical allografts. MATERIAL AND METHODS Carinal reconstruction was performed with allotransplantation of cylindrical trachea in dogs, and graft healing was evaluated by bronchoscopic observation, mucosal blood flow measurement, and histologic examination. A section of the recipient carina containing five tracheal rings and two main stem bronchi was removed, and a donor trachea seven rings long was inserted between the recipient trachea and the left main stem bronchus; then side-to-end anastomosis was performed between the graft midportion and recipient right main stem bronchus (new carina). The grafts were wrapped with pedicled omentum. Fresh grafts were transplanted into one group of dogs (n=8 ), and grafts cryopreserved for 1 week were transplanted into another group (n=7). RESULTS No anastomotic leakage occurred in any dog. Excellent healing of grafts and graft anastomoses was observed by fiberoptic bronchoscopy in six dogs (75%) in the fresh graft group and in four dogs (57%) in the cryopreserved graft group. The mucosal blood flow in the new carina decreased remarkably and, although it recovered, mucosal blood flow remained under the preoperative level on day 28 after the operation. CONCLUSION Cylindrical tracheal allotransplantation is useful for carinal reconstruction, and the method of side-to-end anastomosis between the donor trachea and recipient bronchus is a feasible and accessible procedure in dogs.

Aspergilloma Within Cavitating Pulmonary Carcinoma: Case Report

Aspergillosis was diagnosed in a 69-year-old man presenting with blood-stained sputum, and was treated with an antifungal agent. As radiographic lesions persisted after 3 months, left upper lobectomy was performed. The surgical specimen revealed pulmonary carcinoma associated with an intracavitary aspergillar infection.

Successful treatment of bronchial anastomotic stenosis with modified Dumon Y-stent insertion in lung transplantation: Report of a case

Bronchial complications owing to airway anastomosis still remain a cause of morbidity and mortality following lung transplantation, and bronchial stenosis is the most common manifestation. Current treatment strategies include endoscopic balloon dilation, laser ablation, and stent insertion. Although a variety of stent types are currently available, it is unclear as to which type of prosthesis is most suitable for post-transplant bronchial complications with regard to the primary effects and long-term outcomes. We herein discuss a case of stenosis of the right bronchial anastomosis in a patient who underwent right single lung transplantation for idiopathic pulmonary fibrosis. This complication was successfully treated with the placement of a modified Dumon Y-stent. The stent was removed 2 months after insertion, and the patient has subsequently maintained an adequate airway caliber. Computed tomography, especially the sagittal section through the chest, is useful for detecting bronchial stenosis and monitoring the healing of this condition.

Giant Hamartoma of the Lung With a High Production of Carbohydrate Antigen 19-9

A rare case of a giant pulmonary hamartoma with a high production of carbohydrate antigen (CA) 19-9 is presented. A 43-year-old woman with complaints of cough, fever, and chest pain was diagnosed as having a posterior mediastinal tumor with pneumonia. The serum CA 19-9 level was high. A thoracotomy revealed an intrapulmonary solid mass with a histologic diagnosis of cartilaginous hamartoma with no evidence of malignancy. The CA 19-9 concentration in the mucus of the tumor was high, and postoperatively the serum CA 19-9 level returned to normal. The CA 19-9 could be immunohistochemically demonstrated on the surface of the tumor.

Effects of treatment with a combination of cardiac rehabilitation and bosentan in patients with pulmonary Langerhans cell histiocytosis associated with pulmonary hypertension

Pulmonary hypertension (PH), which is classified as group 5 in the clinical classification of PH, is sometimes a complication of Pulmonary langerhans cell histiocytosis (PLCH), and is associated with high mortality. A 36-year-old woman had suffered from severe dyspnea 9 years previously and was diagnosed with PLCH and was on a waiting list for a lung transplant. Right heart failure had been observed and the mean pulmonary artery pressure was over 40 mmHg. The patient was diagnosed as PLCH with PH. After combined treatment with exercise rehabilitation and bosentan for 6 months, the cardiothoracic ratio, brain natriuretic peptide, and bodyweight were significantly decreased (cardiothoracic ratio from 43 to 38%, brain natriuretic peptide from 284 to10 pg/ml and bodyweight from 63 to 58 kg). Six-minute walk test also improved from 214 to 275 meters and the SF36 score for screening of depressive and anxiety disorders was improved. This is the report demonstrating the efficacy and safety of cardiac rehabilitation in combination with bosentan in a single patient with PLCH associated with PH.

Long-term follow-up of living-donor single-lobe lung transplantation for bronchiolitis obliterans in a four-year-old male: improvement of over-sized lung allograft.

We report a long-term outcome of extremely oversized lung allograft. A left lower lobe transplantation from an adult donor was performed on a four-year-old recipient after left pneumonectomy. Lobar lung allograft volume was calculated to be approximately 180% of the recipients predicted left thoracic capacity. Accordingly, the lung allograft was compressed to 47% of its original size immediately after transplantation. Initial postoperative functional recovery of the allograft was excellent despite this severe compression. As the patient grew physically, both his forced expiratory volume in 1 s (FEV(1)) and his left lung volume increased slowly but steadily during an observation period of two years and four months after transplantation.