Ryo Harada

Surgical treatment for primary lung cancer combined with idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is defined as a specific form of chronic, progressive fibrosing interstitial pneumonia of unknown cause. IPF is associated with an increased risk of lung cancer, and lung cancer patients with IPF undergoing pulmonary resection for non-small cell lung cancer have increased postoperative morbidity and mortality. Especially, postoperative acute exacerbation of IPF (AEIPF) causes fatal status and long-term outcomes are worse than for patients without IPF, although certain subgroups have a good long-term outcome. A comprehensive review of the current literature pertaining to AEIPF and the late phase outcome after the context of a surgical intervention was performed.

Spinal cord protection with selective spinal perfusion during descending thoracic and thoracoabdominal aortic surgery

Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30-40 ml/min for each intercostal artery and was adjusted to keep the proximal circuit pressure at 150-200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesis/paraplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation.

Thoracoscopic Mediastinal Lymph Node Dissection for Lung Cancer

In lung cancer, mediastinum lymphatic spread occurs. We review our technique and experience of thoracoscopic mediastinal lymphnode dissection (MLND). Between 1997 and 2011, 992 patients with primary lung cancer underwent thoracoscopic major pulmonary resection with MLND. Initially we used a combination of electrocautery and clips to divide blood vessels and lymphatic channels; our current technique relies on a vessel sealing system (VSS) which is expeditious and leads to less lymphorrhea. Furthermore, dissection of station 7 nodes is performed after each main bronchus or right intermediate bronchus is taped with a 0 silk suture, which is then brought out of the thorax through the access incision for antero-lateral retraction of the tracheal carina. We dissect between 3 and 4 N2 lymph node stations and a total of approximately 20 N2 lymph nodes. Postoperative complications related to MLND occurred in 35 of 992 patients (3.5%), 15 (1.5%) for recurrent laryngeal nerve injury, 3 (0.3%) for bilateral vagal injury, 14 (1.4%) for chylothorax and 3 (0.3%) for airway injury. However, none were lethal. Thoracoscopic mediastinal dissection is safe and feasible in treating lung cancer. We believe our technique and VSS are very useful for thoracoscopic MLND.

Renal cysts as strongest association with abdominal aortic aneurysm in elderly.

OBJECTIVE The aim of this study is to investigate the positive association between the presence of renal cysts and AAA. PATIENTS AND METHODS A retrospective chart review on the clinical data of 396 consecutive patients, who underwent CT scans for preoperative evaluation of thoracic and cardiovascular surgery in Sapporo Medical University from the period of January 2007 to December 2008, was conducted. RESULTS When comparing patients with renal cysts (n = 164) to those without (n = 233), there was a statistically significant difference between the presence of renal cysts and male gender (p = 0.007), hypertension (p = 0.003), and AAA (p < 0.001) on univariate analysis. In addition, when comparing patients with AAA to those without, although COPD but not AAA was associated with renal cysts in less than 65 years old, the presence of renal cysts was the strongest association with AAA among patients belonging to the 65 to 74 years old group and over 75 years old group on multivariate analysis. CONCLUSIONS There is a statistically higher incidence of renal cysts in patients with AAA compared to patients without AAA in the group of elder cardiovascular patients. It is likely that AAA and renal cysts share a common pathogenesis.

Morphological predictor of remodelling of the descending thoracic aortic false lumen that remains patent after repair of acute type A dissection

OBJECTIVES Some patients achieve complete recovery through false lumen remodelling in the descending aorta after surgery for acute type A aortic dissection. Our goal was to investigate the relationship between false lumen remodelling during later postoperative stages and quantitative analysis of the true lumen shape during the early postoperative stages. METHODS We examined 88 surgical patients between January 2007 and December 2016. Three points of the descending aorta were assessed from the 6th (T6), the 9th (T9) and the 11th (T11) vertebral levels. The shape of the true lumen was evaluated during the early postoperative stages, and false lumen remodelling 1 year after surgery was the end point. The parameters obtained by evaluating the shape of the true lumen comprised the first principal component analysis using elliptic Fourier analysis, the minor diameter ratio and the ratio of the area of the true lumen to that of the descending aorta, and the number of contact points on the true lumen wall during the early stages. RESULTS Using univariate analysis, we detected significant differences in the first principal components, the minor diameter ratio, the area ratio and the number of contact points at each thoracic vertebral level (P < 0.05). The cut-off value of the minor diameter ratio was 0.55, and the area ratio was 0.48 as determined by analysis of the receiver operating characteristic. Multivariable logistic analysis indicated that the first principal component was the most significant predictor from the proximal to the middle descending aorta. CONCLUSIONS Quantitative evaluation of shape of the true lumen in the early postoperative stages after surgery for acute type A dissection can serve as a viable predictor for false lumen remodelling in later stages. Furthermore, the first principal component could serve as a more astute predictor than other quantitative parameters according to multivariate analysis.

Traumatic dislocated clavicle fracture with the oppression of superior vena cava.

For reprint information contact: Tohru Mawatari, MD Tel: 81 11 611 2111 ext 3312 Fax: 81 11 613 7318 Email: mawatari@sapmed.ac.jp Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo 060-8556, Japan Figure 2. Postoperative CT: The stenosis of the SVC improved and the infl ow from a left brachiocephalic vein to SVC was smooth. A 21-year-old man with traumatic dislocated fracture of the sternum, fi rst rib and clavicle due to a traffi c accident was admitted to our hospital. Although his symptoms did not indicate superior vena cava (SVC) syndrome, computed tomography (CT) showed stenosis of SVC due to a depression caused by posterior dislocation (Figure 1). An operation was performed to repair the dislocation and depression. Midline sternotomy was made, and the adhesion between bone and SVC were dissected following taping of a proximal SVC, bilateral brachiocephalic veins and an azygos vein. The dislocated portion consisting of the sternum, clavicle, and first rib, which pressed the SVC, was resected, and the three bones were re-fi xed by non-absorbable sutures. The postoperative enhanced CT showed that the stenosis of SVC improved (Figure 2).