Naoki Kanauchi

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.

Role of diffusion-weighted magnetic resonance imaging for predicting of tumor invasiveness for clinical stage IA non-small cell lung cancer

OBJECTIVES Recently, diffusion-weighted MR imaging (DWI) for the whole body has become available for clinical use, as has been previously used for the central nervous system. Favorable results have been reported using this imaging system to differentiate between benign and malignant lesions in some organs, and to correlate with the degree of cell differentiation in lung cancer. The purpose of this study was to assess the role of DWI for predicting tumor invasiveness of non-small cell lung cancers (NSCLC), especially for clinical stage IA patients. METHODS From January 2006 to September 2007, preoperative DWI and 18F-FDG-PET/CT were performed on 41 patients with clinical stage IA NSCLC who had undergone curative operations. Lung cancers that exhibited nodal, lymphovascular or pleural invasion were defined as invasive lung cancers. Nodules with strong dark signal, as observed by DWI in spinal cords, were defined as DWI-positive. We analyzed the associations between the pathological findings and the following preoperative clinical factors: age, gender, smoking history, preoperative CEA levels (<5.0 or >/=5.0ng/ml), preoperative tumor size, SUV max on PET/CT (<5.0 or >/=5.0) and DWI (positive or negative). RESULTS A total of 15 lesions (37%) were assessed as DWI-positive and 26 lesions (63%) were DWI-negative. Univariate analyses showed positive correlations for development of invasive cancer with the preoperative CEA level (p=0.049), SUV max (p=0.001) and DWI (p<0.001). Multivariate analysis showed that DWI (p=0.005) was an independent predictive factor for tumor invasiveness. CONCLUSION Our results suggest that DWI might be a useful method for predicting tumor invasiveness for clinical stage IA NSCLC.

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.

Preoperative prognostic nutritional index as a predictor of outcomes in elderly patients after surgery for lung cancer

Background and objective The prognostic nutritional index (PNI) is based on the serum albumin level and lymphocyte count, and is a useful predictor of survival in various cancers. However, the utility of PNI in lung cancer has not been examined. The aim of this study is to assess PNI as a prognostic factor in elderly patients after surgery for primary lung cancer. Methods A retrospective review was performed in 131 elderly patients (≥75 years old) with lung cancer who underwent curative operations at our hospital from July 2008 to December 2014. Survival was calculated by the Kaplan-Meier method. The effects of PNI and clinicopathological factors on survival were evaluated in univariate and multivariate Cox regression analyses. Results The 5-year cancer-specific survival (CSS) rates of patients with PNI ≥ 45 and <45 were 76.2% and 47.8%, respectively (P = 0.0166), and the 5-year overall survival (OS) rates were 61.9% and 39.8%, respectively (P = 0.0275). Among patients who died within 5 years, mortality due to other diseases was 31%. Univariate analysis identified gender (P = 0.003), serum carcinoembryonic antigen (CEA) (P = 0.009), PNI (P = 0.027), c-stage (P = 0.005), histological type (P = 0.001) and p-stage (P < 0.001) as prognostic factors. In multivariate analysis, CEA (HR 2.487, P = 0.0169), PNI (HR 2.737, P = 0.0289) and p-stage (HR 3.294, P = 0.007) were independent prognostic factors in elderly patients after curative surgery for lung cancer. Conclusions CEA, PNI and p-stage are independent prognostic factors in elderly patients after surgery for primary lung cancer. Therefore, determination of preoperative PNI may be useful for treatment planning in elderly patients with lung cancer.

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.

Torsion of extralobar pulmonary sequestration

A 19-year-old male experienced discomfort in the left chest. Chest computed tomography detected a 5-cm solid mass on the left diaphragm (Fig. 1). Surgery was performed for suspected diaphragmatic herniation. The mass had developed from the mediastinum with torsional pedunculation (Fig. 2). His condition was diagnosed as extralobar pulmonary sequestration with torsion. www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 39 (2011) e31

Thoracoscopic surgery versus open surgery for lung metastases of colorectal cancer: a multi-institutional retrospective analysis using propensity score adjustment†

OBJECTIVES Thoracoscopic surgery for lung metastasectomy remains controversial. The study aimed at determining the efficacy of thoracoscopic surgery for lung metastasectomy. METHODS This was a multi-institutional, retrospective study that included 1047 patients who underwent lung metastasectomy for colorectal cancer between 1999 and 2014. Prognostic factors of overall survival were compared between the thoracoscopic and open thoracotomy groups using the multivariate Cox proportional hazard model. The propensity score, calculated using the preoperative covariates, included the era of lung surgery as a covariate. A stepwise backward elimination method, with a probability level of 0.15, was used to select the most powerful sets of outcome predictors. The difference between the radiological tumour number and the resected tumour number (delta_num) was also evaluated. RESULTS The c -statistics and the P -value of the Hosmer-Lemeshow Chi-square of the propensity score model were 0.7149 and 0.1579, respectively. After adjusting for the propensity score, the thoracoscopy group had a better survival rate than the open group (stratified log-rank test: P  = 0.0353). After adjusting for the propensity score, the most powerful predictive model for overall survival was that which combined thoracoscopy [hazard ratio (HR): 0.468, 95% CI: 0.262-0.838, P  = 0.011] and anatomical resection (HR: 1.49, 95% CI: 1.134-1.953, P  = 0.004). Before adjusting for the propensity score, the delta_num was significantly greater in the open group than in the thoracoscopy group (thoracoscopy: 0.06, open: 0.33, P  = 0.001); however, after adjustment, there was no difference in the delta_num (thoracoscopy: 0.04, open: 0.19, P  = 0.114). CONCLUSIONS Thoracoscopic metastasectomy showed better overall survival than the open approach in this analysis. The thoracoscopic approach may be an acceptable option for resection of pulmonary metastases in terms of tumour identification and survival outcome in the current era.

Morcellation Technique to Remove Large Tumor in Thoracoscopic Surgery

Extraction of tumors remains a major problem in thoracoscopic surgery. In this study, we used an efficient instrument to morcellate a tumor during thoracoscopic surgery. The cosmetic result of this technique was satisfactory; thus, we suggest that this technique is a reliable option for use during thoracoscopic surgery for benign solid tumors.