Ryohei Yoshikawa

Troubleshooting for bleeding in thoracoscopic anatomic pulmonary resection

Introduction The objective of this study was to evaluate intraoperative vessel injury and assess troubleshooting during thoracoscopic anatomic pulmonary resection. Methods Between April 2012 and March 2016, 240 patients underwent thoracoscopic anatomic lung resection, 26 of whom were identified as having massive bleeding intraoperatively. We analyzed the injured vessel and the hemostatic procedure employed, then compared the perioperative outcomes in patients with (n = 26) and without (n = 214) vessel injury. In addition, we compared perioperative results based on the period when surgery was performed: early period: April 2012 to March 2014 (n = 93) or late period: April 2014 to March 2016 (n = 146). Results The surgical procedures included 20 lobectomies and 6 segmentectomies. One of the 26 patients had vessel injury at 2 points, giving a total of 27 points of injury. Hemostasis was mostly achieved by application of thrombostatic sealant (63.0%). There were no significant differences in the length postoperative hospitalization (p = 0.67) or morbidity rate (p = 0.43) between the vessel injury and the no-vessel injury groups. There were no significant differences in the incidence of significant intraoperative bleeding (p = 0.13) and total blood loss (p = 0.13) between the early and late periods. Conclusions Application of thrombostatic sealant is one of the useful methods to achieve hemostasis during thoracoscopic anatomic pulmonary resection. Vascular hazards are inherent to a thoracoscopic approach. Therefore, thoracic surgeons should always be concerned about significant intraoperative bleeding and treat it appropriately.

The risk of misdiagnosing pulmonary adenocarcinoma as traumatic pseudocyst in a young adult

A 35-year-old man was transferred to our institution because of bruising on the chest. A computed tomography scan revealed a pulmonary pseudocyst. Although the pulmonary pseudocyst remained unchanged it accumulated fluid. Based on our concern regarding hemoptysis, the patient underwent S6 segmentectomy of the right lower lobe. The postoperative pathological examination revealed a cystic lesion, including a white mass on the cystic wall. Unexpectedly, the mass was composed of papillary adenocarcinoma. Acute care surgeons should be alert to the possible presence of tumor in trauma patients. A cystic lesion must be carefully distinguished from a traumatic pulmonary pseudocyst and lung cancer.

Schwannoma arising in a lymph node mimicking metastatic pulmonary carcinoma

Schwannomas commonly arise in the torso, extremities, and mediastinum. However, no interlobar lymph node (#11i) lesions have ever been reported. This is a thought-provoking case, because it involved a schwannoma arising in a lymph node mimicking metastatic pulmonary carcinoma. A 72-year-old man was diagnosed with primary pulmonary carcinoma, and 18F-fluorodeoxyglucose (FDG) positron emission tomography demonstrated high FDG uptake in the primary lesion and in #11i, which suggested metastasis (clinical stage IIA). A right lower lobectomy with lymph node dissection was performed. Fortunately, the enlarged #11i was a schwannoma and not metastasis. The take-home message is “a patient with multiple neuromatosis tends to have schwannomas throughout the body”.

Synchronous Pulmonary Adenocarcinoma and Lymph Node Small Cell Carcinoma of Unknown Primary Origin

To the Editor: Metastatic thoracic (peribronchial, hilar, or mediastinal) cancer of unknown primary origin is very rare. We describe here a case of synchronous pulmonary adenocarcinoma combined with lymph node small cell carcinoma of unknown primary origin. Primary pulmonary adenocarcinoma combined with metastatic thoracic lymph node carcinoma without a primary site is ultimately rare, and no cases have been reported in the English literature. A 74-year-old woman was referred to our hospital with an abnormal shadow on a chest radiograph. She had no smoking history and a history of allergy to local anesthetic agents. A computed tomography scan showed a partially solid nodule in the right lower lobe (Fig. 1A) and a slightly enlarged interlobar lymph node (#11i; Fig. 1B). 18F-fluorodeoxyglucose positron-emission tomography showed no uptake in the primary lesion but high 18F-fluorodeoxyglucose uptake in the #11i lymph node. These findings suggested primary pulmonary carcinoma, clinical stage IIB (T1aN1[#11i]M0). There-

Invited editorial on “Fissureless fissure-last video-assisted thoracoscopic lobectomy for all lung lobes: a better alternative to decrease the incidence of prolonged air leak?”

Thoracic surgeons sometimes have difficulty controlling postoperative air-leakage, particularly in patients with dense fissures. Several studies have shown that prolonged air leak (PAL) is a frequent complication after anatomic pulmonary resections, occurring in 7.6–10% of all patients with anatomic pulmonary resections (1-4).

Three-Dimensional Computed Tomography Helps Identify Muscles for Use in an Empyema Cavity

The Supplemental Figures and Video can be viewed in Fmary lung cancer, a 52-year-old man acquired an empyema cavity with an aspergilloma in the remaining right lower lobe (Supplemental Fig 1). A corrective operation was scheduled. We use 3-dimensional computed tomography (SOMATOM Definition Flash, Siemens, Munich, Germany) to assist with the preoperative planning [1]. The 3-dimensional computed tomographic scan demonstrated the feeding artery to each muscle (Fig 1 and Supplemental Fig 2). We also determined the positional relationships of the cavity (shown in green in Supplemental Fig 2) and ribs. We then decided where we should enter the thoracic cavity and which muscles we should use (Video). The muscle flaps,

Successful treatment of a bronchopleural fistula after en masse lobectomy

A 72-year-old man underwent en masse lobectomy of the lower left lobe because of continued hemoptysis. We chose en masse lobectomy as a last resort because the patient had cardiopulmonary problems including chronic obstructive pulmonary disease (COPD), pulmonary hypertension, and continued hemoptysis. The patient developed a bronchopleural fistula 2 weeks later, so the Clagett window procedure was performed. After gauze exchange and cleaning of the pleural space, the Clagett window was closed using a latissimus dorsi muscle flap. He was discharged about 3 months after the initial operation. One of the most critical complications after en masse lobectomy is a bronchopleural fistula because the bronchial stump and vessel are too close to each other. The space between the bronchus and vessel can fill with tissue, such as pulmonary parenchyma or lymph nodes, which cover the fistula.

The optimal starting point for survival time in pulmonary metastasectomy.

Aim Studies of metastatic lung cancer have used various starting points for calculating the survival period, including the time of primary tumor resection and the first and final pulmonary metastasectomy. This study examined differences in prognostic factors according to the starting point used to calculate survival time. Methods We performed surgical resection of pulmonary metastases in 202 consecutive patients between 1999 and 2013. Of these, 146 (excluding overlapping cases) underwent pulmonary metastasectomy. We examined the survival period after resection in patients with pulmonary metastases (group M) and primary tumors (group P). The prognostic influence of variables on survival was analyzed. Results The 5-year survival rate was 76.7% in group P and 62.0% in group M. The significant prognostic factors were the disease-free interval (>1 and >2 years) in group P, and maximum tumor diameter in group M. Interestingly, multivariate analysis showed that the significant prognostic factors (age and nodule diameter) were identical in both groups. Conclusions We believe that the potential confounding factors were counterbalanced by the effect of prognostic factors on multivariate analysis in patients undergoing pulmonary metastasectomy. If the survival period is defined as starting from the time of the primary tumor resection, this may resolve the variance in survival, because pulmonary metastasectomy is only one option among several available treatments.