Masayuki Okui

Effect of cutting technique at the intersegmental plane during segmentectomy on expansion of the preserved segment: Comparison between staplers and scissors in ex vivo pig lung

OBJECTIVE Cutting the intersegmental plane by using a stapler during segmentectomy might interfere with the expansion of the preserved lung due to visceral pleura caught in a staple line, especially in a large regional segmentectomy, such as left upper division or basal segmentectomy. We compared the preserved lung volume after segmentectomy among the methods using stapler, sharp dissection, and their combination for cutting the intersegmental plane in ex vivo pig lungs. We also examined a covering effect of polyglycolic acid mesh and fibrin glue. METHODS To assume a large regional segmentectomy in clinical practice, segments of the left caudal lobe except the lateral segment 2 (L2 segment) were resected, and the lung volume of the preserved L2 segment was measured. The intersegmental plane was cut by the following three methods: (1) stapler (n = 8); (2) scissors (n = 8); and (3) the combined method, that is, cutting the shallow lung tissue with scissors and the deep one with stapler (n = 8). The opened intersegmental plane was covered with polyglycolic acid mesh and fibrin glue. The air leakage was checked by injecting air through the bronchus at pressures of up to 30 cmH(2)O. Thereafter, normal saline was injected through the bronchus at pressures of 10, 20, and 30 cmH(2)O, to measure lung volumes by the volume-displacement method. RESULTS Polyglycolic acid mesh and fibrin glue prevented air leakage completely at up to 30 cmH(2)O. At the saline injection pressures of 10, 20, and 30 cmH(2)O, the mean volumes of L2 segment were 72 ± 14, 96 ± 14, and 109 ± 26 ml with the stapler; 86 ± 11, 117 ± 19, and 135 ± 39 ml with scissors; and 98 ± 10, 140 ± 20, and 155 ± 40 ml with the combined methods, respectively. The volume of the preserved L2 segment was significantly lower with the stapler method than with either the scissors or combined method at each pressure (p < 0.01). The difference was not significant between the scissors and combined methods. CONCLUSIONS Coverage with polyglycolic acid mesh and fibrin glue prevented air leakage from the opened intersegmental plane. The stapler interferes with the expansion of preserved lung in comparison to scissors or combined methods in a large regional segmentectomy.

Combined subsegmentectomy for S(2)(b) (horizontal subsegment of the posterior segment) and S(3)(a) (lateral subsegment of the anterior segment) in the right upper pulmonary lobe.

A technique for combined resection of S2b (horizontal subsegment of the posterior segment) and S3a (lateral subsegment of the anterior segment) of the right upper lobe of the lung is presented. Although both the S2b and S3a should be resected from the interlobar fissure, an approach for the artery and bronchus of S3a (A3a and B3a, respectively) is easier from the ventral side of the hilum rather than from the interlobar fissure, because B3 runs in back of V2 at the interlobar fissure. To resolve this contradiction, we devised a procedure as follows: (1) A2b and B2b are cut at the interlobar fissure; (2) A3a and B3a are cut from the ventral side of hilum; (3) the peripheral stumps of A3a and B3a are transferred to the interlobar fissure; and (4) subsegments of S3a and S2b are resected with the peripheral stumps of A2b, B2b, A3a, and B3a from the side of the interlobar fissure. We believe this procedure makes the combined resection of S2b and S3a easy.

Bronchioloalveolar carcinoma as a second malignancy in a pediatric osteosarcoma survivor: case report

BackgroundPrimary lung cancer is extremely rare in children, while secondary malignancies reportedly develop in 2% to 3% of pediatric osteosarcoma survivors.Case presentationA 14-year-old girl was found to have two pulmonary lesions on computed tomography. These tumors had developed 1 year after osteosarcoma surgery. Segmentectomy of right segment 1 and wedge resection of right segment 9 were performed. Both lesions were completely resected and postoperative histopathological examination revealed metastasis of osteosarcoma and bronchioloalveolar carcinoma, respectively.ConclusionBronchioloalveolar carcinoma may present as a solitary pulmonary lesion indistinguishable from a metastatic lesion and should be included in the differential diagnosis of pulmonary lesions in survivors of pediatric cancer. Thus, pulmonary lesions identified in these patients should be biopsied or resected to establish a histological diagnosis.

Intractable Pneumothorax Treated With Endobronchial Watanabe Spigots.

Pneumothorax secondary to nontuberculous mycobacterial lung disease is often intractable and associated with high mortality. An endobronchial Watanabe spigot (EWS) is a silicon plug developed for bronchoscopic bronchial occlusion. Here we report a case of intractable pneumothorax secondary to nontuberculous mycobacterial lung disease successfully treated using EWSs. Occlusion of the multiple ectatic bronchi connected to the bronchopleural fistula was essential for optimal effect of the EWSs.

Innovative segmentectomy to remove the posterior segment of the lower lobe (S 10 ) of the lung

We describe our innovative technique for performing segmentectomy of the posterior segment of the lower lobe of the lung, being segment number 10 (S10). In segmentectomy of S10, it is difficult to identify A10 from the interlobar fissure because the pulmonary artery to S10 (A10) branches from A9+10 and runs dorsally and deeply into the lung tissue. Moreover, to reach S10 from the interlobar fissure, the lung tissue should be cut between S6 and S8, because S10 is not located beside the interlobar fissure. However, it is difficult to identify the boundary between the S6 and S8 without a route marker. To solve these difficulties, we divided S6 and S10 from each other at the beginning of the procedure, which enabled A10 to be identified easily from the dorsal side. Because S6 and S8–10 should be divided in S10 segmentectomy at the end, the division between S6 and S8–10 at the beginning of procedure is not only reasonable, but makes the procedure simple.

Surgery for Pulmonary Fungal Infections Complicating Hematological Malignancies

Background The complication rate of fungal disease is higher among patients with hematological malignancies. We investigated the clinicobacteriological outcomes of resected pulmonary fungal infections complicating hematological malignancies. Methods Between 2001 and 2017, 21 patients with pulmonary fungal infections complicating hematological malignancies underwent resection, and their clinical records and survival were retrospectively reviewed. Results The median age of the patients was 47 years, and 13 were male. The histological diagnoses were pulmonary aspergillosis (19 cases), mucormycosis (1 case), and cryptococcosis (1 case). The indications for surgery were resistance to antifungal therapy and the necessity of surgery before hematopoietic stem cell transplantation in 13 and 8 cases, respectively. The diagnoses of the hematological malignancies were acute myelogenous leukemia (10 cases), acute lymphocytic leukemia (5 cases), myelodysplastic syndrome (3 cases), and chronic myelogenous leukemia, malignant lymphoma, and extramedullary plasmacytoma (1 case each). The surgical procedures were partial resection (11 cases), segmentectomy (5 cases), lobectomy (4 cases), and cavernostomy (1 case). The size of the lesions was 0.9–8.5 cm. Fourteen cases had cavitation. There were no surgical-related deaths or fungal progression. Conclusion Pulmonary fungal infections are resistant to treatments for hematological malignancies. Since the treatment of the underlying disease is extended and these infections often recur and are exacerbated, surgery should be considered when possible.

Dyspnea caused by osteochondroma of the clavicle head: a case report

Osteochondroma is a benign cartilaginous neoplasm and is the most common benign bone tumor. Osteochondromas arising from the clavicular head are extremely rare and symptomatic cases are even less common. We report a 23-year-old man who presented with dyspnea due to tracheal displacement resulting from a clavicular osteochondroma. The patient underwent successful resection involving a trap-door thoracotomy.

Intrathoracic ganglioneuroma surrounding left vertebral and subclavian arteries successfully resected by modified trapdoor thoracotomy

Neurogenic tumors are derived from tissue of the neural crest. Most of the mediastinal neurogenic tumors occur in the posterior compartment. Extension to the cervical area and the surrounding major arteries is rare. We report a patient with a ganglioneuroma arising from the brachial plexus, extending into the cervical region, and surrounding the left vertebral and subclavian arteries. The patient underwent successful resection by modified trapdoor thoracotomy.