Noboru Nishiumi

Application of the fold plication method for unilateral lung volume reduction in pulmonary emphysema

BACKGROUND Unilateral lung volume reduction procedures are used to treat pulmonary emphysema. The most significant technical problem with this operation is an air leak from the pulmonary stump. Bovine pericardium has been used to prevent air leaks but is associated with interstitial pneumonia and a high cost. METHODS The fold plication method was devised to prevent postoperative air leaks to avoid interstitial pneumonia, and to decrease cost. This technique was applied in 20 consecutive patients with emphysema who underwent a unilateral lung volume reduction operation via a thoracoscopic two windows approach. RESULTS The operative time was approximately 1 hour. There was minimal postoperative bleeding, no persistent air leaks, and no evidence of pneumonia. Pulmonary function improved in all patients. CONCLUSIONS The unilateral fold plication method is an economical and safe alternative to bovine pericardial patching after lung volume reduction operation to prevent stump air leaks.

Experience With the Two-Windows Method for Mediastinal Lymph Node Dissection in Lung Cancer

BACKGROUND Continuing to refine minimally invasive thoracoscopic surgical procedures, we have established the two-windows method. METHODS Skin incisions required by this method consist of a 2- to 3-cm skin incision posteriorly, and a 2- to 3-cm skin incision anteriorly in the fourth intercostal space, with the inferior angle of the scapula as the midpoint. We used this method to perform pulmonary lobectomies in combination with thoracoscopy and mediastinal lymph node dissection in 100 consecutive patients with lung cancer (preoperative diagnosis, stage I, T1 N0 M0). RESULTS The mean operative time was 2 hours 46 minutes, the mean blood loss was 68.2 mL, and the mean number of mediastinal lymph nodes dissected was 24.3. In developing this minimally invasive thoracoscopic procedure, which facilitates mediastinal lymph node dissection, we realized that it is best performed through the fourth intercostal space. Because the tracheal bifurcation can be seen directly below this level, surgical manipulation in this area can be easily performed. This enables the same extent of mediastinal lymph node dissection as that performed during a standard thoracotomy. Another advantage of this method is that a standard posterolateral thoracotomy incision can be made whenever necessary by simply connecting the two incisions. CONCLUSIONS We believe that the two-windows method is capable of serving as the standard method for the surgical treatment of stage I lung cancer.

Blunt chest trauma with deep pulmonary laceration

BACKGROUND Deep pulmonary laceration (DPL) is rare and its survival rate is low. The present study focused on the prognostic factors of DPL. METHODS The present study concerned 17 DPL patients treated in Tokai University Hospital between 1988 and 1998. The prognostic factors of DPL were compared with systolic blood pressure (SBP), PaO2, and the volume of intrathoracic blood loss. Characteristic findings of initial chest roentgenograms of DPL were investigated. RESULTS Eleven patients were saved and 6 patients died. An SBP of less than 80 mm Hg on arrival at the hospital and a blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival were poor prognostic factors. Hypoxemia on arrival was not a poor prognostic factor. Chest roentgenograms showed macular infiltrative shadow with moderate lung collapse and deviation of the mediastinal shadow toward the unaffected side. Selective bronchial occlusion with a Univent prevented suffocation by intrabronchial blood. CONCLUSIONS Two poor prognostic factors of DPL are SBP less than 80 mm Hg on arrival and blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival.

Diagnosis and Treatment of Deep Pulmonary Laceration With Intrathoracic Hemorrhage From Blunt Trauma

BACKGROUND Blunt chest trauma resulting in massive hemothorax requires immediate attention. We investigated the diagnostic and prognostic utility of various clinical factors in patients with deep pulmonary laceration caused by blunt chest trauma with a view toward interventional treatment. METHODS We reviewed 42 patients with deep pulmonary laceration resulting from blunt chest trauma who were treated between 1988 and 2008. Various clinical factors were compared between survivors and nonsurvivors. RESULTS Of the 42 patients, 29 (69%) survived. Median (25th, 75th percentile) systolic blood pressure at arrival was 102 (76, 121) mm Hg for survivors and 70 (60, 90) mm Hg for nonsurvivors (p = 0.015). The median heart rate at arrival was 107 (98, 120) beats/min for survivors and 130 (120, 140) beats/min for nonsurvivors (p = 0.014). Respiratory rate, Glasgow Coma Scale score, and arterial blood gas values did not affect prognosis. Blood loss through the chest tube at insertion was 500 (400, 700) mL for survivors and 700 (500, 1000) mL for nonsurvivors (p = 0.147) and within 2 hours of arrival was 850 (590, 1100) mm Hg and 1600 (1400, 2000) mL, respectively (p < 0.001). Blood loss during thoracotomy was 1170 (600, 1790) mL and 3500 (2000, 6690), respectively (p < 0.001). CONCLUSIONS In patients with deep pulmonary laceration, hemorrhagic shock with systolic blood pressure less than 80 mm Hg and heart rate more than 120 beats/min leads to a poor prognosis. Emergency thoracotomy and pulmonary lobectomy should be performed before the intrathoracic hemorrhage reaches 1200 mL.

Relation Between Gastrointestinal Mucus Production and Lymph Node Metastasis in Cases in Samll-sized Lung Adenocarcinoma.

Objective. The evaluation of reduction surgery for small-sized lung adenocarcinoma is still being debated, and the indications for reduction surgery in these patients have not been adequately discussed. Gastrointestinal mucus is not secreted by normal alveolar cells, but some lung adenocarcinomas secrete gastrointestinal mucus, and it is reported that the prognosis of patents with lung adenocarcinomas secreting gastrointestinal mucus is poor. We therefore investigated the relation between lymph node metastasis and the secretion of gastrointestinal mucus in surgically treated cases of small-sized lung adenocarcinoma. Methods. We studied 79 lung adenocarcinoma lesions measuring 2.0 cm or less in patients treated by lobectomy and ND2a dissection between 1989 and 1999. We separated the lesions into two groups according to nodal metastasis: the node-negative group(pN0, 60 lesions) and the node-positive group(pN1, 8 lesions; pN2, 11 lesions). We investigated the incidence of lymph node metastasis in relation to gastrointestinal mucus production, which was determined immunohistologically by staining for HGM, MUC2, MUC5AC, and MUC6, in these two groups. Results. Staining for HGM was negative in all samples. MUC2 was detected in 1 lesion(2%) in the nodenegative group and in 5 lesions(26%) in the node-positive group. MUC6 was detected in 5 lesions(8%) in the nodenegative group and in 6 lesions(32%) in the node-positive group. The difference in the frequency of MUC2 and MUC6 production between lesions with and without lymph node metastasis was statistically significant(p< 0.001, p= 0.006, re東海大学医学部1外 科学系呼吸器外科学部門,2病 態診断系病理 学部 門. 別刷請求先:西 海 昇,東 海大学医学部外科学系 呼吸器外科学部 門,〒259-1193神 奈川県伊勢原市望星台(e-mail:nishiumi@is.icc. u-tokai.ac.jp). 1Division of General Thoracic Surgery, Department of Surgery, 2Department of Pathology , Tokai University School of Medicine, Japan. Reprints: Noboru Nishiumi, Division of General Thoracic Surgery, Department of Surgery, Tokai University, School of Medicine, Bohseidai, Isehara, Kanagawa 259-1193, Japan(e-mail: nishiumi@is. icc.u-tokai.ac.jp). Received September 4, 2002; accepted February 13, 2003