Mie Shimamura

Staple Line Reinforcement with Fleece-Coated Fibrin Glue (TachoComb) After Thoracoscopic Bullectomy for the Treatment of Spontaneous Pneumothorax

BackgroundWe investigated the cause of pneumothorax recurrence after thoracoscopic surgery and the effectiveness of staple line reinforcement with fleece-coated fibrin glue (TachoComb) in the prevention of postoperative pneumothorax recurrence.MethodsFrom April 3, 1992 to the end of December 2005, thoracoscopic bullectomy was performed on 499 patients of primary spontaneous pneumothorax. The causes of recurrence were investigated on 39 patients on the basis of surgical observations, preoperative chest computed tomography, and so on. The most common cause was new bulla formation (37 cases), 19 of which were apparently related to the staple line (within 1 cm of the staple lines) and 15 of which were not related to the staple line. After 2000, we stopped using forceps to grasp lungs and we have reinforced the staple line by applying fleece-coated fibrin glue.ResultsThe staple line reinforced with fleece-coated fibrin glue, or sprayed with fibrin glue solution and the untreated group (bullectomy only with staples) were compared, and the recurrence rates were 1.22%, 7.25%, and 10.00%, respectively (P = 0.0006021).ConclusionsThe recurrence rate after thoracoscopic bullectomy with fleece-coated fibrin glue was significantly lowered and we consider this procedure to be the treatment of choice for the management of spontaneous pneumothorax.

Treatment strategies for chronic expanding hematomas of the thorax

PurposeTo investigate retrospectively the treatment strategies for chronic expanding hematoma (CEH) of the thorax.MethodsWe reviewed the medical records of six patients treated for CEH of the thorax at our institution between October 1996 and October 2006.ResultsAll of the patients had a history of thoracic surgery or tuberculosis with a latent period of 12–55 years before onset. One elderly patient with ischemic heart disease and in poor general health demonstrated a substantial improvement of symptoms after undergoing arterial embolization twice instead of surgery. The remaining five patients underwent either pleuropneumonectomy or a total capsule excision, following which their clinical condition improved remarkably. All six patients were discharged from the hospital. Arterial embolization was performed before surgery, and the amount of intraoperative bleeding ranged from 905 ml to 6 590 ml (average: 2 396 ml).ConclusionChronic expanding hematoma of the thorax may occur after thoracic surgery and a tuberculosis infection; however, considering the risk of massive bleeding during surgery, the decision to perform surgery should be made with extreme care.

Pulmonary Langerhans Cell Histiocytosis With Recurrent Pneumothorax

A 20-year-old woman with recurrent right pneumothorax was admitted to our hospital. A thoracoscopic bullectomy and lung biopsy was performed under general anesthesia. According to the histopathologic findings of permanent sections, a tissue specimen of diffuse lung disease revealed eosinophil infiltration and the presence of fibroblasts. Immunohistochemical stain showed S-100 protein-positive, as well as cluster of differentiation-68-positive large Langerhans cells. As a result, pulmonary Langerhans cell histiocytosis was diagnosed. The patient had an uncomplicated postoperative course and was discharged from the hospital on postoperative day 5. No recurrence was observed during the 6-month observation period.

Cause and Management of Recurrent Primary Spontaneous Pneumothorax After Thoracoscopic Stapler Blebectomy

BACKGROUND As the number of patients treated by thoracoscopic stapler blebectomy increased, the postoperative recurrence rate had risen unexpectedly. We retrospectively investigated the cause and management of primary spontaneous pneumothorax recurrence after thoracoscopic stapler blebectomy. METHODS From March 1992 to the end of December 2006, thoracoscopic stapler blebectomy was performed in 357 patients with primary spontaneous pneumothorax at the Nihon University Itabashi Hospital. The causes and management of recurrence were investigated in 30 patients with postoperative recurrence based on items such as the resurgical observations, preoperative chest computed tomography findings, previous operative notes. RESULTS Among the patients with bilateral pneumothorax, young patients exhibited a higher tendency for postoperative recurrence. The most common cause was new bulla formation (28 slides, 16 of which were apparently related to the staple line and 12 of which were not related to the staple line). CONCLUSION In thoracoscopic stapler blebectomy for primary spontaneous pneumothorax, the most common cause of recurrence was new bulla formation. It is necessary to establish additional procedures involving either the visceral pleura or the parietal pleura to reduce the recurrence rate.

Surgical Treatment of Catamenial Pneumothorax

OBJECTIVE To discuss the aetiology and determine the optimal surgical treatment of catamenial pneumothorax. METHODS Between January 1980 and December 2007, 17 patients with catamenial pneumothorax were treated at our institution. Regarding the surgical approach, thoracotomy was performed until 1991, and thoracoscopic surgery was performed from 1992 onward. RESULTS Pneumothorax was on the right side in all but two patients. Surgery was performed on 15 of the 17 patients. The surgical procedure was a diaphragm resection plus a partial bleb resection in eight patients, a diaphragm resection in two patients, a diaphragm resection plus an absorbable polyglycolic acid sheet in four patients, and a partial bleb resection in one patient. Five patients demonstrated a postoperative recurrence (33.0%). However, no recurrence has been observed thus far in the four patients with an absorbable polyglycolic sheet placed on the diaphragmatic surface. CONCLUSION Although the postoperative recurrence rate of patients undergoing surgical procedures remains high, there were some patients with no postoperative recurrence. Placement of an absorbable sheet on the diaphragmatic surface may therefore prevent recurrence of catamenial pneumothorax.

Thoracoscopic Resection of Mediastinal Bronchogenic Cysts in Adults

OBJECTIVE The aim of this study was to discuss the diagnosis and determine the optimal thoracoscopic surgical treatment of mediastinal bronchogenic cysts. METHODS From May 1996 to April 2008, 13 consecutive patients with mediastinal bronchogenic cysts underwent thoracoscopic surgery at our institution. There were eight men and five women aged 16-74 years (mean age, 41.5 years). RESULTS In the majority of patients (69.2%), there were no clinical symptoms and the lesions were found incidentally by chest radiography that was performed as part of physical screening. Lesions were found in the posterior mediastinum in five patients (38.5%) and in the upper mediastinum in four (30.8%). In the histopathological examinations, ciliary epithelium was observed in 13 patients (100.0%), bronchial cartilage in 7 patients (53.8%), bronchial glands in 6 patients (46.2%), and smooth muscle in 5 patients (38.5%). No serious postoperative complications were observed. In 3 patients (23.1%), conversion to open thoracotomy was necessary due to major pleural adhesions and intraoperative vascular injury. CONCLUSION Thoracoscopic resection of mediastinal bronchogenic cyst is minimally invasive and has no serious postoperative complications, and should therefore be considered as the primary therapeutic option.

Pulmonary Artery Pseudoaneurysm Secondary to Lung Inf lammation

Pulmonary artery aneurysms (PAA) and pseudoaneurysms (PAP) are caused by infections, vasculitis, trauma, pulmonary hypertension, congenital heart disease, and connective tissue disease. Most cases of such aneurysm occur in the trunk or major branches of the pulmonary artery, while the peripheral type is less common. The treatment modalities are medical therapy, surgery, and percutaneous catheter embolization. The mortality rate associated with rupture is approximately 50%. We encountered a case of a 53-year-old man with a pulmonary artery pseudoaneurysm secondary to pneumonia and cavity formation during chemotherapy for acute myeloid leukemia (AML). In diagnosis, contrast-enhanced chest computed tomography (CT) scan and pulmonary angiography were very useful. He was treated with right middle and lower lobectomy. After 1-month follow-up, he could restart additional chemotherapy.

Study of Thoracic Egg for spontaneous pneumothorax

自然気胸に対し，近年，簡易型胸腔ドレナージキット（ソラシックエッグ®）を挿入し，外来経過観察となる症例が増加している．今回，ソラシックエッグ®の有用性の有無を検討した．対象は過去2年間，当科外来でのソラシックエッグ®挿入46症例．ソラシックエッグ®挿入前の肺虚脱度は軽度から中等度虚脱43症例，高度虚脱3症例．予定手術12症例を除く非予定手術34症例のうち外来観察のみで軽快したのは21症例（61.8％）．膨張不良による入院となったのは13症例（38.2％）であり，このうち12症例（35.3％）に気漏遷延のため手術が必要であった．これらの平均外来観察期間は8.6日であった．一方，予定手術12症例では平均在院日数が8.25日で当科における入院期間の短縮が得られた．ソラシックエッグ®は軽度から中等度虚脱症例に対し有用であり，外来観察期間は7～9日間が限界で，以降の観察期間で膨張不良である場合，入院による治療が必要であると考える．

Type 1 congenital pulmonary airway malformation with a complication of abnormal blood vessel

An infant was suspected to have congenital pulmonary airway malformation (CPAM) according to magnetic resonance imaging (MRI) and computed tomography (CT) (Fig. 1(A) and (B)). A lower lobectomy was performed at 6 days of age, and the pathological examination was type 1 CPAM with a complication of abnormal blood vessel (Fig. 2(A)—(C)). Fig. 1. (A) Coronal MRI at 30 weeks of gestation revealed fetal ascites (arrow) and hypoplasia in the right lung (arrowhead). (B) Chest computed assisted tomography after birth revealed a localized consolidation at the right lower lobe (arrow). Fig. 2. (A) Macroscopic findings of the resected right lower lobe demonstrating an anomalous artery derived from the descending aorta (arrow). (B) Macro-scopic findings of the right lower lobe fixed in formaldehyde

A Case of Spontaneous Mediastinal Emphysema with Spontaneous Pneumothorax

症例は 72 歳の男性．慢性腎不全で透析を受けていた．胸部違和感と労作時の呼吸苦を主訴に胸部 X 線写真を行い，右肺の虚脱を認めため，直ちに胸腔ドレナージを行った．ドレナージ直後より肺の膨張は良好で気漏も認めなかったが，3 日後より著明な皮下気腫が出現した．ドレナージチューブからの空気の流出を認めなかったため，ドレーンの閉塞を考えドレナージを入れ替えたが気漏は認めなかった．胸部 CT 上，皮下気腫，縦隔気腫を認め，ドレーンからの気漏は認めないことから，自然気胸に続発した特発性縦隔気腫と診断した．肺の気腫化や透析患者などの肺の脆弱化した症例では，特発性縦隔気腫を併発することも考慮して治療にあたる必要がある．