Masashi Muraoka

Management of anastomotic complications after sleeve lobectomy for lung cancer

One hundred twelve patients (102 male and 10 female) underwent sleeve lobectomy for lung cancer from January 1969 to December 1991. Bronchopleural fistula occurred in 6 (5.6%), bronchovascular fistula in 2 (1.8%), pulmonary arterial occlusion in 2 (1.9%), anastomotic stricture or stenosis in 7 (6.3%), and local recurrence in 7 patients (6.3%). Early repair of bronchopleural fistula combined with an omentopexy achieved permanent closure of the fistula. Two patients who underwent a completion pneumonectomy for a pulmonary arterial occlusion died of respiratory failure. Two patients experienced uncontrollable bleeding into the bronchial tree through a bronchovascular fistula and sudden death. Completion pneumonectomy is indicated for a stricture due to scar formation. If pneumonectomy is precluded by poor pulmonary reserve, endoscopic excision using biopsy forceps is an alternative. Endoscopic resection is the treatment of choice for suture granulomas. Complications associated with bronchial or vascular anastomoses are serious and frequently fatal.

Video-assisted thoracic surgery lobectomy reduces the morbidity after surgery for stage I non-small cell lung cancer

OBJECTIVE We conducted this study to evaluate the surgical invasiveness and the safety of video-assisted thoracic surgery lobectomy for stage I lung cancer. METHODS Video-assisted thoracic surgery lobectomies were performed on 43 patients with clinical stage IA non-small cell lung cancer. We compared the surgical invasiveness parameters with 42 patients who underwent lobectomy by conventional thoracotomy. RESULTS Intraoperative blood loss was significantly less than that in the conventional thoracotomy group (151+/-149 vs. 362+/-321 g, p<0.01). Chest tube duration (3.0+/-2.1 vs. 3.9+/-1.9 days) was significantly shorter than those in the conventional thoracotomy group (p<0.05). The visual analog scale which was evaluated as postoperative pain level on postoperative day 7, maximum white blood count and C-reactive protein level were significantly lower than those in the conventional thoracotomy group (p<0.05). The morbidity rate was significantly lower than that in the conventional thoracotomy group (25.6% vs. 47.6%, p<0.05). Sputum retention and arrhythmia were significantly less frequent than in the conventional thoracotomy group (p<0.05). We experienced no operative deaths in both groups. CONCLUSION We conclude that video-assisted thoracic surgery lobectomy for stage I non-small cell lung cancer patients is a less invasive and safer procedure with a lower morbidity rate compared with lobectomy by thoracotomy.

Surgical Treatment for Lung Cancer in Octogenarians

PurposeWe conducted this study in order to determine how we should perform the surgical treatment for clinical stage I non-small cell lung cancer (NSCLC) in octogenarians.MethodsThirty-three octogenarians with clinical stage I NSCLC participated in this study. They were retrospectively divided into two groups: one group of 11 patients who underwent a lymph node dissection (ND group), and one group of 22 patients who did not undergo this procedure (ND0 group). We analyzed the surgical invasiveness, morbidity, mortality, and survival in both groups.ResultsThe morbidity rate in the ND group (45%) was higher than that in the ND0 group (23%); however, the difference was no statistically significant (P = 0.1805). There was no significant difference in the overall survival rates of the two groups (P = 0.1647), and the median survival time of the ND0 group (76 months) was slightly longer than that of the ND group (26 months). There was no significant difference in local recurrence rate between the two groups (9.1% vs 4.5%, P = 0.6059).ConclusionWe thus conclude that a limited operation without lymph node dissection might be the best surgical treatment for carefully selected octogenarians with clinical stage I NSCLC.

Thoracoscopic drainage with wound edge protector for descending necrotizing mediastinitis

It has recently been found that wide recognition of descending necrotizing mediastinitis (DNM) and its resultant early diagnosis can reduce the high mortality rate associated with this disease by allowing for rapid surgical intervention. Nevertheless, thoracotomy remains controversial as a treatment for DNM. We report a successful case of DNM in which the mediastinitis had spread below the carina and which was treated by drainage through cervicotomy and by thoracoscopic drainage with mini-thoracotomy using the newly available wound edge protector called a Lap-protector.

Postoperative Complications of Pulmonary Resection After Platinum-Based Induction Chemotherapy for Primary Lung Cancer

Abstract.Purpose: We investigated the postoperative complications that developed in patients who underwent surgery after induction chemotherapy (IC) for primary lung cancer. Methods: Twenty-seven patients underwent surgery after receiving IC; for advanced non-small cell lung cancer in 16, and for small cell lung cancer in 11. All patients were given the platinum-based chemotherapy regimen. Results: Lobectomies were performed for 18 patients, bilobectomies for 4, pneumonectomies for 2, and partial resections or segmentectomies for 3. There were two postoperative deaths; one caused by adult respiratory distress syndrome (ARDS) and one caused by respiratory failure, resulting in a mortality rate of 7.4%. The postoperative complications included sputum retention in six patients, ARDS in two, anastomotic dehiscence after bronchoplasty in one, and pneumonia in one, resulting in 44.4% morbidity. The morbidity of patients who had received IC (IC group) was higher than that of a comparative group of 560 who underwent lung resection without IC during the same period (non-IC group), but the difference was not significant (44.4% vs 22.6%; P = 0.16). Both ARDS and bronchial insufficiency occurred more frequently in the IC group than in the non-IC group, but the differences were not significant (P = 0.25). Conclusions: These findings indicate the feasibility of treating primary lung cancer with IC followed by surgery as long as a cautious operative procedure is used and careful postoperative management is given, paying particular attention to the risk of ARDS and bronchial complications.

Completion pneumonectomy for recurrent or second primary lung cancer

OBJECTIVE We studied 8 patients undergoing completion pneumonectomy for recurrent or second primary lung cancer. METHODS Subjects were men who averaged 62 years of age. Of these 6 had p-stage I, and 2 p-stage II disease at initial operation. At the second operation, we diagnosed 3 with second primary lung cancer and 5 with recurrent lung cancer. We predicted postoperative pulmonary function by calculating the predicted forced expiratory volume in 1.0 second (FEV1.0) from residual numbers of subsegments after completion pneumonectomy. All predicted FEV1.0 in our 8 cases ranged from 544 to 926 (773 +/- 144) ml/m2. RESULTS Six patients experienced postoperative complications and morbidity was 75%. One patient undergoing completion sleeve pneumonectomy after radiation therapy for local carina recurrence died on 7th postoperative day due to anastomotic dehiscence and pneumonia. Overall operative mortality was 12.5% (1/8). Four remain alive and actuarial 5-year survival was 37.5%. CONCLUSIONS Careful consideration is needed in determining operative indications for completion pneumonectomy for patients after radiation therapy. Patients with recurrent squamous cell carcinoma who have p-stage I disease at initial operation and those with second primary lung cancer and p-stage I or II disease can expect relatively a long-term survival, and we concluded that completion pneumonectomy could be conducted in these cases with a satisfactory prognosis.

An aberrant left subclavian artery aneurysm with right aortic arch: Report of a case

The case of a 41-year-old man who developed an aneurysm in his aberrant left subclavian artery is described. The patient had a right aortic arch. After a successful aortosubclavian artery bypass, symptoms due to brain ischemia disappeared. This is a very rare disease that is sometimes associated with an aortic anomaly, therefore the optimal therapeutic procedure need to be carefully selected, including the operative indications and approach.

Prognostic Impact of the ABCC11/MRP8 Polymorphism in Adjuvant Oral Chemotherapy with S-1 for Non-Small Cell Lung Cancer

Background: Postoperative 1-year administration of S-1, an oral derivative of 5-fluorouracil (5-FU), was shown to be feasible in lung cancer. The 5-year survival rates of postoperative patients treated with S-1 adjuvant chemotherapy and the prognostic impact of clinicopathological factors were examined. Methods: The data of 50 patients with curatively resected pathological stage IB to IIIA non-small cell lung cancer, who were treated with S-1 postoperatively, were analyzed. The prognostic impacts of 22 clinicopathological factors including expressions of the 5-FU pathway enzymes were evaluated. A single-nucleotide polymorphism (SNP), i.e. 538G>A (rs17822931), of ABCC11/MRP8, which encodes a 5-FU excretion enzyme that is known as an earwax type determinant, was also evaluated. Results: The 5-year overall and relapse-free survival rates were 72.5 and 67.5%, respectively. A performance status ≥1, lymphatic vessel invasion, blood vessel invasion, and the A/A type of SNP538, which is responsible for the dry earwax type, were significantly associated with shorter relapse-free survivals. In 34 patients who showed a relative performance of 70% or more for chemotherapy, multivariate survival analysis indicated significant hazard ratios only for the A/A type of SNP538 (p = 0.007). Conclusions: S-1 has sufficient power as adjuvant chemotherapy. However, its effect might be small in the dry earwax type patient group in an adjuvant setting.

Pulmonary Tractotomy for a Patient with Traumatic Penetrating Lung Injury: Report of a Case

We report a case of traumatic hemopneumothorax caused by penetrating lung injury in a 26-year-old man. The patient underwent emergency thoractomy, which revealed hemorrhage in the lingular segment of the left lung. We found the bleeding point and controlled the hemorrhage using pulmonary tractotomy by inserting a linear stapler into the stab wound in the pulmonary parenchyma. The original technique of pulmonary tractotomy was performed for complete through-and-through injury by dividing the bridge of lung tissue between the aortic clamps. We were able to apply this procedure safely to stop bleeding from a stab wound that did not go through the lung. Thus, pulmonary tractotomy is an effective damage-control operation for the lung with obvious advantages over major lung resection.

GRAFT DAMAGE AFTER A SINGLE LUNG TRANSPLANTATION FOR PULMONARY HYPERTENSION IN A RAT MODEL

The hemodynamic effect and degree of damage in grafts of single lung transplants for pulmonary hypertension were studied in rats with monocrotaline-induced pulmonary hypertension. Inbred male Lewis rats (weight 200–230 g) were divided into two groups. Group 1 (control group,n = 16) underwent isogenic left lung transplantation, while group 2 (n = 15) received an intravenous administration of monocrotaline (80 mg/kg i.v.) and underwent isogenic left single lung transplantation 3 weeks later. Hemodynamic evaluations were performed prior to transplantation, at 1h postoperatively, and on days 3 and 7 after transplantation. Mean pulmonary arterial pressure (mPAP) rapidly declined after transplantation in group 2, from 39.3 ± 8.7 mmHg to 18.5 ±3.0 mmHg 1h after transplantation, and remained stable on day 7 after tranaplantation. No significant difference in the mPAP between the two groups was observed after tranaplantation. The extravascular lung water volume (ELWV: dry/wet ratio) in the right lung of group 2 significantly increased on day 3 (0.86 ± 0.02) (P < 0.01), and subsequently decreased to control levels on day 7 (0.83 ± 0.02). There was no significant difference in the ELWV in the grafted lungs between the two groups (0.84 ± 0.03 vs 0.86 ± 0.04), but there was tendency toward an increase in ELWV in group 2 on days 3 and 7. These data thus demonstrated that a hemodynamic improvement was obtained by single lung transplantation; however the degree of graft damage was remarkable in the pulmonary hypertension group.