Okada Y

Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy

BackgroundWith the recent widespread use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), there have been occasional reports on complications associated with its use. Previous reviews on EBUS-TBNA have been limited to studies by skilled operators, thus the results may not always be applicable to recent clinical practice. To assess the safety of EBUS-TBNA for the staging and diagnosis of lung cancer in Japan, a nationwide survey on its current usage status and complications associated with its use was conducted by the Japan Society for Respiratory Endoscopy (JSRE).MethodsA questionnaire about EBUS-TBNA performed between January 2011 and June 2012 was mailed to 520 JSRE-accredited facilities.ResultsResponses were obtained from 455 facilities (87.5%). During the study period, EBUS-TBNA was performed in 7,345 cases in 210 facilities (46.2%) using a convex probe ultrasound bronchoscope, for 6,836 mediastinal and hilar lesions and 275 lung parenchymal lesions. Ninety complications occurred in 32 facilities. The complication rate was 1.23% (95% confidence interval, 0.97%-1.48%), with hemorrhage being the most frequent complication (50 cases, 0.68%). Infectious complications developed in 14 cases (0.19%) (Mediastinitis, 7; pneumonia, 4; pericarditis, 1; cyst infection, 1; and sepsis, 1). Pneumothorax developed in 2 cases (0.03%), one of which required tube drainage. Regarding the outcome of the cases with complications, prolonged hospitalization was observed in 14 cases, life-threatening conditions in 4, and death in 1 (severe cerebral infarction) (mortality rate, 0.01%). Breakage of the ultrasound bronchoscope occurred in 98 cases (1.33%) in 67 facilities (31.9%), and that of the puncture needle in 15 cases (0.20%) in 8 facilities (3.8%).ConclusionsAlthough the complication rate associated with EBUS-TBNA was found to be low, severe complications, including infectious complications, were observed, and the incidence of device breakage was high. Since the use of EBUS-TBNA is rapidly expanding in Japan, an educational program for its safe performance should be immediately established.

Deaths and complications associated with respiratory endoscopy: a survey by the Japan Society for Respiratory Endoscopy in 2010.

Background and objective:  In order to survey the current status of the use and complications associated with respiratory endoscopy, the Japan Society for Respiratory Endoscopy conducted a nationwide postal questionnaire survey.

Results of Long-Term Follow-Up of Patients With Completely Resected Non-Small Cell Lung Cancer

BACKGROUND In patients with completely resected non-small cell lung cancer, recurrence-free survival, postrecurrence survival, and metachronous primary lung cancer have not been well studied at the same time. METHODS A total of 315 patients with non-small cell lung cancer who underwent complete resection between 2001 and 2005 were examined. Patients were routinely assessed with computed tomography of the chest and physical checkups every 4 months for the first 2 years and every 6 months from the third to the fifth year. After that, they were examined annually. RESULTS The overall 5-year survival was 70%. Of all 315 patients, 107 had recurrent disease. The median recurrence-free survival was 15.7 months. Multivariate analysis showed that pathologic stage and pleural invasion were associated with decreased recurrence-free survival. The median postrecurrence survival was 18.7 months. Multivariate analysis indicated that male sex, pleural invasion, extrathoracic recurrence, and supportive care for recurrence were associated with decreased postrecurrence survival. The cumulative rate of metachronous primary lung cancer at 5 years was 3.7%, and it developed even 8 years after the initial operation. CONCLUSIONS Only pleural invasion of the original lung cancer was related to both recurrence-free survival and postrecurrence survival. Moreover, postrecurrence survival was related to both site and treatment of the initial recurrence. The incidence of metachronous primary lung cancer was stable over time after the initial operation.

The nuclear factor erythroid 2-related factor 2 activator oltipraz attenuates chronic hypoxia-induced cardiopulmonary alterations in mice.

Nuclear factor erythroid 2-related factor 2 (Nrf2) is a key regulator that activates many antioxidant enzymes. Oxidative stress, which accumulates in diseased lungs associated with pulmonary hypertension (PH), is thought to be responsible for the progression of cardiopulmonary changes. To test whether Nrf2 activation would exert therapeutic efficacy against cardiopulmonary changes in a hypoxia-induced PH model, wild-type (WT) and Nrf2-deficient mice as well as Kelch-like ECH associating protein 1 (Keap1) (negative regulator of Nrf2) knockdown mutant mice were exposed to hypobaric hypoxia for 3 weeks. This chronic hypoxia exacerbated right ventricular systolic pressure, right ventricular hypertrophy (RVH), and pulmonary vascular remodeling in the WT mice. These pathological changes were associated with aberrant accumulation of Tenascin-C, a disease-indicative extracellular glycoprotein. Simultaneous administration of oltipraz, a potent Nrf2 activator, significantly attenuated RVH and pulmonary vascular remodeling and concomitantly ameliorated Tenascin-C accumulation in the hypoxic mice. Hypoxia-exposed Nrf2-deficient mice developed more pronounced RVH than WT mice, whereas hypoxia-exposed Keap1-knockdown mice showed less RVH and pulmonary vascular remodeling than WT mice, underscoring the beneficial potency of Nrf2 activity against PH. We also demonstrated that expression of the Nrf2-regulated antioxidant enzymes was decreased in a patient with chronic obstructive pulmonary disease associated with PH. The decreased antioxidant enzymes may underlie the pathogenesis of cardiopulmonary changes in the patient with chronic obstructive pulmonary disease and PH. The pharmacologically or genetically induced Nrf2 activity clearly decreased RVH and pulmonary vascular remodeling in the hypoxic PH model. The efficacy of oltipraz highlights a promising therapeutic potency of Nrf2 activators for the prevention of PH in patients with hypoxemic lung disease.

Bronchoscopic practice in Japan: A survey by the Japan Society for Respiratory Endoscopy in 2010

Background and objective:  To ensure the safety of bronchoscopic practice, the Japan Society for Respiratory Endoscopy conducted a national survey to investigate the current state of procedure for this technique.

Successful thoracoscopic surgery for intractable pneumothorax after pneumonectomy under local and epidural anesthesia

the long and narrow patent ductus arteriosus, was diagnosed and dealt with. Dysphagia owing to right aortic arch with left ligamentum is known to present late, unlike double aortic arch, which usually presents early. We were surprised by the relative ease with which the arch could be mobilized and translocated anteriorly from behind the esophagus. The LSCA, which was already stenosed, was sacrificed to achieve a tension-free anastomosis. During the development of normal aortic arches, there is dissolution of the right sixth aortic arch and of the dorsal aorta distal to the right subclavian artery. The right aortic arch with mirror-image branching is almost always associated with an intracardiac defect. A large percentage of patients with right aortic arch and retroesophageal LSCA do not have intracardiac anomalies. The pathologic anatomy in this patient could be explained by the dissolution of the left fourth aortic arch with the presence of a left dorsal aorta. The ‘‘ductal theory’’ of development of coarctation could explain the development of this condition in the absence of an intracardiac anomaly. The ductal tissue migration to the origin of the LSCA and the arch could possibly explain the stenotic origin of the LSCA and the hypoplastic arch. TheKommerell diverticulum is formed by the proximal portion of the left dorsal aorta, the presence of which is an indirect indicator of the presence of ligamentum on that side. Kommerell diverticulum is known to cause residual tracheoesophageal obstruction in patients with vascular ring. This could be because of the gradual enlargement of the diverticulum and also because of the tugging effect of the LSCA. It is also known to be prone to aneurysmal and degenerative atherosclerotic changes.We excluded the diverticulumbyusing

A total pleural covering technique in patients with intractable bilateral secondary spontaneous pneumothorax: Report of five cases

We herein present five cases of bilateral intractable secondary spontaneous pneumothorax associated with chronic severe lung diseases that were successfully treated with a modified form of a previously reported surgical procedure, the “total pleural covering technique,” under video-assisted thoracic surgery. We performed the total pleural covering technique modified with a preceding coverage of air-leak points with polyglycolic acid sheets. In this series, the median length of surgery was 106 min (range: 67–220 min) on the unilateral side (10 sides). No significant surgical complications were observed, but one patient died on day 23 after the operation, due to respiratory insufficiency on the basis of the underlying lung disease. The remaining four patients have been followed up regularly (mean follow-up time: 23 months; range: 1–54 months) and there has been no recurrences of pneumothorax. We believe that the total pleural covering technique is a useful method; however, special attention should be paid to the underlying disease in order to identify patients who would be most likely to benefit from the procedure.

p190A RhoGAP is involved in EGFR pathways and promotes proliferation, invasion and migration in lung adenocarcinoma cells

Overcoming acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR‑TKIs) is an emerging issue in lung cancer treatment. We report evidence that a GTPase-activating protein, p190-A RhoGAP (p190), is a potential molecular target for the treatment of lung adenocarcinoma. We documented inhibition of phosphorylation of p190 by EGFR-TKI treatment in lung adenocarcinoma cell lines. Small interfering RNA-mediated knockdown of p190 leads lung adenocarcinoma cells to growth suppression and to inhibition of invasion/migration through inducing cell cycle arrest but not apoptosis. These findings were observed not only in EGFR-TKI-sensitive cells but also in EGFR-TKI-resistant cells; even in cell lines harboring K-ras mutations. The mechanism of this inhibitory effect on growth and invasion/migration was Ras inactivation through disrupting the p190-A RhoGAP/p120RasGAP complex. In addition, a high level of p190 mRNA expression was observed in majority of surgically obtained tissue from lung adenocarcinoma patients. Overexpression of p190 mRNA associated with poor disease-free survival. The results suggest that overexpression of p190 mRNA may be involved in the carcinogenesis of lung adenocarcinoma. These findings indicate that p190 is a possible molecular target for treatment of lung adenocarcinoma.

Successful management of intractable chylothorax in Gorham–Stout disease by awake thoracoscopic surgery

Gorham–Stout is an extremely rare disease, which is characterized by proliferation of vascular and lymphatic bone structures. A 15-year-old male patient was the diagnosis of Gorham–Stout disease of the cervical spine with chylothorax. Awake thoracoscopic ablation was performed using bronchoscopic tools and awake thoracoscopic debridement of the thoracoscopic cavities and chemical pleurodesis with OK-432 were repeated. The amount of drained liquid was controlled. There was no recurrence of pleural effusion.

Awake video-thoracoscopic surgery for intractable pneumothorax in pregnancy by using a single portal plus puncture

A 31-year old female patient in the ninth week of pregnancy complained of chest pain and dyspnoea. The patient had experienced an episode of spontaneous pneumothorax on the left side at the age of 20 and had undergone chest tube drainage. Her medical history was unremarkable and she had no history of smoking. She had no family history of pulmonary disease. Thoracic radiography showed a pneumothorax on the right side. The patient underwent chest tube drainage in the thoracic space. When surgical intervention for continuous air leakage was unavoidable, we selected video-assisted thoracic surgery under local and epidural anaesthesia in consideration of her general condition. We conclude that awake surgical intervention is applicable in selected patients with pneumothorax in pregnancy and is particularly useful in those in whom general anaesthesia is best avoided.